Motherhood in Childhood

Motherhoodin ChildhoodFacing the challenge ofadolescent pregnancystate of world population 2013

The State of World Population 2013This report was produced by the Informationand External Relations Division of UNFPA, theUnited Nations Population Fund.LEAD RESEARCHER AND AUTHORNancy Williamson, PhD, teaches at the Gillings School ofGlobal Public Health, University of North Carolina. Earlier,she served as Director of USAID’s YouthNet Project and theBotswana Basha Lesedi youth project funded by the U.S.Centers for Disease Control and Prevention. She taught atBrown University, worked for the Population Council and forFamily Health International. She lived in and worked on familyplanning projects in India and the Philippines. Author ofnumerous scholarly papers, Ms. Williamson is also the authorof Sons or daughters: a cross-cultural survey of parental preferences,about preferences for sons or daughters around the world.RESEARCH ADVISERRobert W. Blum, MD, MPH, PhD, is the William H. Gates,Sr. Professor and Chair of the Department of Population,Family and Reproductive Health and Director of the HopkinsUrban Health Institute at the Johns Hopkins BloombergSchool of Public Health. Dr Blum is internationally recognizedfor his expertise and advocacy related to adolescentsexual and reproductive health research. He has edited twobooks and written more than 250 articles, book chaptersand reports. He is the former president of the Society forAdolescent Medicine, past board chair of the GuttmacherInstitute, a member of the United States National Academy ofSciences and a consultant to the World Health Organizationand UNFPA.UNFPA ADVISORY TEAMBruce CampbellKate GilmoreMona KaidbeyLaura LaskiEdilberto LoaizaSonia Martinelli-HeckadonNiyi OjuolapeJagdish UpadhyaySylvia WongEDITORIAL TEAMEditor: Richard KollodgeEditorial associate: Robert PuchalikEditorial and administrative associate: Mirey ChaljubDistribution manager: Jayesh GulrajaniDesign: Prographics, Inc.Cover photo: © Mark Tuschman/Planned Parenthood GlobalACKNOWLEDGMENTSThe editorial team is grateful for additional insights, contributionsand feedback from UNFPA colleagues, including AlfonsoBarragues, Abubakar Dungus, Nicole Foster, Luis Mora andDianne Stewart. Edilberto Loiaza produced the statistical analysisthat provided the foundation for this report.Our thanks also go to UNFPA colleagues Aicha El Basri,Jens-Hagen Eschenbaecher, Nicole Foster, Adebayo Fayoyin,Hugues Kone, William A. Ryan, Alvaro Serrano and numerouscollegues from UNFPA offices around the world for developingfeature stories and for making sure that adolescents’ own voiceswere reflected in the report.A number of recommendations in the report are based onresearch by Kwabena Osei-Danquah and Rachel Snow atUNFPA on progress achieved since the Programme of Actionwas adopted at the 1994 International Conference on Populationand Development.Shireen Jejeebhoy of the Population Council reviewed literatureand provided text on sexual violence against adolescents. NicolaJones of the Overseas Development Institute summarizedresearch on cash transfers. Monica Kothari of Macro Internationalanalysed Demographic and Health Survey data on adolescentreproductive health. Christina Zampas led the research anddrafting of aspects of the report that address the human rightsdimension of adolescent pregnancy.MAPS AND DESIGNATIONSThe designations employed and the presentation of material inmaps in this report do not imply the expression of any opinionwhatsoever on the part of UNFPA concerning the legal statusof any country, territory, city or area or its authorities, or concerningthe delimitation of its frontiers or boundaries. A dottedline approximately represents the Line of Control in Jammu andKashmir agreed upon by India and Pakistan. The final status ofJammu and Kashmir has not yet been agreed upon by the parties.UNFPADelivering a world whereevery pregnancy is wantedevery childbirth is safe andevery young person’spotential is fulfilled

state of world population 2013Motherhoodin ChildhoodFacing the challenge ofadolescent pregnancyForewordpage iiOverviewpage iv1A global challengepage 123Pressures4The impact on girls' health,education and productivityfrom many directionsTaking actionpage 17page 31page 57Charting a way forwardpage 835Indicators page 99Bibliography page 111© Getty Images/Camilla Watson

ForewordWhen a girl becomes pregnant, her present and future change radically,and rarely for the better. Her education may end, her job prospects evaporate,and her vulnerabilities to poverty, exclusion and dependency multiply.Many countries have taken up the cause ofpreventing adolescent pregnancies, often throughactions aimed at changing a girl’s behaviour.Implicit in such interventions are a belief thatthe girl is responsible for preventing pregnancyand an assumption that if she does becomepregnant, she is at fault.Such approaches and thinking are misguidedbecause they fail to account for the circumstancesand societal pressures that conspire againstadolescent girls and make motherhood a likelyoutcome of their transition from childhood toadulthood. When a young girl is forced into marriage,for example, she rarely has a say in whether,when or how often she will become pregnant. Apregnancy-prevention intervention, whether anadvertising campaign or a condom distributionprogramme, is irrelevant to a girl who has nopower to make any consequential decisions.What is needed is a new way of thinkingabout the challenge of adolescent pregnancy.Instead of viewing the girl as the problem andchanging her behaviour as the solution, governments,communities, families and schoolsshould see poverty, gender inequality, discrimination,lack of access to services, and negativeviews about girls and women as the realchallenges, and the pursuit of social justice,equitable development and the empowermentof girls as the true pathway to fewer adolescentpregnancies.Efforts—and resources—to prevent adolescentpregnancy have typically focused on girlsages 15 to 19. Yet, the girls with the greatestvulnerabilities, and who face the greatest risk ofcomplications and death from pregnancy andchildbirth, are 14 or younger. This group of veryyoung adolescents is typically overlooked by, orbeyond the reach of, national health, educationand development institutions, often because thesegirls are in forced marriages and are preventedfrom attending school or accessing sexual andreproductive health services. Their needs areimmense, and governments, civil society, communitiesand the international community must domuch more to protect them and support their safeand healthy transition from childhood and adolescenceto adulthood. In addressing adolescentpregnancy, the real measure of success—or failure—ofgovernments, development agencies, civilsociety and communities is how well or poorly werespond to the needs of this neglected group.Adolescent pregnancy is intertwined with issuesof human rights. A pregnant girl who is pressuredor forced to leave school, for example, is deniedher right to an education. A girl who is forbiddenfrom accessing contraception or even informationabout preventing a pregnancy is denied her rightii ii FOREWORD

to health. Conversely, a girl who is able to enjoyher right to education and stays in school is lesslikely to become pregnant than her counterpartwho drops out or is forced out. The enjoymentof one right thus puts her in a better position toenjoy others.From a human rights perspective, a girlwho becomes pregnant—regardless of thecircumstances or reasons—is one whose rightsare undermined.Investments in human capital are critical toprotecting these rights. Such investments notonly help girls realize their full potential, but theyare also part of a government’s responsibility forprotecting the rights of girls and complying withhuman rights treaties and instruments, such as theConvention on the Rights of the Child, and withinternational agreements, including the Programmeof Action of the 1994 International Conference onPopulation and Development, which continues toguide the work of UNFPA today.The international community is developinga new sustainable development agenda tosucceed the Millennium Declaration and itsassociated Millennium Development Goals after2015. Governments committed to reducing thenumber of adolescent pregnancies should alsobe committed to ensuring that the needs, challenges,aspirations, vulnerabilities and rights ofadolescents, especially girls, are fully consideredin this new development agenda.There are 580 million adolescent girls in theworld. Four out of five of them live in developingcountries. Investing in them today will unleashtheir full potential to shape humanity’s future.Dr Babatunde OsotimehinUnited Nations Under-Secretary-Generaland Executive DirectorUNFPA, the United Nations Population Funds Dr Osotimehinwith adolescentpeer educatorsin South Africa.© UNFPA/RayanaRassoolTHE STATE OF WORLD POPULATION 2013iii

OverviewEvery day, 20,000 girls below age 18 give birth in developing countries.Births to girls also occur in developed countries but on a much smaller scale.In every region of the world, impoverished,poorly educated and rural girls are more likelyto become pregnant than their wealthier, urban,educated counterparts. Girls who are from anethnic minority or marginalized group, who lackchoices and opportunities in life, or who havelimited or no access to sexual and reproductivehealth, including contraceptive information andservices, are also more likely to become pregnant.Most of the world’s births to adolescents—95 per cent—occur in developing countries, andnine in 10 of these births occur within marriageor a union.About 19 per cent of young women in developingcountries become pregnant before age18. Girls under 15 account for 2 millionof the 7.3 million births that occur toadolescent girls under 18 every year indeveloping countries.Impact on health, education andproductivityA pregnancy can have immediate and lastingconsequences for a girl’s health, education andincome-earning potential. And it often alters thecourse of her entire life. How it alters her lifedepends in part on how old—or young—she is.The risk of maternal death for mothers under 15in low- and middle-income countries is double thatof older females; and this younger group facesFACING THE CHALLENGE OF ADOLESCENT PREGNANCY• 20,000 girls giving birth every day• Missed educational and other opportunities• 70,000 adolescent deaths annually fromcomplications from pregnancy, childbirth• 3.2 million unsafe abortions amongadolescents each year• Perpetuation of poverty and exclusion• Basic human rights denied• Girls' potential going unfulfillediv©Naresh Newar/ipsnews.net

“I was 14… My mom and her sisters began toprepare food, and my dad asked my brothers,sisters and me to wear our best clothesbecause we were about to have a party.Because I didn’t know what was going on, Icelebrated like everyone else. It was that daysignificantly higher rates of obstetric fistulaethan their older peers as well.About 70,000 adolescents in developingcountries die annually of causes related topregnancy and childbirth. Pregnancy andchildbirth are a leading cause of deathfor older adolescent females in developingcountries. Adolescents who becomepregnant tend to be from lower-incomehouseholds and be nutritionally depleted.Health problems are more likely if a girlbecomes pregnant too soon after reachingpuberty.Girls who remain in school longer areless likely to become pregnant. EducationI learned that it was my wedding and that Ihad to join my husband. I tried to escape butwas caught. So I found myself with a husbandthree times older than me…. This marriage wassupposed to save me from debauchery. Schoolwas over, just like that. Ten months later, Ifound myself with a baby in my arms. One dayI decided to run away, but I agreed to comeback to my husband if he would let me goback to school. I returned to school, havethree children and am in seventh grade.”Clarisse, 17, ChadUNDERLYING CAUSES• Child marriage• Gender inequalityPREGNANCY BEFORE AGE 18• Obstacles to human rights• Poverty• Sexual violence and coercion• National policies restricting access tocontraception, age-appropriate sexuality education• Lack of access to education and reproductivehealth services• Underinvestment in adolescent girls’ human capital19%About 19 per centof young women indeveloping countriesbecome pregnantbefore age 18v

prepares girls for jobs and livelihoods, raises theirself-esteem and their status in their householdsand communities, and gives them more say indecisions that affect their lives. Education alsoreduces the likelihood of child marriage anddelays childbearing, leading eventually to healthierbirth outcomes. Leaving school—because ofpregnancy or any other reason—can jeopardize agirl’s future economic prospects and exclude herfrom other opportunities in life.Many forces conspiring againstadolescent girlsAn “ecological” approach to adolescent pregnancyis one that takes into account the full range ofcomplex drivers of adolescent pregnancy and theinterplay of these forces. It can help governments,policymakers and stakeholders understand thechallenges and craft more effective interventionsthat will not only reduce the number of pregnanciesbut that will also help tear down the manybarriers to girls’ empowerment so that pregnancyis no longer the likely outcome.One such ecological model, developed byRobert Blum at the Johns Hopkins BloombergSchool of Public Health, sheds light on theconstellation of forces that conspire against theadolescent girl and increase the likelihood thatshe will become pregnant. While these forces arenumerous and multi-layered, they all, in one wayor another, interfere with a girl’s ability to enjoyor exercise rights and empower her to shape herown future. The model accounts for forces atthe national level—such as policies regardingadolescents’ access to contraception or lack ofenforcement of laws banning child marriage—all the way to the level of the individual, suchas a girl’s socialization and the way it shapesher beliefs about pregnancy.Most of the determinants in this modeloperate at more than one level. For example,national-level policies may restrict adolescents’PRESSURES FROM MANY DIRECTIONS AND LEVELSAn “ecological” approach to adolescent pregnancy is one that takes into account the fullrange of complex drivers of adolescent pregnancy and the interplay of these forces.Pressures from all levels conspire against girls and lead to pregnancies, intended or otherwise. National laws may prevent agirl from accessing contraception. Community norms and attitudes may block her access to sexual and reproductive healthservices or condone violence against her if she manages to access services anyway. Family members may force her intomarriage where she has little or no power to say “no” to having children. Schools may not offer sexuality education, so shemust rely on information (often inaccurate) from peers about sexuality, pregnancy and contraception. Her partner may refuseto use a condom or may forbid her from using contraception of any sort.viINDIVIDUALFAMILYSCHOOL/PEERSCOMMUNITY

access to sexual and reproductive health services,including contraception, while the community orfamily may oppose girls’ accessing comprehensivesexuality education or other information abouthow to prevent a pregnancy.This model shows that adolescent pregnanciesdo not occur in a vacuum but are the consequenceof an interlocking set of factors such aswidespread poverty, communities’ and families’acceptance of child marriage, and inadequateefforts to keep girls in school.For most adolescents below age 18, and especiallyfor those younger than 15, pregnanciesare not the result of a deliberate choice. To thecontrary, pregnancies are generally the resultof an absence of choices and of circumstancesbeyond a girl’s control. Early pregnancies reflectpowerlessness, poverty and pressures—frompartners, peers, families and communities. Andin too many instances, they are the result ofsexual violence or coercion. Girls who havelittle autonomy—particularly those in forcedmarriages—have little say about whether orwhen they become pregnant.Adolescent pregnancy is both a cause andconsequence of rights violations. Pregnancyundermines a girl’s possibilities for exercisingthe rights to education, health and autonomy,as guaranteed in international treaties such asthe Convention on the Rights of the Child.Conversely, when a girl is unable to enjoy basicrights, such as the right to education, she becomesmore vulnerable to becoming pregnant. Accordingto the Convention on the Rights of the Child,anyone under the age of 18 is considered achild. For nearly 200 adolescent girls every day,early pregnancy results in the ultimate rightsviolation—death.Girls’ rights are already protected—on paper—by an international, normative framework thatrequires governments to take steps that will makeit possible for girls to enjoy their rights to anADOLESCENT BIRTHS95%95 per cent of theworld’s births toadolescents occurin developingcountriesNATIONALvii

education, to health and to live free fromviolence and coercion. Children have the samehuman rights as adults, but they are also grantedspecial protections to address the inequities thatcome with their age.Upholding the rights that girls are entitled tocan help eliminate many of the conditions thatcontribute to adolescent pregnancy and helpmitigate many of the consequences to the girl,her household and her community.Addressing these challenges through measuresthat protect human rights is key to ending avicious cycle of rights infringements, poverty,inequality, exclusion and adolescent pregnancy.A human rights approach to adolescentpregnancy means working with governmentsto remove obstacles to girls’ enjoyment of rights.This means addressing underlying causes, suchas child marriage, sexual violence and coercion,lack of access to education and sexual andreproductive health, including contraception andinformation. Governments, however, cannot dothis alone. Other stakeholders and duty-bearers,such as teachers, parents, and community leaders,also play an important role.Addressing underlying causesBecause adolescent pregnancy is the result ofdiverse underlying societal, economic and otherforces, preventing it requires multidimensionalstrategies that are oriented towards girls’ empowermentand tailored to particular populations ofgirls, especially those who are marginalized andmost vulnerable.Many of the actions by governments and civilsociety that have reduced adolescent fertilitywere designed to achieve other objectives, suchas keeping girls in school, preventing HIV infection,or ending child marriage. These actions canalso build human capital, impart information orskills to empower girls to make decisions in lifeand uphold or protect girls’ basic human rights.FOUNDATIONS FOR PROGRESSEMPOWER GIRLSBuilding girls' agency, enablingthem to make decisions in lifeRECTIFY GENDERINEQUALITYPut girls and boys on equal footingRESPECT HUMANRIGHTS FOR ALLUpholding rights can eliminateconditions that contribute toadolescent pregnancyREDUCE POVERTYIn developing and developedcountries, poverty drives adolescentpregnancyviii

Research shows that addressing unintendedpregnancy among adolescents requires holisticapproaches, and because the challenges aregreat and complex, no single sector or organizationcan face them on its own. Only byworking in partnership, across sectors, and incollaboration with adolescents themselves, canconstraints on their progress be removed.Keeping adolescent girls on healthy, safeand affirming life trajectories requires comprehensive,strategic, and targeted investmentsthat address the multiple sources of theirvulnerabilities, which vary by age, abilities,income group, place of residence and manyother factors. It also requires deliberate effortsto recognize the diverse circumstances ofadolescents and identify girls at greatest riskof adolescent pregnancy and poor reproductivehealth outcomes. Such multi-sectoralprogrammes are needed to build girls’ assetsacross the board—in health, education andlivelihoods—but also to empower girls throughsocial support networks and increase their statusat home, in the family, in the community and inrelationships. Less complex but strategic interventionsmay also make a difference. These couldinclude the provision of conditional cash transfersto girls to enable them to remain in school.The way forwardMany countries have taken action aimed at preventingadolescent pregnancy, and in some cases,to support girls who have become pregnant. Butmany of the measures to date have been primarilyabout changing the behaviour of the girl, failingto address underlying determinants and drivers,including gender inequality, poverty, sexualviolence and coercion, child marriage, socialpressures, exclusion from educational and jobopportunities and negative attitudes and stereotypesabout adolescent girls, as well as neglectingto take into account the role of boys and men.EIGHT WAYS TO GET THERE1 Girls 10 to 14Preventive interventions for young adolescents2 Child marriageStop marriage under 18, prevent sexual violence and coercion5 EducationGet girls in school and enable them to stay enrolled longer6 Engage men and boysHelp them be part of the solution3 Multilevel approachesBuild girls' assets across the board; keep girls on healthy,safe life trajectories4 Human rightsProtect rights to health, education, security and freedomfrom poverty7 Sexuality education and access to servicesExpand age-appropriate information, provide healthservices used by adolescents8 Equitable developmentBuild a post-MDG framework based on human rights,equality, sustainabilityix

“The reality is that people are veryjudgmental, and that’s how human beingsare. To hear that even after all youraccomplishments… all the stuff you’vegone through to pass these hurdles, tobecome a better person… people can bevery unforgiving because they are goingto remember ‘Oh, she had a baby whenshe was 15’.”Tonette, 31, pregnant at 15, JamaicaExperience from effective programmes suggeststhat what is needed is a transformativeshift away from narrowly focused interventionstargeted at girls or at preventing pregnancy,towards broad-based approaches that build girls’human capital, focus on their agency to makedecisions about their lives (including mattersof sexual and reproductive health), and presentreal opportunities for girls so that motherhoodis not seen as their only destiny. This new paradigmmust target the circumstances, conditions,norms, values and structural forces that perpetuateadolescent pregnancies on the one handand that isolate and marginalize pregnant girlson the other. Girls need both access to sexualand reproductive health services and informationand to be unburdened from the economicand social pressures that too often translate intoa pregnancy and the poverty, poor health andunrealized human potential that come with it.THE BENEFITSHEALTHEDUCATIONALEQUALITYBETTERMATERNAL ANDCHILD HEALTHMORE GIRLSCOMPLETINGTHEIR EDUCATIONEQUALRIGHTS ANDOPPORTUNITYLater pregnancies reducehealth risks to girls and totheir children.This reduces the likelihood of childmarriage and delays childbearing,leading eventually to healthier birthoutcomes. Also builds skills, raisesgirls' status.Preventing pregnancy helpsensure girls enjoy all basichuman rights.x

Additional efforts must be made to reachgirls under age 15, whose needs and vulnerabilitiesare especially great. Efforts to preventpregnancies among girls older than 15 or tosupport older adolescents who are pregnantor who have given birth may be unsuitable orirrelevant to very young adolescents. Very youngadolescents have special vulnerabilities, and toolittle has been done to understand and respondto the daunting challenges they face.Girls who have become pregnant needsupport, not stigma. Governments, internationalorganizations, civil society, communities,families, religious leaders and adolescentsthemselves all have an important role ineffecting change. All will gain by nurturingthe vast possibilities that these young girls,brimming with life and hope, represent.UNFPA, RIGHTS AND ADOLESCENT PREGNANCYFor UNFPA, which is guided by the Programme of Action of theInternational Conference on Population and Development (ICPD),respecting, protecting and fulfilling adolescents’ human rights, includingtheir right to sexual and reproductive health and their reproductive rights:• Reduces vulnerabilities, especially among those who are the mostmarginalized, by focusing on their particular needs;• Increases and strengthens the participation of civil society, thecommunity and adolescents themselves;• Empowers adolescents to continue their education and lead productiveand satisfying lives;• Increases transparency and accountability; and• Leads to sustained social change as human rights-based programmeshave an impact on norms and values, structures, policy and practice.ECONOMICPOTENTIALINCREASED ECONOMICPRODUCTIVITY ANDEMPLOYMENTInvestments that empowergirls improve income-earningprospects.ADOLESCENTGIRLS' POTENTIALFULLY REALIZEDProspects are brighter for agirl who is healthy, educatedand able to enjoy rights.©Mark Tuschman

xiiCHAPTER 1: A GLOBAL CHALLENGE

1A globalchallengeEvery year in developing countries,7.3 million girls under the age of 18give birth.© Mark Tuschman/AMMDTHE STATE OF WORLD POPULATION 20131

“I was 16 and never missed a day of school. I liked studying so much, I would much ratherspend time with my books than watch TV! I dreamt of going to college and then getting agood job so that I could take my parents away from the dingy house we lived in.Then one day, I was told that I had to leave it all, as my parents bartered me for a girl my elderbrother was to marry. Such exchange marriages are called atta-satta in my community. I was sadand angry. I pleaded with my mother, but my father had made up his mind.My only hope was that my husband would let me complete my studies. But he got mepregnant even before I turned 17. Since then, I have hardly ever been allowed to step out of thehouse. Everyone goes out shopping and for movies and neighbourhood functions, but not me.Sometimes, when the others are not at home, I read my old school books, and hold my babyand cry. She is such an adorable little girl, but I am blamed for not having a son.But things are gradually changing. Hopefully, customs like atta-satta and child marriage will betotally gone by the time my daughter grows up, and she will get to complete her education andmarry only when she wants to.”Komal, 18, IndiaEvery year in developing countries, 7.3 milliongirls under the age of 18 give birth (UNFPA,2013). The number of pregnancies is even higher.Adolescent pregnancies occur with varyingfrequency across regions and countries, withincountries and across age and income groups.What is common to every region, however, isthat girls who are poor, live in rural or remoteareas and who are illiterate or have little educationare more likely to become pregnant thantheir wealthier, urban, educated counterparts.Girls who are from an ethnic minority ormarginalized group, who lack choices andopportunities in life, or who have limited orno access to sexual and reproductive health,including contraceptive information and services,are also more likely to become pregnant.Worldwide, a girl is more likely tobecome pregnant under circumstances ofsocial exclusion, poverty, marginalizationand gender inequality, where she is unableto fully enjoy or exercise her basic human2 CHAPTER 1: A GLOBAL CHALLENGE

ights, or where access to health care, schooling,information, services and economic opportunitiesis limited.Most births to adolescents—95 per cent—occur in developing countries, and nine in 10of these births occur within marriage or a union(World Health Organization, 2008).According to estimates for 2010,36.4 million women in developingcountries between ages 20 and 24report having had a birth before age 18.Births to girls under age 18About 19 per cent of young women in developingcountries become pregnant before age 18(UNFPA, 2013).According to estimates for 2010, 36.4 millionwomen in developing countries between ages 20and 24 report having had a birth before age 18.Of that total, 17.4 million are in South Asia.Among developing regions, West and CentralAfrica have the largest percentage (28 per cent)of women between the ages of 20 and 24 whoreported a birth before age 18.Data gathered in 54 countries through twosets of demographic and health surveys (DHS)and multiple indicator cluster surveys (MICS)carried out between 1990 and 2008 andbetween 1997 and 2011 show a slight declinein the percentage of women between the ages of20 and 24 who reported a birth before age 18:from about 23 per cent to about 20 per cent.tAbriendoOportunidadesoffers safe spaces,mentoring, educationalopportunitiesand solidarity foradolescent Mayangirls. It also introducesnew possibilities intotheir lives.© Mark Tuschman/UNFPATHE STATE OF WORLD POPULATION 20133

The 54 countries covered by these surveys arehome to 72 per cent of the total population ofdeveloping countries, excluding China.Of the 15 countries with a “high” prevalence(30 per cent or greater) of adolescentpregnancy, eight have seen a reduction, whencomparing findings from DHS and MICSsurveys (1997–2008 and 2001–2011). Thesix countries that saw increases were all insub-Saharan Africa.Under the Convention on the Rights of theChild, anyone under age 18 is considered a“child.” Girls who become pregnant before 18are often unable to enjoy or exercise their rights,such as their right to an education, to healthand an adequate standard of living, and thus aredenied these basic rights. Millions of girls under18 become pregnant in marriage or in a union.The Human Rights Committee has joined otherrights-monitoring bodies in recommending legalreform to eliminate child marriage.Births to girls under age 15Girls under age 15 account for 2 million of the7.3 million births to girls under 18 every yearin developing countries.COUNTRIES WITH 20 PER CENT OR MORE OF WOMENAGES 20 TO 24 REPORTING A BIRTH BEFORE AGE 18Per cent5545352515505144 46 484233 34 35 35 36 38 38 38 4020 20 21 21 21 22 22 22 22 22 23 24 24 25 25 25 25 25 26 26 28 28 28 28 29 30ColombiaSource: www.devinfo.org/mdg5b4 CHAPTER 1: A GLOBAL CHALLENGEBoliviaZimbabweMauritaniaEcuadorSenegalIndiaCape VerdeSwazilandEthiopiaBeninEl SalvadorGuatemalaYemenDominican RepublicSão Tomé and PrincipeDemocratic Republic of CongoEritreaKenyaHondurasNigeriaNicaraguaBurkina FasoTanzaniaRepublic of the CongoCameroonUgandaZambiaMalawiGabonMadagascarCentral African RepublicLiberiaSierra LeoneBangladeshMozambiqueGuineaMaliChadNiger

According to DHS and MICS surveys,3 per cent of young women in developingcountries say they gave birth before age 15(UNFPA, 2013).Among developing regions, West andCentral Africa account for the largestpercentage (6 per cent) of reported birthsbefore age 15, while Eastern Europe andCentral Asia account for the smallestpercentage (0.2 per cent).Data gathered in 54 countries through twosets of DHS and MICS surveys carried outbetween 1990 and 2008 and between 1997and 2011 show a decline in the percentage ofwomen between the ages of 20 and 24 whoreported a birth before age 15, from 4 per centto 3 per cent. The decline, which has beenrapid in some countries, is attributed largelyto a decrease in very early arranged marriages(World Health Organization, 2011b).Still, one girl in 10 has a child before the ageof 15 in Bangladesh, Chad, Guinea, Mali,Mozambique and Niger, countries wherechild marriage is common.Latin America and the Caribbean is the onlyregion where births to girls under age 15 rose.In this region, such births are projected to riseslightly through 2030.In sub-Saharan Africa, births to girls underage 15 are projected to nearly double in thenext 17 years. By 2030, the number of mothersunder age 15 in sub-Saharan Africa isexpected to equal those in South Asia.First-hand and qualitative data on this groupof very young adolescents—between the agesof 10 and 14—are scarce, incomplete or nonexistentfor many countries, rendering thesegirls and the challenges they face invisible topolicymakers.“I was going out with my boyfriend for ayear and he used to give me money andclothes. I got pregnant when I was 13.I was still in school. My parents askedmy boyfriend to stay at our place. Hepromised them that he would take care ofme. After that, he left. He stopped callingand I had no contact with him. After Idelivered my baby my parents took careof me and taught me how to take care ofhim. All I want is…to go back to school.After school I will be able to have aprofession like being a teacher andhave a driver’s license.”Ilda, 15, MozambiqueThe main reason for the paucity of reliable,complete data is that 15-year-olds are typicallythe youngest adolescents included in nationalDHS surveys, the primary source of informationabout adolescent pregnancies. This is sobecause there are ethical challenges in collectingdata from this group, especially aboutsensitive issues of sexuality and pregnancies.Therefore, most data about those under age15 are obtained retrospectively—that is,THE STATE OF WORLD POPULATION 20135

FACING THE CHALLENGE OFADOLESCENT PREGNANCYPERCENTAGE OF WOMEN AGES 20 TO 24WHO REPORTED GIVING BIRTH BY AGE 18(MOST RECENT DATA FROM DEVELOPING COUNTRIES, 1996-2011)Less than 1010–1930 and aboveNo data or incomplete data20–29Source: www.devinfo.org/mdg5b. Map shows only countries where data weregathered from DHS or MICS surveys.PERCENTAGE OF WOMEN BETWEEN THE AGESOF 20 AND 24 REPORTING A BIRTH BEFORE AGE 18AND BEFORE AGE 15Reporting first birth before age 15 Reporting first birth before age 18DevelopingCountries319West &Central AfricaEast & SouthernAfrica462528South Asia422Latin America &the Caribbean218Arab States110East Asia &PacificEastern Europe& Central Asia1⊳0.2 485 10 15 20 25 30 35Source: UNFPA, 2013. Calculations based on data for 81 countries, representing more than 83 per cent of the population covered inthese regions, using data collected between 1995 and 2011.6 CHAPTER 1: A GLOBAL CHALLENGE

The boundaries and names shownand the designations used onthis map do not imply officialendorsement or acceptance bythe United Nations. Dotted linerepresents approximately theLine of Control in Jammu andKashmir agreed upon by Indiaand Pakistan.The final status of Jammu andKashmir has not yet been agreedupon by the parties.“Efforts—and resources—toprevent adolescent pregnancyhave typically focused on girlsages 15 to 19. Yet, the girls withthe greatest vulnerabilities, andwho face the greatest risk ofcomplications and death frompregnancy and childbirth,are 14 or younger.”BIRTHS BEFORE AGE 15ONE GIRL IN 10has a child before the age of 15 inBangladesh, Chad, Guinea, Mali,Mozambique and Niger6%Among developingcountries, Westand Central Africaaccount for the largestpercentage (6 per cent)of reported birthsbefore age 15.THE STATE OF WORLD POPULATION 20137

“I was 12 years old when a man came to askmy parents for my hand in marriage. They toldme to marry him and after some time I fell inlove with him. I have two older brothers. Bothof them went to school, but my parents neverlet me. I don’t know why, maybe because Iam a girl and they knew that I was going toget married later on. I had my first child whenI was 13 years old. It is not normal but it justhappened. I had problems giving birth buteverything went well. I have three girls andI am pregnant for the fourth time.”Marielle, 25, pregnant at 13, Madagascareither because of social norms concerningage-appropriate behaviours, ethical concernsregarding potentially harmful effects of theresearch, or doubts about the validity of youngadolescents’ responses (Chong et al., 2006).In a report on DHS data concerning adolescentsbetween the ages of 10 and 14, thePopulation Council emphasized the needfor research about important markers of thetransition from childhood to adolescence: “Inreviewing these DHS data on very young adolescents,what we mainly know is that we don’tknow very much.” (Blum et al., 2013)Some researchers question whether veryyoung adolescents have the cognitive ability toanswer questions requiring a thoughtful assessmentof the barriers they face or of potentialconsequences of future actions. Others believethat the stigma surrounding premarital sexualactivity for girls is too high to obtain accurateinformation (Chong et al., 2006).researchers ask women who are between 20 and24 to report the age at which they married andhad their first pregnancy or birth.Maintaining high ethical standards is crucialin conducting information-gathering activities.Children and adolescents require special protections,both because they are vulnerableto exploitation, abuse, and other harmfuloutcomes, and because they have less powerthan adults. Information about schooling andgeneral well-being has long been collected onyoung adolescents, but most researchers haveshied away from covering sensitive topics,Birth rates vary within countriesAdolescent birth rates often vary within acountry, depending on a number of variables,such as poverty or the local prevalence ofchild marriage. Niger, for example, has theworld’s highest adolescent birth rate and thehighest child marriage rate overall, but girlsin the country’s Zinder region are more thanthree times as likely to give birth before age 18than their counterparts in the nation’s capital,Niamey. Zinder is a poor, predominantly ruralregion, where malnutrition is common andaccess to health care is limited.A review of data gathered through DHSand MICS surveys in 79 developing countriesbetween 1998 and 2011 shows that adolescentbirth rates are higher in rural areas, among8 CHAPTER 1: A GLOBAL CHALLENGE

adolescents with no education and in thepoorest 20 per cent of households.Variations within a country may resultnot only from differences in incomes, butalso from inequitable access to educationand sexual and reproductive health services,including contraceptives, the prevalence ofchild marriage, local customs and social pressures,and inadequate or poorly enforced lawsand policies.Understanding these differences can helppolicymakers develop interventions that aretailored to the diverse needs of communitiesacross a country.Pregnancies and births amongmarried childrenDespite near-universal commitments to endchild marriage, one in three girls in developingcountries (not including China) is marriedbefore age 18 (UNFPA, 2012).Most of these girls are poor, less-educatedand live in rural areas. In the next decade, anestimated 14 million child marriages will occurannually in developing countries.Adolescent birth rates are highest where childmarriage is most prevalent, and child marriagesare generally more frequent where poverty isextreme. The prevalence of child marriagetSixteen-year-oldUsha Yadab, classleader for ChooseYour Future, aUNFPA-supportedprogramme in Nepalthat teaches girlsabout health issuesand encourages thedevelopment of basiclife skills.©William Ryan/UNFPATHE STATE OF WORLD POPULATION 20139

“All of a sudden the worldbecame a lonely place. I feltexcluded from my familyand the community. I nolonger fitted in as a youngperson, nor did I fit in asa woman.”Tarisai, 20, pregnant at 16, Zimbabwevaries substantially across countries, ranging from2 per cent in Algeria to 75 per cent in Niger,which has the world’s fifth-lowest per capitagross national income (World Bank, 2013).While child marriages are declining amonggirls under age 15, 50 million girls could stillbe at risk of being married before their 15thbirthday in this decade.Today, one in nine girls in developing countriesis forced into marriage before age 15. InBangladesh, Chad and Niger, more than one inthree girls is married before her 15th birthday. InEthiopia, one in six girls is married by age 15.Age differences within unions or marriagesalso influence adolescent pregnancy rates.ADOLESCENT BIRTH RATES (DATA FROM 79 COUNTRIES)By RegionBy Background CharacteristicsWest &Central AfricaEast &Southern AfricaLatin America& CaribbeanWorldArab States50507923109129DevelopingCountriesRuralUrbanNo EducationPrimarySecondaryor Higher565685103119154South AsiaEastern Europe &Central AsiaEast Asia& Pacific0 50 100 150203149PoorestSecondMiddleFourthRichest1181099577420 50 100 150 200Source: UNFPA, 2013.10 CHAPTER 1: A GLOBAL CHALLENGE

A UNFPA review of four countries found thatthe greater the age difference, the greater thechances are that the girl will become pregnantbefore age 18 (United Nations, 2011a).In countries where women tend to marry atyoung ages, the differences between the singulatemean age at marriage, or SMAM, betweenmales and females are generally large. Thethree countries with the lowest female SMAMsas of 2008 were Niger (17.6 years), Mali (17.8years) and Chad (18.3 years). All had age differencesbetween male and female SMAMs ofat least six years. SMAM is the average lengthof single life among persons between ages15 and 49 (United Nations, 2011a).“I was given to my husbandwhen I was little and I don’teven remember when I wasgiven because I was so little.It’s my husband who broughtme up.”Kanas, 18, EthiopiaWOMEN BETWEEN THE AGES OF 20 AND 24 REPORTING A BIRTH BEFOREAGE 18 AND BEFORE AGE 15, 2010 AND PROJECTIONS THROUGH 2030South Asia Sub-Saharan Africa Latin America and the CaribbeanBefore Age 18 Before Age 15254Millions20151017.410.117.9 18.1 18.2 18.414.712.916.411.4Millions322.91.83.0 3.0 3.0 3.03.02.72.42.154.5 4.6 4.7 4.7 4.610.5 0.5 0.5 0.5 0.5002010 2015 2020 2025 2030 2010 2015 2020 2025 2030Source: www.devinfo.org/mdg5bTHE STATE OF WORLD POPULATION 201311

PER CENT OF ADOLESCENT GIRLS IN MARRIAGESAND ADOLESCENT BIRTH RATESGirls, ages 15–19Developing RegionsCurrently married (%)Adolescent birth rateArab States 12 50Asia and Pacific 15 80East Asia and Pacific 5 50South Asia 25 88Eastern Europe and Central Asia 9 31Latin America and Caribbean 12 84Sub-Saharan Africa 24 120East and Southern Africa 19 112West and Central Africa 28 129Developing countries 16 85Source: www.devinfo.org/mdg5bPER CENT OF WOMEN REPORTING A FIRST BIRTH BEFORE AGE 18,BY AGE DIFFERENCE BETWEEN PARTNERSAge differences between female and male partners Niger Burkina Faso Bolivia IndiaFemale is older than male partner or up to 4 years younger 39.9 21.5 29.7 21.6Female is between 5 and 9 years younger than male partner 60.1 34.4 41.5 32.3Female is at least 10 years younger than male partner 59.0 38.5 45.8 39.1Total 56.8 33.4 34.7 28.5Source: United Nations, 2011a.12 CHAPTER 1: A GLOBAL CHALLENGE

Developed countries facechallenges tooAdolescent pregnancy occurs in both developedand developing countries. The levelsdiffer greatly, although the determinantsare similar.Of the annual 13.1 million births to girlsages 15 to 19 worldwide, 680,000 occur indeveloped countries (United Nations, 2013).Among developed countries, the UnitedStates has the highest adolescent birth rate.According to the United States Centers forDisease Control and Prevention, 329,772births were recorded among adolescentsbetween 15 and 19 in 2011.Among member States of the Organisationfor Economic Co-operation andDevelopment, which includes a number ofmiddle-income countries, Mexico has thehighest birth rate (64.2 per 1,000 births)among adolescents between 15 and 19 whileSwitzerland ranks the lowest, with 4.3. Allbut one OECD member, Malta, saw adecrease in adolescent pregnancy ratesbetween 1980 and 2008.ConclusionMost adolescent pregnancies occur in developingcountries.Evidence from 54 developing countries suggeststhat adolescent pregnancies are occurringwith less frequency, mainly among girls under15, but the decrease in recent years has beenslow. In some regions, the total number ofgirls giving birth is projected to rise. In sub-Saharan Africa, for example, if current trendscontinue, the number of girls under 15 whogive birth is expected to rise from 2 million ayear today to about 3 million a year in 2030.ADOLESCENT FERTILITY RATES IN OECDCOUNTRIES, 1980 AND 2008MexicoChileBulgariaTurkeyUnited StatesLatviaUnited KingdomEstoniaNew ZealandSlovak RepublicHungaryLithuaniaMaltaIrelandPolandPortugalAustraliaIcelandIsraelSpainCanadaGreeceFranceCzech RepublicAustriaGermanyNorwayLuxembourgFinlandBelgiumCyprusDenmarkSwedenRepublic of KoreaNetherlandsSloveniaItalyJapanSwitzerland2008 19800 10 20 30 40 50 60 70 80Source: http://www.oecd.org/social/soc/oecdfamilydatabase.htmTHE STATE OF WORLD POPULATION 201313

ADOLESCENTS AND CHILDREN: DEFINITIONSAND TRENDSAlthough the United Nations defines “adolescent” as anyone betweenthe ages of 10 and 19, most of the internationally comparable statisticsand estimates that are available on adolescent pregnancies or birthscover only part of the cohort: ages 15 to 19. Far less information is availablefor the segment of the adolescent population between the ages of10 and 14, yet it is this younger group whose needs and vulnerabilitiesmay be the greatest.According to the Convention on the Rights of the Child, anyone underthe age of 18 is considered a “child.” This report focuses on pregnanciesand births among children but must often rely on data on pregnanciesand births for the larger cohort of adolescents. Data on children (youngerthan 18) who become pregnant are more limited, covering a little morethan one third of the world’s countries.LARGE AND GROWING ADOLESCENTPOPULATIONSIn 2010, the worldwide number of adolescents was estimated to be1.2 billion, the largest adolescent cohort in human history. Adolescentsmake up about 18 per cent of the world’s population. Eighty-eightper cent of all adolescents live in developing countries. About half(49 per cent) of adolescent girls live in just six countries: China, India,Indonesia, Nigeria, Pakistan and the United States.If current population growth trends continue, by 2030 almost onein four adolescent girls will live in sub-Saharan Africa where the totalnumber of adolescent mothers under 18 is projected to rise from10.1 million in 2010 to 16.4 million in 2030.In developing and developed countries,adolescent pregnancies are more likely to occuramong girls from lower-income households,those with lower levels of education and thoseliving in rural areas.Retrospective data on pregnancies are availablefor adolescent girls ages 10 to 14 as wellas those 15 to 19, but much more is knownabout the latter group because householdsurveys reach them directly.Data about pregnancies or births outside ofmarriage are especially scarce. But these dataare crucial to understanding the determinantsof pregnancies among this group, their challengesand vulnerabilities, the impact on theirlives, and on actions that governments, communitiesand families might take to help themprevent pregnancies or support those who havealready become pregnant or given birth.The life trajectories of each pregnant girldepends, however, not only on how youngshe is, but also where she lives, how empoweredshe is through rights and opportunitiesand how much access she has to health care,schooling and economic resources. The impactof a pregnancy on a married 14-year-old girl ina rural area, for example, is very different fromthat of an 18-year-old who is single, lives ina city or has access to family support andfinancial resources.More in-depth data and contextual informationon patterns, trends and the circumstancesof pregnancy among girls under 18 (andespecially the cohort of adolescents ages 10 to14) would help lay the groundwork for thetargeting of interventions, the formulationof policies and for a deeper understanding ofcauses and consequences, which are complex,multidimensional and extend far beyond the14 CHAPTER 1: A GLOBAL CHALLENGE

ESTIMATING ADOLESCENT PREGNANCY AND BIRTH RATESPrecise data on adolescent pregnancies are scarce. Vital registrationsystems collect information on births, not pregnancies.Unlike births, pregnancies are generally not reported andaggregated upward to national statistical institutions. Somepregnancies fail very early, before a woman or girl is aware sheis pregnant. Pregnancies may go undocumented in developingcountries because adolescents often do not—or cannot—accessantenatal care and thus do not come to the attention of healthcare providers. Pregnancies that end in miscarriage or abortion(often performed illegally and clandestinely) are also absentfrom most national databases.Most countries, therefore, rely on information about births,as a proxy for data on the prevalence of adolescent pregnancy.Estimates of birth rates are invariably lower than pregnancyrates. For example, according to a 2008 study, the pregnancyrate among adolescents age 15 to age 19 in the United Stateswas 68/1,000 while the birth rate was 40/1,000 (Kost andHenshaw, 2013). Pregnancy rates include miscarriages, abortions,stillbirths, and pregnancies carried to term, while the birthrate includes only live births.The proxy data that demographers rely on is gathered in two ways:• Through a retrospective approach, which asks womenbetween the ages of 20 and 24 if they had had a childat an earlier age, usually before age 18. Data used in theretrospective approach and cited in this report come fromdemographic and health surveys, or DHS, and multiple indicatorcluster surveys, or MICS, which have been carried outin 81 developing countries.• By calculating the adolescent birth rate:AdolescentBirth Rate=Total number of live birthsamong girls between theages of 15 and 19DIVIDED BYx 1,000Total number of adolescents betweenthe ages of 15 and 19The retrospective approach yields insights into births togirls before the age of 18, but can also provide insights intobirths to girls younger than 15. The adolescent birth rate,however, includes only live births to girls between the agesof 15 and 19.sphere of a pregnant girl. But just as important—andjust as limited—are data andinsights about the men and boys who father thechildren of adolescent girls.Adolescent pregnancies are not the soleconcern of developing countries. Hundredsof thousands of them are reported each yearin high- and middle-income countries, too.But some of the patterns found in developingcountries are also relevant in developed ones:girls who live in low-income households, arerural, have less education or have dropped outof school, or who are ethnic minorities, immigrants,or marginalized sub-populations aremore likely to become pregnant. In developingcountries, most adolescent pregnancies occurwithin marriages, while in developed countries,they increasingly occur outside of marriage.THE STATE OF WORLD POPULATION 201315

16 CHAPTER 2: THE IMPACT ON GIRLS' HEALTH, EDUCATION AND PRODUCTIVITY

2The impact on girls’health, educationand productivityWhen a girl becomes pregnant orhas a child, her health, education,earning potential and her entire futuremay be in jeopardy, trapping her ina lifetime of poverty, exclusion andpowerlessness.sA 13-year-old fistula patient at a VVF centre in Nigeria.© UNFPA/Akintunde AkinleyeTHE STATE OF WORLD POPULATION 201317

When a girl becomes pregnant or has a child,her health, education, earning potential and herentire future may be in jeopardy, trapping her ina lifetime of poverty, exclusion and powerlessness.The impact on a young mother is often passeddown to her child, who starts life at a disadvantage,perpetuating an intergenerational cycle ofmarginalization, exclusion and poverty.And the costs of early pregnancy and childbirthextend beyond the girl’s immediate sphere,taking a toll on her family, the community, theeconomy and the development and growth ofher nation.While pregnancy can affect a girl’s life innumerous and profound ways, most quantitativeresearch has focused on the effects on health,education and economic productivity:• The health impact includes risks of maternaldeath, illness and disability, including obstetricfistula, complications of unsafe abortion, sexuallytransmitted infections, including HIV, andhealth risks to infants.• The educational impact includes the interruptionor termination of formal education andthe accompanying lost opportunities to realizeone’s full potential.• The economic impact is closely linked to theeducational impact and includes the exclusionfrom paid employment or livelihoods, additionalcosts to the health sector and the lossof human capital.Health impactAbout 70,000 adolescents in developing countriesdie annually of causes related to pregnancyand childbirth (UNICEF, 2008). Complicationsof pregnancy and childbirth are a leading causeof death for older adolescent females (WorldHealth Organization, 2012).Adolescents who become pregnant tend to befrom lower-income households and be nutritionallydepleted. Although rates vary by region,overall, approximately one in two girls in developingcountries has nutritional anaemia, whichHortência, 25,developed anobstetric fistulaat 17, during acomplicated delivery.© UNFPA/Pedro Sá daBandeirat18 CHAPTER 2: THE IMPACT ON GIRLS' HEALTH, EDUCATION AND PRODUCTIVITY

can increase the risk of miscarriage, stillbirth,premature birth and maternal death (PathfinderInternational, 1998; Balarajan et al., 2011;Ransom and Elder, 2003).A number of factors directly contribute tomaternal death, illness and disability amongadolescents. These include the girl’s age, herphysical immaturity, complications from unsafeabortion and lack of access to routine and emergencyobstetric care from skilled providers. Othercontributing factors include poverty, malnutrition,lack of education, child marriage and thelow status of girls and women (World HealthOrganization, 2012b).Health problems are more likely if a girlbecomes pregnant within two years of menarcheor when her pelvis and birth canal are still growing(World Health Organization, 2004).Obstetric fistulaPhysically immature first-time mothers are particularlyvulnerable to prolonged, obstructed labour,which may result in obstetric fistula, especiallyif an emergency Caesarean section is unavailableor inaccessible. Although fistula can occurto women at any reproductive age, studies inEthiopia, Malawi, Niger and Nigeria show thatabout one in three women living with obstetricfistula reported developing it as an adolescent(Muleta et al., 2010; Tahzib, 1983; Hilton andWard, 1998; Kelly and Kwast, 1993; Ibrahim etal., 2000; Rijken and Chilopora, 2007).Obstetric fistula is a debilitating condition thatrenders a woman incontinent and, in most cases,results in a stillbirth or the death of the babywithin the first week of life.Between 2 million and 3.5 million women andgirls in developing countries are thought to beliving with the condition. In many instances, aOBSTETRIC FISTULA: ANOTHER BLIGHT ON THECHILD BRIDEIt was personal experience that turned Gul Bano and her cleric husband,Ahmed Khan, into ambassadors against early marriage and itsworst corollary—obstetric fistula.As is the custom in the remote mountain village of Kohadast in theKhuzdar district of Balochistan province in Pakistan, Bano was marriedoff as soon as she reached adolescence, at 15, and was pregnant thefollowing year.There being no healthcare facility near Kohadast, Bano did notreceive antenatal care and no one thought there would be complications.But, events were to prove different. After an extended labourlasting three days, Bano delivered a dead baby. “I never saw the colourof my son’s eyes or his hair. I never held him once to my bosom,” recallsBano, now 20.Her troubles had only begun. A week later, Bano realized she wasalways wet with urine and reeking of fecal matter. “I was passing urineand stools together.”Unable to handle the prolonged labour, Bano’s young body haddeveloped an obstetric fistula caused by the baby’s head pressing hardagainst the lining of the birth canal and tearing into the walls of herrectum and the bladder.Obstetric fistula is now generally acknowledged to be anotherburden on the girl child, deprived of basic education and forced intomarriage—for which she is neither physically nor mentally prepared.Khan stood by his young wife and sought medical help. He discovereda hospital in Karachi specializing in treating fistula and other conditionsrelated to reproductive health. Koohi Goth Women’s Hospital, wherefistula victims are treated free, was started by Dr. Shershah Syed, oneof Pakistan’s first gynaecologists to train in repairing the painful andsocially embarrassing condition.“It’s been almost three years and she [Bano] has gone through sixoperations,” says Dr. Sajjad Ahmed, who worked at Koohi Goth as managerof UNFPA’s fistula project from June 2006 to February 2010.Today Bano and Khan have become vocal advocates of the campaignagainst fistula. They travel across Pakistan, spreading the word abouthow to prevent the injury and what to do about it. “Khan is a cleric andyet he does not conform to the stereotype of a religious person,” saidSyed. “He tells parents that fistula can be avoided if they stop marryingoff their daughters at a very early age.” Bano shares her story andtells married women about the importance of birth spacing, antenatalcheckups and timely access to emergency obstetric care.—Zofeen Ebrahim, Inter Press ServiceTHE STATE OF WORLD POPULATION 201319

Developing regionswoman—or girl—living with obstetric fistula isostracized from her home and her communityand is at risk of poverty and marginalization.The persistence of obstetric fistula is a reflectionof chronic health inequities and health-caresystem constraints, as well as wider challenges,such as gender and socio-economic inequality,child marriage and early child bearing, all ofwhich can undermine the lives of women andgirls and interfere with their enjoyment of theirbasic human rights.In most cases, fistula can be repaired throughsurgery, but few actually undergo the procedure,mainly because services are not widely availableor accessible, especially in poor countries lackingquality medical services and infrastructure,or because the surgery, which can cost as little as$400, is prohibitively expensive for most womenand girls in developing countries. Of the 50,000to 100,000 new cases per year, only about 14,000undergo surgery, so the total number of womenliving with the condition rises every year.While a skilled birth attendant and emergencyCaesarean section can help an adolescent avertobstetric fistula, the best way to protect a girlESTIMATES OF UNSAFE ABORTIONS AND UNSAFEABORTION RATES FOR GIRLS, AGES 15 TO 19, 2008Annual numberof unsafeabortions togirls 15–19Unsafe abortionrate (per 1,000girls 15–19)Developing countries 3,200,000 16Africa 1,400,000 26Asia excluding East Asia 1,100,000 9Latin America and the Caribbean 670,000 25Source: Shah and Ahman, 2012.from the condition is to help her delay pregnancyuntil she is older and her body matures. Oftenthis means protecting her from early marriage.Unsafe abortionUnsafe abortions account for almost half ofall abortions (Sedgh et al., 2012; Shah andAhman, 2012). According to the World HealthOrganization, an unsafe abortion is “a procedurefor terminating unwanted pregnancy eitherby persons lacking the necessary skills or in anenvironment lacking minimal medical standardsor both” (World Health Organization, 2012c).Almost all (98 per cent) of the unsafe abortionstake place in developing countries, where abortionis often illegal. Even where abortion is legal,adolescents may find it difficult to access services.Data on abortions, safe or unsafe, for girlsbetween the ages of 10 and 14 in developingcountries are scarce but rough estimates havebeen made for the 15 to 19 age group, whichaccounts for about 3.2 million unsafe abortionsin developing countries each year (Shah andAhman, 2012).This study covers Africa, Asia (excludingEast Asia) and Latin America and the Caribbean(Shah and Ahman, 2012). Rates of unsafe abortionsper 1,000 are similar for sub-SaharanAfrica and Latin America and the Caribbean:26 versus 25, respectively; however, the totalnumber of unsafe abortions in sub-SaharanAfrica is more than double that of Latin Americaand the Caribbean, because of the former’s largerpopulation size. Sub-Saharan Africa accountsfor 44 per cent of all unsafe abortions amongadolescents between the ages of 15 and 19 in thedeveloping world (excluding East Asia), whileLatin America and the Caribbean account for23 per cent.20 CHAPTER 2: THE IMPACT ON GIRLS' HEALTH, EDUCATION AND PRODUCTIVITY

In sub-Saharan Africa, an estimated 36,000women and girls die each year from unsafe abortion,and millions more suffer long-term illnessor disability (UN Radio, 2010).Compared to adults who have unsafe abortions,adolescents are more likely to experiencecomplications such as haemorrhage, septicaemia,internal organ damage, tetanus, sterility and evendeath (International Sexual and ReproductiveRights Coalition, 2002). Some explanations forworse health outcomes for adolescents are thatthey are more likely to delay seeking and havingan abortion, resort to unskilled persons toperform it, use dangerous methods and delayseeking care when complications arise.Adolescents make up a large proportion ofpatients hospitalized for complications of unsafeabortions. In some developing countries, hospitalrecords suggest that between 38 per cent and68 per cent of those treated for complicationsof abortion are adolescents (International Sexualand Reproductive Rights Coalition, 2002).“I have accepted myHIV status because whensomething has happened,it has happened.”Neo, 15, BotswanaPERCENTAGE OF GIRLS, AGES 15 TO 19, WHO EVERHAD SEXUAL INTERCOURSE AND REPORTED ANSTI OR SYMPTOMS IN THE PAST 12 MONTHS(COUNTRIES WITH 20 PER CENT OR MORE)GuineaGhanaCongo, Republic ofNicaraguaCôte d’IvoireDominican RepublicUgandaSource: Kothari et al., 2012.Sexually transmitted infectionsWorldwide each year, there are 340 millionnew sexually transmitted infections, or STIs.Youth between the ages of 15 and 24 have thehighest rates of STIs. Although STIs are not aconsequence of adolescent pregnancy, they area consequence of sexual behaviour—non-use orincorrect use of condoms—that may lead to adolescentpregnancy. If untreated, STIs can causeinfertility, pelvic inflammatory disease, ectopicpregnancy, cancer, and debilitating pelvic painfor women and girls. They may also lead to lowbirth-weight babies, premature deliveries andlife-long physical and neurological conditions forchildren born to mothers living with STIs.In seven of 35 countries covered in a recentreview of demographic and health surveys, at leastone in five female adolescents between the ages of15 and 19 who ever had sexual intercourse indicatedthat they had an STI or symptoms of onein the past 12 months (Kothari et al., 2012).35 per cent29 per cent29 per cent26 per cent25 per cent21 per cent21 per centTHE STATE OF WORLD POPULATION 201321

Demographic and health surveys show that,in general, the percentage of females betweenthe ages of 15 and 19 who ever had sex andwho reported STIs or symptoms in the past 12months is higher than that reported by malesHIV PREVALENCE AMONG ADOLESCENTS AGES15 TO 19, BY SEX, IN SELECTED SUB-SAHARANAFRICAN COUNTRIES, 2001–2007MaleFemaleSenegal 2005Ghana 2003Mali 2006Rwanda 2005Ethiopia 2005Burkina Faso 2003Guinea 2005Liberia 2007United Republic ofTanzania 2007–08Cameroon 2004Uganda 2004–05Kenya 2003Zambia 2007–08Zimbabwe 2005–06Lesotho 2004Swaziland 2006–07Source: World Health Organization, 2009a.0246Adolescents aged 15–19 years living with HIV (%)81012who ever had sex in that same age group. InCôte d’Ivoire, for example, 25 per cent of femalesbetween 15 and 19 and who had ever had sexreported an STI or symptoms of one comparedto 14 per cent of males in the same age group.Other studies of STIs and adolescents alsoshow that girls are more frequently affected thanboys (Dehne and Riedner, 2005). STIs are commonamong sexually assaulted adolescents andabused children.Adolescent girls are also more likely than boysto be living with HIV. Young women are morevulnerable to HIV infection because of biologicalfactors, having older sex partners, lack of accessto information and services and social norms andvalues that undermine their ability to protectthemselves. Their vulnerability may increase duringhumanitarian crises and emergencies wheneconomic hardship can lead to increased risk ofexploitation, such as trafficking, and increasedreproductive health risks related to the exchangeof sex for money and other necessities (WorldHealth Organization, 2009a).Health risks to infants and childrenThe health risks to the infants and children ofadolescent mothers have been well documented.Stillbirths and newborn deaths are 50 per centhigher among infants of adolescent mothersthan among infants of mothers between theages of 20 and 29 (World Health Organization,2012a). About 1 million children born to adolescentmothers do not make it to their firstbirthday. Infants who survive are more likely tobe of low birth weight and be premature thanthose born to women in their 20s. In addition,without a mother’s access to treatment, thereis a higher risk of mother-to-child transmissionof HIV.22 CHAPTER 2: THE IMPACT ON GIRLS' HEALTH, EDUCATION AND PRODUCTIVITY

ADOLESCENTS, AGES 10 TO 19, LIVING WITH HIV, 2009Female Male TotalRegionEstimate(low estimate -high estimate)Estimate(low estimate -high estimate)Estimate(low estimate -high estimate)East and Southern Africa 760,000 (670,000 - 910,000) 430,000 (370,000 - 510,000) 1,200,000 (1,000,000 - 1,400,000)Western and Central Africa 330,000 (270,000 - 440,000) 190,000 (140,000 - 240,000) 520,000 (390,000 - 680,000)Middle East and North Africa 22,000 (17,000 - 30,000) 9,700 (7,800 - 12,000) 32,000 (25,000 - 40,000)South Asia 50,000 (44,000 - 57,000) 54,000 (47,000 - 66,000) 100,000 (90,000 - 130,000)East Asia and the Pacific 27,000 (15,000 - 30,000) 23,000 (14,000 - 34,000) 50,000 (29,000 - 73,000)Latin America and the Caribbean 44,000 (34,000 - 55,000) 44,000 (31,000 - 82,000) 88,000 (62,000 - 160,000)CEE/CIS 9,000 (7,700 - 10,000) 3,900 (3,400 - 4,500) 13,000 (11,000 - 15,000)World 1,300,000 (1,100,000 - 1,500,000) 780,000 (670,000 - 900,000) 2,000,000 (1,800,000 - 2,400,000)Source: UNICEF, 2011.Health risks to girls giving birth beforeage 15Research indicates that very young adolescents inlow- and middle-income countries have doublethe risk for maternal death and obstetric fistulathan older women (including older teens),especially in sub-Saharan Africa and South Asia(Blum et al., 2013).As young people transition from the early tolate adolescent years, sexual and reproductivebehaviours contribute to diverging mortalityand morbidity patterns by gender, with youngeradolescent girls facing an increased risk ofsexual coercion, sexually transmitted infections,including HIV, as well as the gender-specific consequencesof unintended pregnancies andpsychological trauma (Blum et al., 2013).Neal et al. (2012) also show that girls whoare 15 or younger are at markedly higher oddsfor conditions such as eclampsia, anaemia, postpartumhaemorrhage and puerperal endometritisthan older adolescents. Evidence also suggeststhat the adverse neonatal outcomes associatedwith adolescent pregnancies are greater foryounger adolescents.Many countries with high levels of early adolescentmotherhood are also those with very highmaternal mortality ratios (Neal et al., 2012).A study by the World Health Organizationshows that girls who become pregnant at 14 oryounger are more likely to experience prematuredelivery, low infant birth weight, perinatalmortality and health problems in newborns(World Health Organization, 2011). The risksTHE STATE OF WORLD POPULATION 201323

s Marielle, 25,gave birth whenshe was 13.© UNFPA/Berge, Borghildto very young mothers and their newborns areexacerbated for girls who are malnourished. Apregnancy can compromise a mother’s statuseven further and disrupt normal growthpatterns, while their babies are more likelyto be underweight and die.Girls under 15 are not physically ready forsexual intercourse or childbearing and lack thecognitive capacities and power to make safe,informed or voluntary decisions (Dixon-Mueller,2008). Still, in more than 30 countries, 10 percent of adolescents have had sexual intercourse byage 15, with rates as high as 26 per cent in Niger.Research shows that in some countries, many girls’first sexual encounters are non-consensual, andthe incidence of forced sex is higher among veryyoung adolescents (Erulkar, 2013).Psychosocial impactMillions of girls are forced into marriage everyyear, and an estimated 90 per cent of adolescentswho give birth are married. This means millionsmove from being a child to being a marriedmother with adult responsibilities with little timein between. One day, they are under a parent’sauthority. The next, they are under a partner’s orhusband’s authority, perpetuating and reinforcinga cycle of gender inequality, dependenceand powerlessness.In the transition from childhood to forcedmarriage and motherhood, a girl may experiencestress or depression because she is notpsychologically prepared for marriage, sex orpregnancy, and especially when sex is coerced ornon-consensual. Depending on her home and24 CHAPTER 2: THE IMPACT ON GIRLS' HEALTH, EDUCATION AND PRODUCTIVITY

community environments, she may feel stigmatizedby an early pregnancy (especially if it isoutside of marriage) and seek an abortion, evenin settings where abortions are illegal and unsafe,often accepting the risk of a disastrous healthoutcome.Impact on girls’ educationGirls who remain in school longer are less likelyto become pregnant. Education prepares girls forjobs and livelihoods, raises their self-esteem andtheir status in their households and communities,and gives them more say in decisions thataffect their lives. Education also reduces the likelihoodof child marriage and delays childbearing,leading to healthier eventual birth outcomes.A new survey of countries to assess theirprogress in implementing the Programme ofAction of the 1994 International Conferenceon Population and Development confirms thathigher literacy rates among women between ages15 and 19 are associated with significantly loweradolescent birth rates (UNFPA, 2013a).A recent analysis of 39 countries foundthat—with the exceptions of Benin and Mali—unmarried girls (ages 15 to 17) who attendschool are considerably less likely to have hadpremarital sex, as compared to their out-ofschoolpeers (Biddlecom et al., 2008; Lloyd,2010). These findings underscore the protectiveeffects that an education may confer against adolescentpregnancy and its adverse outcomes.The social and economic benefits to a girl whostays in school are great, but so are the costs toa girl who leaves school early—or is forced outbecause of a pregnancy.The causal relationship, however, betweenadolescent pregnancies and early school-leavingcan be difficult to disentangle (UNFPA, 2012a).Girls who become pregnant may have alreadydropped out of school before the pregnancy orwere never in school to begin with. One study offrancophone African countries showed that onlybetween 5 per cent and 10 per cent of girls leaveschool—or are expelled—because of pregnancy(Lloyd and Mensch, 2008). Instead, the studyfound that “union formation”—first marriage orcohabitation—is more likely to be the reason.Still, for many adolescents who become mothers,their formal education comes to a permanenthalt, either because of individual circumstances,MARRIED, AND BACK IN SCHOOLFilesia is a free-spirited, bubbly 15-year-old, chatting and gigglingamong her friends. She is enjoying her life as a Standard 8 primaryschool student in Malawi and says she cannot wait to get to secondaryschool within the year.But Filesia is not quite like all the other students in her class. Herparents forced her to drop out of school and get married after shebecame pregnant at the age of 13.“My boyfriend, who was 18 at the time, enticed me to have sex withhim. He told me that I was too young to get pregnant and I believedhim,” said Filesia. She became pregnant after having sex twice. “I knewnothing about contraceptives so we did not use any protection.”“My parents said they could no longer keep me in their houseafter they discovered I was pregnant. They handed me over to myboyfriend’s family and we started living together after conducting atraditional wedding,” Filesia said.Filesia stayed married for two years after giving birth to a baby boy,but she has now returned to school, rescued from life as an underagebride by the Community Victim Support Unit, supported by the UnitedNations Joint Programme on Adolescent Girls led by UNFPA.“I now know about contraceptives through the youth club I joined.I do not intend to indulge in sex again until I finish school because Ilived under a lot of poverty when I got married,” said Filesia. Filesiasays she wants to be a policewoman. “I want to be rescuing other girlswho are forced into early marriages.”THE STATE OF WORLD POPULATION 201325

such as child marriage or family or communitypressures, or because schools forbid pregnantgirls from attending or forbid their return oncethey have had a baby (Panday et al., 2009).And even in countries where laws allow girlsto return, a minority of girls actually resumeseducation. In South Africa, for example, theConstitution and the Schools Act of 1996 statethat girls who become pregnant should not bedenied access to education, but one review foundthat only about one in three adolescents who leftschool because of a pregnancy ever returned. Astudy in Chile found that being a mother reducesa girl’s likelihood of attending and completinghigh school by between 24 per cent and 37per cent (Kruger et al., 2009).The problem of truncated education foradolescent mothers is not unique to developingcountries. In the United States, for example,329,772 children were born to adolescentsbetween the ages of 15 and 19 in 2011. Only“I was happy and sad at the sametime. Happy because I gave birthto a precious baby boy… But myparents have to support me and mybaby now… I dropped out of school,and since then I have to find a job tosupport my child… I’m a single mom.I have to do everything for my baby.”Thoko, South Africa (no age given)about half of the girls who become pregnant asteenagers manage to complete their high schooleducation by age 22. In contrast, nine tenths ofgirls who do not become pregnant as teenagersobtain their high school diploma by age 22(Perper et al., 2010).The longer girls are out of school, the lesslikely they are to return.For girls to be able to return to school,supportive policies are necessary but often insufficient:new mothers are also likely to needfinancial assistance, child care and one-on-onecounselling to help them deal with the challenges,including stigma, of adolescent motherhood.Economic impactWhen a girl has the power to delay a pregnancy,she may also be empowered socially to stay inschool, and then economically to secure a morelucrative job or pursue other income-earningopportunities, according to a World Bank study(Chaaban and Cunningham, 2012). Investmentsthat empower girls are beneficial to the economy;conversely, the costs of not investing in them arehigh. The lifetime opportunity cost related toadolescent pregnancy—measured by the mother’sforegone annual income over her lifetime—ranges from 1 per cent of annual GDP in Chinato 30 per cent of annual GDP in Uganda. Theopportunity cost is a measure of “what couldhave been” if only the additional investmenthad been made in girls.The World Bank study illustrates the opportunitycosts associated with adolescent pregnancyand dropping out of school. If all 1.6 millionadolescent girls in Kenya, for example, completedsecondary school, and if the 220,098adolescent mothers there were employed insteadof having become pregnant, the cumulative26 CHAPTER 2: THE IMPACT ON GIRLS' HEALTH, EDUCATION AND PRODUCTIVITY

THE HUMAN RIGHTS DIMENSIONRights violations are often an underlying cause and frequentlya consequence of adolescent pregnancy.Girls who become pregnant are often not able to enjoy orexercise their rights as guaranteed in international treatiessuch as the Convention on the Rights of the Child. Similarly,when a girl is unable to enjoy basic rights such as her rightto an education, she becomes more vulnerable to becomingpregnant before adulthood.If an adolescent becomes pregnant as a result of forced orcoerced sex, her rights are further undermined. If that samegirl is unable to attend school because she is pregnant orresponsible for taking care of her children, her rights are againdenied. If she cannot attend school, her income-earningpotential in life is blunted, and her chances of spending therest of her life in poverty increase dramatically.Last year, the Office of the High Commissioner for HumanRights issued a groundbreaking report, which framed theUnited Nations Human Rights Council’s numerous resolutionson maternal mortality and morbidity as human rightsviolations and identified some of the underlying causes ofadolescent pregnancy:The first step is to analyse not only why adolescent girls sufferfrom high rates of maternal morbidity and death, but also why theyare becoming pregnant. A human rights-based approach definesthe problem and addresses it in terms of both the immediate andunderlying causes of maternal mortality and morbidity, given thatthey determine the possibilities for resolving concrete problems atthe local level. Amidst many other factors, adolescent pregnancymight be due to a lack of comprehensive sexuality education; gendernorms that reinforce early pregnancy; early marriage; high levelsof sexual violence and/or transactional sex; a lack of youth-friendlyhealth services; lack of affordable and accessible contraception; or acombination of the above. (Office of the High Commissioner forHuman Rights, 2012, paragraph 59).Intersecting forms of inequality compound the situation.Adolescent girls living in poverty or in rural areas, or who arealso disabled, or indigenous, face additional barriers to accessingsexual and reproductive health information and services,and in some cases, are more likely to be subject to sexualviolence.Addressing adolescent pregnancy through human rightsprotections builds on an international, normative frameworkthat requires governments to take steps that will make itpossible for girls to enjoy their rights to an education, tohealth and to live free from violence. Children have the samehuman rights as adults but they are also granted special protectionsto address the inequities that come with their age.Upholding rights, therefore, can help eliminate many ofthe conditions that contribute to adolescent pregnancy andhelp mitigate many of the consequences to the girl, herhousehold and her community. Addressing these challengesthrough human rights protections is key to ending a viciouscycle of rights infringements, poverty, inequality, exclusionand adolescent pregnancy.At the International Conference on Population andDevelopment (ICPD) in 1994, 179 governments acknowledgedthe connections among early marriage, adolescentchildbearing and elevated rates of adolescent maternal mortality.The ICPD Programme of Action highlighted the criticalrole that education can play in preventing these harms (ICPDProgramme of Action, Principle 4 and paragraph 7.41).Governments agreed to protect and promote adolescents’rights to reproductive health education and information andto guarantee universal access to comprehensive and factualinformation on reproductive health.Since the ICPD, United Nations treaty-monitoring bodies,which interpret and monitor governments’ compliance withhuman rights treaties, have recognized the need to empoweradolescents to make informed decisions about their lives andhave asserted that adolescents have the same human rights,including reproductive rights, as adults have. The Convention onthe Rights of the Child, the most ratified human rights treatyin the world, expressly recognizes children as rights holders.However, lacking the legal capacity to act on their ownbehalf, in many cases children as rights-holders are not giventhe ability or choice to claim their rights. This lack of autonomyin decision-making, combined with their low socialand economic status and their physical vulnerability, makeit more difficult for them to enjoy and exercise those rights.28 CHAPTER 2: THE IMPACT ON GIRLS' HEALTH, EDUCATION AND PRODUCTIVITY

One hundred seventy-nine governmentsagreed in 1994 at the International Conferenceon Population and Development (ICPD) on theneed to “promote the rights of adolescents toreproductive health education, information andcare and greatly reduce the number of adolescentpregnancies.” (ICPD Programme of Action,paragraph 7.46).Yet many of the actions—before and since1994—to achieve the objectives of reducing thenumber of adolescent pregnancies have beennarrowly focused, targeting girls as the problemand aiming to change their behaviour as thesolution.Such actions generally fail to reduce adolescentpregnancies because they neglect the underlyingeconomic, social, legal and other circumstances,structures, systems, norms and rights violationsthat drive adolescent pregnancy around theworld. Another shortcoming of these approachesis their failure to take into account the role ofmen and boys in perpetuating and preventingadolescent pregnancy.An “ecological” approach to adolescent pregnancyis one that takes into account the fullrange of complex drivers of adolescent pregnancyand the interplay of these forces. It can helpgovernments, policymakers and stakeholdersunderstand the challenges, and craft more effectiveinterventions that will not only reduce thenumber of pregnancies but will also take stepsthat can tear down the many barriers to girls’empowerment so that pregnancy is no longerthe likely outcome.One such ecological model sheds light onthe constellation of forces that conspire againstthe adolescent girl and increase the likelihoodthat she will become pregnant (Blum and JohnsHopkins, 2013). While these forces are numerousand multi-layered, they are all in one way oranother about a girl’s inability to enjoy or exerciserights and about the lack of power to shape herown future.Most of the determinants in this model operateat more than one level. For example, nationallevelpolicies may restrict adolescents’ access tosexual and reproductive health services, includingfamily planning, while the community or familymay oppose girls’ accessing comprehensive sexualityeducation or other information about howto prevent a pregnancy.This model shows that adolescent pregnanciesdo not occur in a vacuum but are the consequenceof an interlocking set of factors such aswidespread poverty, communities’ and families’acceptance of child marriage, and inadequateefforts to keep girls in school.In technical guidance on applying rights-basedapproaches to reduce maternal mortality in2012, the Office of the High Commissioner forHuman Rights called on States to address thediverse, multidimensional drivers of adolescentpregnancy by eliminating “immediate and underlyingcauses.” (Human Rights Council, 2012).Gender norms that reinforce early pregnancy,child marriage, sexual violence and other suchunderlying causes cited by the Office of the HighCommissioner for Human Rights also feature inthis ecological model.National-level determinantsNational laws and policies, the level of governmentcommitment to meeting obligations underhuman rights instruments and treaties, the extentof poverty or deprivation, and political stabilitycan all influence whether a girl becomes pregnant.These determinants are beyond anadolescent’s—or any individual’s—control,32 CHAPTER 3: PRESSURES FROM MANY DIRECTIONS

DETERMINANTS OF ADOLESCENT PREGNANCY: AN ECOLOGICAL MODEL• Laws limiting access to contraception• Unenforced laws against child marriage• Economic decline, poverty• Underinvestment in girls’ human capital• Political instability, humanitarian crises and disastersNATIONAL• Negative attitudes about girls’ autonomy• Negative attitudes about adolescent sexualityand access to contraception• Limited availability of youth-friendly services• Absence of antenatal and postnatal carefor young mothers• Climate of sexual coercion and violenceCOMMUNITYSCHOOL/PEERS• Obstacles to girls’ attending orstaying enrolled in school• Lack of information or no access toquality comprehensive sexuality education• Pressure from peers• Partners’ negative gender attitudes andrisk-taking behavioursFAMILYINDIVIDUAL• Negative expectations for daughters• Little value on education, especially for girls• Favourable attitudes to child marriage• Age of puberty and sexual debut• Socialization of girls to pursue motherhood as only option in life• Internalized gender-inequitable values• Lack of recognition of evolving capacitiesTHE STATE OF WORLD POPULATION 201333

t Prenatal care atTan Ux’il centrein Guatemala.© Mark Tuschman/Planned ParenthoodGlobalyet they can have a tremendous impact on howmuch power a girl has to shape her own futureand realize her potential.For example, if they are enforced, nationallaws that ban child marriage can help eliminateone of girls’ main vulnerabilities to pregnancy.At the national level, adolescents’ access tocontraception may be blocked because of lawsthat prohibit anyone under age 18 from accessingsexual and reproductive health services,including family planning, without parental orspousal consent, thereby preventing sexuallyactive girls and their partners from obtainingand using contraception. Many countriesalso ban emergency contraception or forbidadolescents’ access to it.In some countries, there is a disconnectbetween age of consent to sexual activityand the minimum age to access sexual andreproductive health services, including contraceptionand information. As a result, adolescentsmay be constrained by requirements for parentalconsent to access services or they may have torely on health providers to deem them capableor eligible for services. Health care providers maybe reluctant to grant access in fear of reprisalsfrom parents or guardians who may not wanttheir children to obtain contraception or othersexual and reproductive health services.The major national-level determinantof adolescent pregnancy is an overallunder-investment in girls’ human capitaldevelopment, especially education and health,including sexual and reproductive health. Lessthan two cents of every dollar spent on internationaldevelopment is directed specificallytoward adolescent girls (International PlannedParenthood Federation, n.d.).Adolescent pregnancies tend to occur morefrequently among indigenous populations orethnic minorities for a variety of reasons, includingdiscrimination and exclusion, lack of accessto sexual and reproductive health services, povertyor the practice of child marriage. In Serbia,for example, the adolescent birth rate amongthe Roma minority is 158, more than six timesthe national average of 23.9 and higher thanthe rate in many of the least developed countries(Statistical Office of the Republic of Serbiaand UNICEF, 2011). In Bulgaria, more than50 per cent of Roma adolescent girls give birthto a child before turning 18, and in Albania,the average age of Roma mothers at the birthof their first child is 16.9 years (UNDP, 2011;UNFPA, 2012c). The high adolescent birth ratesamong Roma populations are linked to limitedaccess to sexual and reproductive health services,including family planning, child marriage,34 CHAPTER 3: PRESSURES FROM MANY DIRECTIONS

social and economic exclusion from mainstreamsociety and pressures within their communities(Colombini et al., 2011).Poverty and economic stagnation are othernational-level forces that can deny adolescentsopportunities in life. With few prospects forjobs, livelihoods, self-sufficiency, a decent standardof living and all that comes with it, a girlbecomes more vulnerable to early marriage andpregnancy because she or her family may seethese as her only options or destiny. In addition,poor adolescents are less likely to completetheir schooling and consequently often have lessaccess to school-based comprehensive sexualityeducation or information about sexual andreproductive health and about preventing a pregnancy(World Health Organization, 2011).In many emergency, conflict and crisis settings,adolescent girls are often separated fromfamily and cut off from protective social structures.They are therefore at increased risk ofrape, sexual exploitation and abuse, furtherincreasing their vulnerability to pregnancy (Savethe Children and UNFPA, 2009). To providefor themselves or the needs of their families incrisis settings (as well as in conditions of extremepoverty), adolescent girls may feel compelled toengage in sex work, exacerbating vulnerabilitiesto violence, sexually transmitted infections andpregnancy. Meanwhile, because of service disruptions,damaged infrastructure, lack of securityor because providers may be overwhelmed bya surge in demand for services, access to sexualand reproductive health care, including familyplanning, may be limited. Similarly, schools,often the main provider of comprehensive sexualityeducation, may be shuttered, and othersources of accurate and complete informationabout how to prevent a pregnancy or a sexually“…I was in the first year of juniorhigh when it happened. One night,I went to fetch water…he took me…he raped me. I was scared, but Iwas still a kid of 15, I could not thinkor imagine that I was going to getpregnant. I knew it after.”Léocadie, 16, Burunditransmitted infection, including HIV, may bescarce or non-existent. In some crisis settings,parents may force their girls into marriage withthe aim of reducing economic hardship or withthe expectation that the arrangement will helpprotect their daughters from harm in environmentswhere sexual violence is common.Community-level determinantsEach community has its own norms, beliefs andattitudes that determine how much autonomyand mobility a girl has, how easily she is able toenjoy and exercise her rights, whether she is safefrom violence, whether she is forced into marriage,how likely she is to become pregnant, orwhether she can resume her education afterhaving had a child.Community-level forces are especially importantin determining whether there is a climateof sexual coercion, whether young people haveTHE STATE OF WORLD POPULATION 201335

a voice in the life of the community, whetheryouth-friendly sexual and reproductive healthservices and contraception are available andaccessible, and how well maternal health servicesare equipped and staffed to support a girl duringher pregnancy and childbirth and then help heravoid a second pregnancy.“I went to a hotel where I met myboyfriend. He told me ‘let’s have sexwithout a condom.’ I told him ‘no,with condom.’ He said ‘if you getpregnant, I will take care of the child,’and that is how I got this girl.”Whitney, 16, SurinameAccess to contraception and sexual andreproductive health servicesComplications from pregnancy and childbirth area leading cause of death for female adolescents,and obstetric fistula (resulting from prolonged,difficult deliveries) is a major source of morbidity(Patton et al., 2009; Abu Zahr, C., 2003).Contraceptives, including male and female condoms,can help prevent pregnancy and sexuallytransmitted infections and eliminate many of theassociated health risks. Yet adolescents’ unmetneed for contraceptives, information and servicesremains great, despite international commitmentsto remove barriers to family planning.The consequence is that a segment of thelargest generation of adolescents in historyis unable to fully exercise their reproductiverights and prevent unintended pregnancies andprotect themselves from sexually transmittedinfections, including HIV (UNFPA 2012a).In sub-Saharan Africa and South Central andSoutheast Asia, more than 60 per cent of adolescentswho wish to avoid pregnancy have anunmet need for modern contraception. Theseadolescents who do not use modern contraceptionor rely instead on a traditional methodof family planning account for more than80 per cent of unintended pregnancies inthis age group (UNFPA 2012a).Attitudes, beliefs and access tocontraceptionAt the community level, access to contraceptionmay be impeded by norms, mores,attitudes and beliefs that adolescents shouldnot be sexually active and that they thereforedo not need contraception. This gap betweenadult attitudes and adolescent realities is arecipe for early pregnancy. Gender norms—in the community or nationally—can alsodetermine whether an adolescent gains accessto contraception. In some societies, girls areexpected to marry young or prove their fertilitybefore unions are formalized. Expectationsfor boys may include gaining sexual experienceas well as proving their fertility (World HealthOrganization, 2012b).The impact of the community-level socioculturalcontext on young women’s reproductivebehaviour cannot be overstated (Goicolea2009). In parts of sub-Saharan Africa and SouthAsia, as well as in low-income communities inhigh-income countries, motherhood may be36 CHAPTER 3: PRESSURES FROM MANY DIRECTIONS

seen as “what girls are for,” and their social valuecomes from their capacity to produce children(Presler-Marshall and Jones, 2012; Edin andKefalas, n.d.).About one in four women between the ages of15 and 49 in developing countries has never beenmarried. This unmarried group consists mostly ofadolescents and young women between the agesof 15 and 24. There has been a steady, long-termtrend towards increased levels of sexual activityamong these unmarried girls and young womenbecause of a combination of factors: the globaldecline in the age of menarche, the rising ageat marriage and changing societal values (Singhand Darroch, 2012). When they become sexuallyactive, never-married adolescent girls and youngwomen face much greater difficulties in obtainingcontraceptives than do married women, inlarge part because of the stigma attached to beingsexually active before marriage.“I knew about condoms, but couldnot ask my husband to use one.I was only 16 when I got marriedand felt he would get angry, as Iwas less educated than him. “Pinki, 19, IndiaAccess and demand among marriedadolescentsExcluding China, approximately one in threeadolescent girls under age 18 in developingcountries is married or in a union (UNFPA,2012b). Within this group, 23 per cent are usinga modern or traditional method of contraception;23 per cent have an unmet need for it;LEVELS OF CONTRACEPTIVE USE AND DEMAND BY SEVEN AGE GROUPS,MOST RECENT DATAContraceptive prevalence rate,total by age group (per cent)Unmet need for family planning,total by age group (per cent)Proportion of demand satisfied,total by age group (per cent)1007550385262 6461494665748082 82 82252125201815 14 13 11015-19 20-24 25-29 30-34 35-39 40-44 45-49 15-19 20-24 25-29 30-34 35-39 40-44 45-49 15-19 20-24 25-29 30-34 35-39 40-44 45-49Source: UNFPA, 2013.THE STATE OF WORLD POPULATION 201337

t Participants in theComprehensiveEmpowermentProgramme forthe Reductionof UnplannedPregnanciesAmong AdolescentMothers, sponsoredby Women AcrossDifferences andUNFPA.© UNFPA Guyanaand 54 per cent have no need for contraceptionbecause they indicate they wanted theirlatest birth. According to the World HealthOrganization (2008), 75 per cent of adolescentbirths are categorized as “intended.”Compared to other age groups, adolescentswho are married or in a union have both the lowestuse of contraception and the highest levels ofunmet need, hence, the lowest levels of demandsatisfied for contraception. Lack of knowledgeand fear or experience of side effects are majorreasons for non-use or discontinuation.In countries with a high prevalence of childmarriage and a strong preference for sons, marriedgirls face pressures to forego contraceptionuntil they give birth to a boy (Filmer et al.,2008). This analysis of 5 million births in 65countries found evidence of preference for sonsaffecting fertility in South Asia, Eastern Europe,and Central Asia.Gender-specific attitudes and behavioursRigid ideals about appropriate attitudes and behavioursof girls, boys, women and men are learnedand socially constructed norms that vary acrosslocal contexts and interact with sociocultural factorssuch as class or caste. These social and gendernorms are carried out and reinforced on multiplelevels, among individuals in peer groups andfamilies and through community attitudes andpractices (UNFPA, 2012a).Differential treatment of boys and girls as theygrow up begins early, and it continues throughouttheir lives. The result is that everyone—boys, girls,men and women—absorbs messages about howthey ought or ought not to behave or think, andearly on, begin to establish divergent expectationsof themselves and other females and males. Often,these expectations can translate into practicesand risk-taking that can have negative sexual andreproductive health outcomes, including adolescentpregnancy (UNFPA, 2012a). In many countries,boys and men are culturally validated for havingmultiple partners or having sex without a condom.Many girls and young women say they donot use contraception—even when they knowit is available and even though they have a rightto it—because their male partners oppose it orview contraception negatively (Presler-Marshalland Jones, 2012). The risks of ignoring maleopposition to contraception may be particularlyserious for adolescent girls who are married or ina union. If married girls secretly use contraception,they may face beatings, divorce or otherforms of punishment if they are caught or failto produce children (Presler-Marshall and Jones,2012). Where male attitudes are the prevailing ormainstream ones, girls may internalize these sameattitudes and express similarly negative views tocontraception.38 CHAPTER 3: PRESSURES FROM MANY DIRECTIONS

Youth-friendly servicesYouth-friendly sexual and reproductive healthservices are those that are conveniently located,have opening hours that are aligned withyoung people’s routines, provide a welcoming,non-judgmental atmosphere and maintainconfidentiality. Lack of confidentiality, or theperception of it, forms a major barrier to girls’accessing contraception (Presler-Marshall andJones, 2012). The effectiveness of stand-alone orparallel youth-friendly services in reducing adolescentpregnancy has not yet, however,been fully evaluated.Services for girls who are pregnantFewer than half the pregnant adolescents inChad, Ethiopia, Mali, Niger and Nigeria havereceived any antenatal care from a skilled provider(Kothari et al., 2012). In these same fivecountries, even fewer delivered with the help ofa skilled attendant. Meanwhile, a DHS analysis(Reynolds, et al., 2006) found that in somecountries, including Brazil, Bangladesh, Indiaand Indonesia, adolescents were less likely thanwomen to obtain skilled care before, during andafter childbirth.Young first-time mothers are more likely thanolder mothers to experience delays in recognizingcomplications and seeking care, reachingan appropriate health care facility and receivingquality care at a facility (UNFPA, 2007). If anadolescent is unmarried, she may have the extraburden of being unfavourably judged by healthcareproviders and her community and family.Antenatal and postnatal care are not only essentialfor the health of the girl and her pregnancy,but they also present opportunities to provideinformation and contraception that may help anadolescent prevent or delay a second pregnancy.“I started dating so thatwe could have food…ended up pregnant.”Malebogo, 19, BotswanaSexual violence and coercionThe social and physical consequences of sexualviolence among adolescents are dire, with immediateand enduring rights, health and socialdevelopment implications (Jejeebhoy et al.,2005; Garcia-Moreno et al., 2005). Forcedsex and intimate partner violence increase girls’vulnerabilities to pregnancy.Young age is a known risk factor for a woman’slikelihood of experiencing violence at thehands of an intimate partner (World HealthOrganization, 2010; Krug et al., 2002).The World Health Organization defines sexualviolence as “any sexual act, attempt to obtain asexual act, unwanted sexual comments or advances,or acts to traffic, or otherwise directed againsta person’s sexuality using coercion, by any personregardless of their relationship to the victim”(Krug et al., 2002: 149).The World Health Organization, whichcharacterizes sexual violence as a violation ofhuman rights, estimates that some 150 millionadolescent girls experienced forced sex or otherforms of sexual violence in a single year, 2002(Andrews, 2004). The first sexual experienceof many young women is forced (Krug et al.,2002; Garcia-Moreno et al., 2005; UNFPAand Population Council, 2009).THE STATE OF WORLD POPULATION 201339

t Guatemala'sSurvivors Foundationcounsels girls andwomen who havebeen sexuallyassaulted.© UNFPA GuatemalaAnalysis of DHS surveys from 14 countriesshows that the proportion of young womenbetween 15 and 24 years old whose first sexualexperience—within or before marriage—was non-consensual ranged widely from 2per cent in Azerbaijan to 64 per cent in theDemocratic Republic of the Congo (UNFPAand Population Council, 2009).Likewise, a World Health Organizationmulti-country study in 10 countries foundthat the share of women reporting forced firstsex ranged from about 1 per cent in Japanand Serbia to about 30 per cent in Bangladesh(Garcia-Moreno et al., 2005).Forced sex also occurs within marriage. Forexample, an analysis of DHS surveys from 27countries found that the proportion of youngwomen, ages 15 to 24, who reported sexualviolence perpetrated by their husbands rangedfrom 1 per cent in Nigeria to 33 per cent in theDemocratic Republic of the Congo (UNFPAand Population Council, 2009).Indeed, as a study in Nyeri, Kenya, amongmarried and unmarried young women betweenthe ages of 10 and 24 showed, married femaleswere at even higher risk of experiencing sexualcoercion than their unmarried, sexually activecounterparts (Erulkar, 2004).Contrary to popular belief, perpetrators ofsexual violence are typically boys and menknown to their adolescent victims: husbands,intimate partners, acquaintances or those inpositions of authority. This finding is observedacross all regions of the world (Jejeebhoy andBott, 2005; Jejeebhoy et al., 2005; Bott et al.,2012; Erulkar, 2004).An estimated one in five adolescent girlsexperiences abuse during pregnancy (WorldHealth Organization, 2007; Parker et al.,1994). Twenty-one per cent of adolescentsexperience intimate-partner violence withinthree months of delivery. Physical abuse andviolence during pregnancy have been recognizedas important risk factors for poor healthin both mothers and infants (World HealthOrganization, 2007; Newberger et al., 1992).Coerced sex is “the act of forcing or attemptingto force another individual throughviolence, threats, verbal insistence, deception,cultural expectations or economic circumstancesto engage in sexual behaviour against her/hiswill” (Heise et al., 1995). Several national andsub-national studies suggest that between 15per cent and 45 per cent of young women whohad engaged in premarital sex reported at leastone coercive experience.40 CHAPTER 3: PRESSURES FROM MANY DIRECTIONS

An adolescent girl whose sexual partner isconsiderably older is at greater risk of coercedsex, sexually transmitted infections, includingHIV, and pregnancy. When a partner is significantlyolder, the power differential in therelationship is especially unfavourable for thegirl, making it more difficult for her to negotiatethe use of contraception, especially condoms,for protection against pregnancy and sexuallytransmitted infections. In five of 26 countriescovered by a recent study (Kothari et al., 2012),at least 10 per cent of adolescent girls (ages 15to 19) reported having had sex in the precedingyear with a man who was at least 10 yearsolder: Dominican Republic (10 per cent), theRepublic of the Congo (11 per cent), Armeniaand Zimbabwe (15 per cent) and Ethiopia(21 per cent).Unmarried girls may face an additional formof sexual coercion that makes them vulnerableto pregnancy: pressures from transactional sex.One study in Zimbabwe found, for example,that of 1,313 men surveyed, 126 of them (10.4per cent) reported having traded money or giftsfor sex with an adolescent girl in the precedingsix months (Wyrod et al., 2011). These “gifts”are “imbued with power differentials and offeredto girls who have little voice to say ‘no’” (Presler-Marshall and Jones, 2012).Human rights bodies condemn sexual violenceagainst women and adolescent girls in allits forms, whether it occurs in times of peace orin times of conflict by State actors or by privatepersons, whether it occurs in the home, schools,the workplace, or in health care facilities, orwhether it results in a pregnancy or not. Therights to be free from violence, ill treatment, andtorture, as well as the rights to life, health, andnon-discrimination create a government dutyto protect women and adolescent girls froms Young peoplein Ecuadorparticipate in amarch organizedto mark adolescentpregnancyprevention week.©UNFPA/JeanninaCrespoTHE STATE OF WORLD POPULATION 201341

t Girls in Rajasthan,India learningto read.© Mark Tuschman/Educate Girls Indiaviolence, regardless of the perpetrator (Center forReproductive Rights, 2009).The ICPD Programme of Action recognizesthat one of the cornerstones of population anddevelopment-related programmes is eliminatingall forms of violence against women, includingsexual abuse and violence against children andadolescents (ICPD, Principles 4 and 11).School, peers, partnersSchoolThe longer girls stay in school, the more likelythey are to use contraception and prevent pregnancyand the less likely they are to marry young(Lloyd, 2006; UNICEF, 2006; Lloyd and Young,2009). Girls who are not in school are morelikely to get pregnant than those remaining inschool, whether or not they are married.The Secretariat of the 65th World HealthAssembly in 2012 called education “a majorprotective factor for early pregnancy: the moreyears of schooling the fewer early pregnancies,”adding that “birth rates among women with loweducation are higher than those with secondaryor tertiary education.”While the correlation between educationalattainment and lower rates of adolescent pregnancyis well documented, the direction ofcausality and the sequencing are still the subjectof some debate, as noted in the previous chapter.In many countries, early school-leaving isattributed to adolescent pregnancy; however,pregnancy and early marriage are more likelyto be consequences rather than causes of earlyschool leaving. Once girls have left school, pregnancyand/or marriage are likely to follow inshort order (Lloyd and Young, 2009).Educational attainment and sexual and reproductivetransitions are closely related in that apregnancy or an early marriage can derail a girl’sschooling. As boys typically marry later thangirls and do not face the same risks and responsibilitiesassociated with pregnancy, their sexualmaturation and behaviour do not have thepotential to interfere with their school progressin the same way (Lloyd and Young, 2009).A 2012 study provides evidence that interventionsthat encourage school attendance areeffective in reducing overall adolescent fertility,making a case for expanding educationalopportunities for girls and creating incentivesfor school continuation (McQueston et al.,2012). Enabling or encouraging girls to attend42 CHAPTER 3: PRESSURES FROM MANY DIRECTIONS

and stay in school, however, may require breakingdown economic barriers to access educationby, for example, waiving fees for girls frompoorer households. It may also require mitigatingrisks to girls’ health and safety by, for example,adequately protecting girls from sexual abuse orviolence in school and on their way to and fromschool, and providing a culturally sensitiveschool environment.“I started living with my partner at age14. My plans were to have a stablerelationship, to keep on with school andto become a professional. However I gotpregnant at 15. At first I didn’t even knowhow to take care of a newborn. I had toquit school.”Marcela, 18, El SalvadorAge-appropriate, comprehensive sexualityeducationFew young people receive adequate preparationfor their sexual and reproductive lives.This leaves them potentially vulnerable tocoercion, abuse and exploitation, unintendedpregnancy and sexually transmitted infections,including HIV. Many young people approachadulthood faced with conflicting and inaccurateinformation and messages about sexuality. Thisis often exacerbated by embarrassment, silenceand disapproval of open discussion of sexualmatters by adults, including parents andteachers, at a time when it is most needed.In many instances, adolescents have inaccurateor incomplete information aboutsexuality, reproduction and contraception(Presler-Marshall and Jones, 2012). A study inUganda, for example, found that one in threeadolescent males and one in two females didnot know that condoms should beused only once (Presler-Marshalland Jones, 2012; Bankole et al.,2007). A study in Central Americafound that one in three adolescentsdid not know a pregnancy couldoccur the first time a girl had sex(Presler-Marshall and Jones, 2012;Remez et al., 2008). And a studyin one area in Ethiopia showedthat although nearly all adolescentsknew that unprotected sexcould result in HIV infection,less than half realized it couldalso result in pregnancy (Presler-Marshall and Jones, 2012; BetaDevelopment Consulting, 2012).Comprehensive sexuality education is anage-appropriate, culturally relevant approachto teaching about sexuality and relationshipsby providing scientifically accurate, realistic,non-judgmental information. Sexualityeducation provides opportunities to exploreone’s own values and attitudes and to builddecision-making, communication and riskreductionskills.The Programme of Action of the ICPDrecognized that providing adolescents withinformation is the first step towards reducingadolescent pregnancies and unsafe abortionsand empowering adolescents to makeTHE STATE OF WORLD POPULATION 201343

PROPORTION OF ADOLESCENTS SURVEYED AGES12-14, BY SEX AND COUNTRY, ACCORDING TO THEIRATTITUDES REGARDING PROVISION OF SEXUALITYEDUCATION FOR YOUNG PEOPLE, 2004Sex/countryFemalesIt is importantthat sexeducation betaught in school12-14 year oldsshould betaught aboutusing condomsto avoid AIDSProvidingsexualityeducation toyoung peopledoes notencourage themto have sexBurkina Faso 78 73 63Ghana 91 49 68Malawi 67 76 68Uganda 82 76 49MalesBurkina Faso 81 78 59Ghana 89 63 62Malawi 73 73 68Uganda 78 76 52Source: Bankole and Malarcher, 2010.conscious and informed decisions (paragraphs7.44 and 11.9). Human rights treaty-monitoringbodies have called on governments to meetobligations to provide access to sexualityeducation and information.By reaching adolescents early in puberty,school settings can provide young people withthe information and skills they will need to makeresponsible decisions about their future sexuallives (Kirby, 2011).Through school-based comprehensivesexuality education programmes, educators havean opportunity to encourage adolescents todelay sexual activity and encourage them tobehave responsibly when they eventually engagein consensual sexual activity, particularly byusing condoms and other modern methods ofcontraception (Kirby, 2011).Sexuality education is more likely to have apositive impact when it is comprehensive andimplemented by trained educators who areknowledgeable about human sexuality, understandbehavioural training and are comfortableinteracting with adolescents and young peopleon sensitive topics. The curriculum shouldfocus on clear reproductive health goals, such aspreventing unintended pregnancy, and on specificrisk behaviours and protective behavioursthat lead directly to the achievement of thosehealth goals (Kirby, 2011).Curriculum-based programmes are moreeffective if they also develop life skills, addresscontextual factors, and focus on the emergingfeelings and experiences that accompany sexualand reproductive maturity. To be effective inpreventing pregnancy and sexually transmittedinfections, sexuality education should be linkedwith reproductive health services, includingcontraceptive services (Chandra-Mouli et al.,2013).Parents and educators sometimes fear thatsexuality education will encourage adolescentsto have sex. But research shows that sexualityeducation does not hasten the initiation of orincrease sexual activity (UNESCO, 2009). Areview of 36 sexuality education programmes inthe United States concluded, for example, thatwhen information about abstinence and contraceptionis provided, adolescents do not becomemore sexually active or have an earlier sexualdebut (Advocates for Youth, 2012).44 CHAPTER 3: PRESSURES FROM MANY DIRECTIONS

A study covering four African countries showsthat adolescents generally welcome sexuality educationin schools. The majority of the girls andboys surveyed also said that sexuality educationin schools did not encourage them to have sex(Bankole and Malarcher, 2010).For girls and boys to benefit from a schoolbasedsexuality-education curriculum, they ofcourse need to be in school. In some countries,two-thirds of the girls between the ages of 12and 14 are not in school. That means thatschool-based sexuality education misses themajority of that cohort (Biddlecom, et al.,2007) and underscores a need to reach thosewho are not in school.In countries where large numbers of youngpeople are not enrolled in secondary school,sexuality education programmes and those aimedat reducing the incidence of sexually transmittedinfections can also be implemented in clinics,through radio programmes, and in communitysettings that attract young people.But the availability of comprehensive sexualityeducation alone does not guarantee impact.Quality, tone, content and delivery are alsoimportant. Teachers who feel awkward with thesubject matter or who are judgmental aboutadolescent sexuality may impart informationthat is inaccurate, confusing or incomplete.Comprehensive sexuality education that is offeredto boys and girls in the same classroom mayresult in low attendance by girls in some settings(Pattman and Chege, 2003; Presler-Marshalland Jones, 2012).The Children’s Rights Committee has alsonoted that “consistent with their obligations toensure the right to life, survival and developmentof the child (article 6), States parties [to theConvention on the Rights of the Child] mustensure that children have the ability to acquirethe knowledge and skills to protect themselvesand others as they begin to express their sexuality”(Committee on the Rights of the Child,2003a).International human rights bodies have notedthat the rights to health, life, non-discrimination,information and education require Statesto both remove barriers to adolescent access tosexual and reproductive health information andto provide comprehensive and accurate sexualityeducation, both in and out of schools. Treatymonitoringbodies have also recommended© Mark TuschmanTHE STATE OF WORLD POPULATION 201345

that sexual and reproductive health educationbe made a compulsory and robust componentof the official curricula in primary and secondaryschools, including vocational schools (Centerfor Reproductive Rights, 2008a; See also ICPD,paragraph 11.9).PeersPeers can influence how adolescents view becomingpregnant, as well as their attitudes towardspreventing pregnancy, dropping out of school orstaying enrolled until graduation. Peer pressurecan thus discourage early sexual debut and marriage,or it can reinforce the likelihood of earlyand unprotected sexual activity (Chandra-Mouliet al., 2013).“I didn’t know he intended to impregnateme this time, I remember our plan waswhen I turn 18… I was not ready to havea baby yet, which made me think of notgoing through with my pregnancy, but myfriends insisted I should since my partnerand I were already living together… But Iknew I was not really ready yet.”K.C., 18, pregnant at 17, the PhilippinesPartnersAnother influence is a girl’s sexual partner orspouse, including his age and his views on marriage,sex, gender roles, contraception, pregnancyand childbearing.Research on the early sexual activity of adolescentmales shows that unhealthy perceptionsabout sex, including seeing women as sexualobjects, viewing sex as performance-oriented andusing pressure or force to obtain sex, begin inadolescence and may continue into adulthood.Perceptions of masculinity among young menand adolescent boys are a driving force for malerisk-taking behaviour, including unsafe sexualpractices.Men and boys: partners in the processStrengthening opportunities for boys and youngmen to participate in supporting gender-equalityefforts can have an impact not only on womenand girls but also on their own lives (UNFPA2013b).Boys and men are often socialized to believethat the enjoyment of sexual relations is viewed astheir prerogative, and they are taught to take thelead in their sexual relationships, creating significantpressure (and insecurity). Traditional views ofwhat it means to be a man can encourage men toseek out multiple sexual partnerships and to takesexual risks (UNFPA, 2012).Though women more consistently suffer thenegative effects of harmful gender norms acrosstheir lifetimes, societies also socialize their men,male adolescents and boys in ways that drivepoor sexual and reproductive health outcomes. Inmany societies, men are encouraged to assert theirmanhood by taking risks, asserting their toughness,enduring pain, being independent providers,and having multiple sex partners. The roles and46 CHAPTER 3: PRESSURES FROM MANY DIRECTIONS

esponsibilities of breadwinner and head of thehousehold are inculcated into boys and men; fulfillingthese behaviours and roles are dominantways to affirm one’s manhood.Gender norms as a rule establish and reinforcewomen’s subordination to men and drivepoor sexual and reproductive health outcomesfor both men and women. Women are oftenprevented from learning about their rights andfrom obtaining the resources that could helpthem plan their lives and families, sustain theiradvancement in school, and support their participationin the formal economy (Greene andLevack, 2010). Men are often not offered mostsources of sexual and reproductive health informationand services and may develop the sensethat planning families is not their domain, butrather is women’s responsibility.In the context of sexual and reproductivehealth and reproductive rights, there is growingrecognition among the international communitythat addressing gender inequities in health,promoting sexual and reproductive health andreproductive rights, and preventing HIV andgender-based violence at all levels in societyis not possible without efforts to directlyengage men and boys as partners in theseprocesses (International Planned ParenthoodFederation, 2010).EXCERPTS FROM THE ICPD PROGRAMME OFACTION ON GENDER EQUALITYThe objectives are to achieve equality and equity based on harmoniouspartnership between men and women and enable women to realize theirfull potential; to ensure the enhancement of women’s contributions tosustainable development through their full involvement in policy- anddecision-making processes at all stages…; to ensure that all women, aswell as men, are provided with the education necessary for them to meettheir basic human needs and to exercise their human rights.Countries should act to empower women and should take steps toeliminate inequalities between men and women as soon as possibleby establishing mechanisms for women’s equal participation and equitablerepresentation at all levels of the political process and public life;promoting the fulfilment of women’s potential through education, skilldevelopment and employment, giving paramount importance to theelimination of poverty, illiteracy and ill health among women; eliminatingall practices that discriminate against women; assisting women to establishand realize their rights, including those that relate to reproductive andsexual health… (Programme of Action, paragraphs 4.1–4.4)especially whether the mother and father marriedas children or whether the mother becamepregnant as an adolescent. Other family-leveldeterminants include the education level ofadults and their expectations for their children,the level of communication within the household,the intensity of cultural and religiousvalues, and the views of family decision makerson gender roles and child marriage.Family-level determinantsUnless a girl lives in a child-headed householdor is homeless, she is going to be influenced byher family or guardian. Family-level determinantsinclude the stability and cohesiveness ofthe family; the degree to which there is conflictor violence in the home; the extent of householdpoverty or wealth; the presence of rolemodels; and the reproductive history of parents,Child marriageThe prevalence of child marriage depends in parton national policies and laws and their enforcement,on community-level norms and on theextent of poverty in a country, but it is at thelevel of the family where decisions are madeabout forcing a child into a marriage or union.By definition, child marriage occurs when atleast one of the partners is under age 18. EveryTHE STATE OF WORLD POPULATION 201347

day, 39,000 girls are married. Once a girlmarries, she is usually expected to have a baby.About 90 per cent of adolescent pregnancies indeveloping countries are within marriage.About 16 per cent of girls in developing countries(excluding China) marry before age 18,compared with 3 per cent of boys. One out of ninegirls is married before age 15. Adolescent birthrates are highest where child marriage is mostprevalent; and independent of the overall wealthof a nation, girls in the lowest income quintileare more likely to have a baby as an adolescentthan their higher income peers.Child marriage persists for reasons includinglocal traditions or parents’ beliefs that it can safeguardtheir daughter’s future. But more often thannot, child marriage is the consequence of limitedchoices. Girls who miss out or drop out of schoolare especially vulnerable—while the more exposurea girl has to formal education and the better-offher family is, the more likely marriage is to bepostponed. Simply stated, when girls have lifechoices, they marry later (UNFPA, 2012).Married girls are often under pressure tobecome pregnant immediately or soon aftermarriage, although they are still childrenthemselves and know little about sex or reproduction.A pregnancy too early in life beforea girl’s body is fully mature is a risk to bothmother and baby.In 146 countries, State or customary laws allowgirls younger than 18 to marry with the consent ofparents or other authorities; in 52 countries, girlsunder age 15 can marry with parental consent. Incontrast, 18 is the legal age for marriage withoutconsent among males in 180 countries. The lackof gender equality in the legal age of marriagereinforces the social norm that it is acceptable forgirls to marry earlier than boys.Men exercise disproportionate power in nearlyevery aspect of life, which restricts women’s andgirls’ exercise of their rights and denies theman equal role in their households and communities.Unequal gender norms tend to place ahigher value on boys and men than on girls andwomen. When girls from birth lack the sameperceived value as boys, families and communitiesmay discount the benefits of educating andinvesting in their daughters’ development.In addition, girls’ perceived value may shiftonce they reach puberty. Child marriage isoften seen as a safeguard against premarital sex,and the duty to protect the girl from sexualharassment and violence is transferred fromfather to husband.Customary requirements such as dowries orbride prices may also enter into families’ considerations,especially in communities where familiescan pay a lower dowry for younger brides.Families, particularly those who are poor, maywant to secure a daughter’s future where thereare few opportunities for girls to be economicallyproductive. Families may want to buildor strengthen alliances, pay off debts, or settledisputes. They may want to be sure that theirchildren have enough children to support themin old age. They may want to divest themselvesof the burden of having a girl. In extreme cases,they may want to earn money by selling the girl.Families may also see child marriage as analternative to education, which they fear mightmake a girl unsuitable for responsibilities as wifeand mother. They may share the social normsand marriage patterns of their neighbours andcommunity or the historical patterns within theirfamily. Or they may fear that the girl will bringdishonour to the family if she has a child outsidemarriage or chooses an inappropriate husband.48 CHAPTER 3: PRESSURES FROM MANY DIRECTIONS

Child marriage does not always lead to immediatesexual relations, however. In some cultures,a girl may marry very young but not live with herhusband for some time. For example, in Nepaland Ethiopia, delayed consummation of marriageis common among young brides, especially inrural areas.While they are often viewed as adults in theeyes of the law or by custom (when childrenare married, they are often emancipated undernational laws and lose protections as children),child brides need particular attention and support,due to their exceptional vulnerability(Committee on the Rights of the Child, 2003).Compared to older women, child brides aregenerally more vulnerable to domestic violence,sexually transmitted infections and unintendedpregnancy due to power imbalances, includingthose that may result from age differences(Guttmacher Institute and International PlannedParenthood Federation, 2013).International human rights standards condemnchild marriage. The Universal Declarationof Human Rights, the foundational humanrights instrument, declares that “marriageshall be entered into only with the free andfull consent of the intending spouses.” TheCommittee on Economic, Social, and CulturalRights and the Committee on the Eliminationof Discrimination Against Women have repeatedlycondemned the practice of child marriage.The Human Rights Committee has joinedother treaty bodies in recommending legalreform to eliminate child marriage (Centerfor Reproductive Rights, 2008), and theConvention on the Rights of the Child and itscorresponding committee require States partiesto “take measures to abolish traditional practicesthat are harmful to children’s health.”WHEN CHILDREN GIVE BIRTH TO CHILDRENRadhika Thapa was just 16 years old when she married a 21-year-oldman three years ago. Now, she is expecting a baby and is well into thelast months of her pregnancy. This is not the first time she has been withchild. Her first two pregnancies ended in miscarriages.“The first time I conceived I was just 16, I didn’t know much abouthaving babies, nobody told me what to do,” Thapa says, while assistingcustomers at the vegetable store she runs with her husband in the smalltown of Champi, some 12 kilometres from Nepal’s capital, Kathmandu.“The second time I wasn’t ready either, but my husband wanted a babyso I gave in,” she admitted. After the second miscarriage, Thapa’s doctorsurged her to wait a few years before trying again, but she was underimmense pressure from her in-laws, who threatened to “find anotherwoman for her husband if she kept losing her babies.”According to the 2011 Nepal Demographic and Health Survey, 17per cent of married adolescent girls between ages 15 and 19 are eitherpregnant or are mothers already. The survey also shows that 86 per centof married adolescents do not use any form of contraception, meaningthat few girls are able to space their births.“You are talking about a child giving birth to another child,” says GiuliaVallese, Nepal’s representative for the United Nations Population Fund(UNFPA).“When girls get pregnant their education stops, which means a lack ofemployment opportunities and poverty,” says Bhogedra Raj Dotel of theGovernment’s family planning and adolescent sexual reproductive healthdivision.Menuka Bista, 35, is a local female community health volunteer inChampi, assisting about 55 households in her area. Bista has been advisingThapa, to ensure that the girl has a safe pregnancy. “Radhika…knowsshe needs to go to the doctor and eat nutritious food for her baby to besafe, but she doesn’t make decisions about her body: her husband andin-laws do,” Bista said.This observation is echoed in research carried out by various experts:according to Dotel, husbands and in-laws make all the major decisionsabout a woman’s reproductive health, from what hospital she visits towhere she will deliver her child. For this reason, Vallese believes it isimportant to train husbands and family members on reproductive healthand rights.—Malika Aryal, Inter Press ServiceTHE STATE OF WORLD POPULATION 201349

ParentsParents play central roles, both directly andindirectly in determining the future of their adolescentdaughters. As role models, parents havethe power to reinforce and perpetuate genderinequality or instil beliefs that boys and girlsshould enjoy the same rights and opportunitiesin life. They may impart information about sexualityand prevention of pregnancy or they maywithhold vital information. They may place avalue on education for both their daughters andsons, or they may socialize girls to believe thattheir only destiny is marriage and having children.They may help develop girls’ life skills andencourage them to be autonomous, or they maysuccumb to economic and community pressuresand force their girls into marriage and a lifetimeof dependency.Individual-level determinantsAdolescence is a critical developmental transitionbetween childhood and young adulthood, a periodin which important individual, behaviouraland health trajectories are established—and aperiod in which problematic or harmful patternscan also be prevented or ameliorated, and positivepatterns enhanced.A pivotal moment in adolescence is puberty.On average, girls enter puberty 18 to 24 monthsbefore boys, whose physical development is slowerand can continue through late adolescence.For girls, many of the developmental changesassociated with adult reproductive capabilities areoften complete before intellectual and decisionmakingcapacities fully mature. Puberty is a timewhen specific gender roles and expectations arereinforced.Girls attendclass in ruralRajasthan, India.© Mark Tuschman/Educate Girls Indiat50 CHAPTER 3: PRESSURES FROM MANY DIRECTIONS

In much of Europe and North America,female puberty is generally completed betweenages 12 and 13, and across the world the age ofpuberty is declining, especially in middle- andhigh-income countries. It is not uncommon insome developed countries for girls today to enterpuberty as early as age eight or nine. Factors associatedwith age of puberty include nutrition andsanitation. As the health status of populationsimproves, the age of menarche declines. Boysgenerally go through puberty between the agesof 14 and 17.Data from Scandinavian countries, for example,show that the average age of menarche hasdeclined from between 15 and 17 years in themid-1800s to between 12 and 13 years today.Data from the Gambia, India, Kuwait, Malaysia,Mexico and Saudi Arabia also show declines inthe age at menarche. The mean age of menarchein Bangladesh is 15.8 and that for Senegal is 16.1,with menarche in other developing countriesbeing a year or two earlier (Thomas et al., 2001).PREGNANCY DESIRES AND CONTRACEPTIVE USEThe proportion of married adolescents who are or wish to becomepregnant varies widely by region10080604020022 25 294767 54 20Sub-SaharanAfricaSouth Central &Southeast AsiaWant to avoid pregnancy, using no methodWant to avoid pregnancy, using a traditional methodWant to avoid pregnancy, using a modern methodWant pregnancy or are intentionally pregnantSource: Guttmacher Institute, 2010.6815 43Latin America& CaribbeanSocialization and expectationsResearch suggests that some adolescent girlsdesire to become pregnant. One study showedthat 67 per cent of married adolescents insub-Saharan African want to be pregnant or areintentionally pregnant (Guttmacher Institute,2010). In places where the culture generallyidealizes motherhood, pregnancy may be seenby an adolescent as a means of gaining statusor becoming an adult. It may also be perceivedby girls as a means for escaping abusive families(Presler-Marshall and Jones, 2012). Helping girlssee themselves as more than potential mothers—and helping communities do the same—is key toreducing the number of adolescent pregnancies(Presler-Marshall and Jones, 2012).As noted by Singh (1998), “From the perspectiveof the adolescent herself, and her family, themeaning and the consequences of childbearingduring the teenage years range widely. Theseconsequences vary from the positive—the fulfilmentof an expected progression from childhoodto the adult status conferred by marriage andmotherhood and the joy and rewards of havinga baby—to the negative—the assumption of theburden of carrying for and bringing up a childbefore the mother is emotionally or physicallyprepared to do so.”Most research on motivations towardspregnancy, however, has focused on adolescentsin developed countries, often from low-incomehouseholds or who are members of aTHE STATE OF WORLD POPULATION 201351

disadvantaged minority. This research suggeststhat some girls may want a baby to love (and tolove them). They may believe that a baby willstrengthen their ties to their partner. If their peershave babies, they may want one too. They maywant to demonstrate that they are responsibleand mature enough to be a mother. If they feelthey have no other options, they may feel theyhave nothing to lose and possibly a few thingsto gain (a baby, a relationship, status).A qualitative study in Taung, South Africa(Kanku and Mash, 2010) drew on findings fromfocus groups of pregnant adolescent girls, youngwomen who had had an adolescent pregnancy,and adolescent boys. It concluded, “Most teenagersperceived falling pregnant as a negative eventwith consequences such as unemployment, lossof a boyfriend, blame from friends and familymembers, feeling guilty, difficulty at school,complications during pregnancy or delivery, riskof HIV, secondary infertility if an abortion isdone and not being prepared for motherhood.A number of teenagers, however, perceived“I decided to have a child because Iwanted to feel like an adult… Now I haveto make it work. For the sake of my son,I need to go back to school and get aproper education. I now know that mydestiny is not to change diapers. I wantto be a lawyer and change the world. Formy son.”Jipara, 17, Kyrgyzstansome benefits and saw that it could be a positiveevent depending on the circumstances.” Thestudy concluded, “Multifaceted and intersectoralapproaches are required, and it is likely thatstrategies to reduce teenage pregnancy will alsoimpact on HIV and other sexually transmittedinfections.”Adolescents’ evolving capacitiesThe Committee on the Rights of the Child, atits 33rd session in 2003, called adolescence “aperiod characterized by rapid physical, cognitiveand social changes, including sexual and reproductivematuration; the gradual building upof the capacity to assume adult behaviours androles involving new responsibilities requiringnew knowledge and skills” (Committee on theRights of the Child, 2003).With adolescence, the Committee stated,come “new challenges to health and developmentowing to their relative vulnerability andpressure from society, including peers, to adoptrisky health behaviour. These challenges includedeveloping an individual identity and dealingwith one’s sexuality. The dynamic transitionperiod to adulthood is also generally a period ofpositive changes, prompted by the significantcapacity of adolescents to learn rapidly, to experiencenew and diverse situations, to develop anduse critical thinking, to familiarize themselveswith freedom, to be creative and to socialize.”The Convention on the Rights of the Childacknowledges minors’ “evolving capacities,”or their acquisition of sufficient maturity andunderstanding to make informed decisions onmatters of importance, including on sexual andreproductive health services. It also recognizesthat some minors are more mature than others(Article 5; Committee on the Rights of the52 CHAPTER 3: PRESSURES FROM MANY DIRECTIONS

Child, 2003; CEDAW, 1999; CRPD, Article7) and calls on States to ensure that appropriateservices are made available to them independentof parental or guardian authorization(Committee on the Rights of the Child, 2003;CEDAW, 1999).Nine years earlier, the Programme of Actionof the International Conference on Populationand Development, which continues to bethe basis for the work of UNFPA today, alsoacknowledged adolescents’ evolving capacitiesand called on governments and familiesto make information and services availableto them, taking into account the rights andresponsibilities of parents (paragraph 7.45).The 179 governments that endorsed theProgramme of Action also agreed that the“response of societies to the reproductivehealth needs of adolescents should be basedon information that helps them attain a levelof maturity required to make responsible decisions.In particular, information and servicesshould be made available to adolescents to helpthem understand their sexuality and protectthem from unwanted pregnancies…. Thisshould be combined with the education ofyoung men to respect women’s self-determinationand to share responsibility with womenin matters of sexuality and reproduction”(Programme of Action, paragraph 7.41).Other individual-level determinantsFactors that place individuals at risk for earlypregnancy do not start only with the onset ofpuberty; rather, many of the risk factors theyexperience have their origins in early childhoodor even generations before they were born. Inhigh-income countries, for example, girls whobecome pregnant at an early age are significant-“Sometimes I think my pregnancy andmotherhood in those years made mestronger. I am more prepared to face allof life’s problems. But, on the other hand,I believe that being a mother at that agecomplicated my life… I have not gonethrough all the steps of growing up as mypeers did. I did not have all the advantagesof being a young person, and I did not haveequal opportunities for success.”Zeljka, 27, pregnant at 17, Bosnia-Herzegovinaly more likely than their non-pregnant peers tohave had a mother who had an early pregnancy.Another influence is maternal nutrition, whichaffects birth weights and can have life-long consequences.In 1995, physician and researcher DavidBarker hypothesized that newborns with lowbirth weights (often the case with babies born topoor adolescent girls) went on as adults to be atsignificantly greater risk than average for a host ofnon-communicable diseases (Barker, 1995).The special vulnerabilities of girlsages 10 to 14Very young adolescents, ages 10 to 14, undergotremendous physical, emotional, social, andintellectual changes. During this period, manyvery young adolescents go through puberty, havetheir first sexual experiences, and in the case ofgirls, may be married as children.THE STATE OF WORLD POPULATION 201353

The onset of puberty brings substantialphysical changes, as well as vulnerabilities toboys and, especially, to girls. Puberty for girlsbegins on average two years earlier than forboys. This fact, combined with very restrictivegender norms and limited assets, often leavesmany girls with only their physical bodies as acore reliable asset. This asset can be potentiallyexploited for non-consensual, unprotected,and underage sexual relations; and it may alsosubject girls to marriage against their rights andwill, with the expectation that they will bearchildren as soon as possible.For most children, early adolescence ismarked by good health and stable familycircumstances, but it can also be a period ofvulnerability because of intense and rapidtransitions to new roles and responsibilities ascaretakers, workers, spouses, and parents. Inmany countries, the impactof HIV, poverty, and politicaland social conflict on familiesand communities has erodedtraditional safety nets andincreased the vulnerability ofyoung adolescents (UNFPAand the Population Council,n.d.).When children of this ageare neither living with theirparents nor attending school,there is a good chance thatthey are not receiving familialor peer support to properlydeal with the challengesthey face and are not beinggiven adequate opportunityto develop into productivemembers of society. In somesettings, young female adolescents are domesticworkers, migrants from rural communities insearch of work and an education, or are fleeinga forced marriage. Others may already be childbrides and are now living with their spouse and,possibly, his family. These youth are amongthe least likely to seek out and receive socialservices and therefore require a proactive set ofprescriptions to minimize their vulnerability toexploitation.DHS data from 26 sub-Saharan Africancountries show that up to 41 per cent of girlsbetween the ages of 10 and 14 were not livingwith either parent (although some may beenliving with other relatives). Somewhat smallershares of girls in that age group were not livingwith either parent in Latin America and theCaribbean. The lowest proportions were inAsia (World Health Organization, 2011b).“When I went into labour, they brought thetraditional daya midwife. She didn’t payattention to the size or the position of thefetus. The whole day, I was in pain, holdingonto the rope until I had no energy left inme. I thought I was going to die. Then theytook me to the hospital, which was overtwo hours away. The moment I reachedthere I lost consciousness. And when Iwoke up, they told me my baby had died.”Awatif, 33, pregnant at 14, Sudan54 CHAPTER 3: PRESSURES FROM MANY DIRECTIONS

Young people who are not living with oneor both parents are also at a higher risk ofparticipating in illegal and unsafe work. Anestimated 30 per cent of girls 10 to 14 wereworking in sub-Saharan Africa, comparedwith 26 per cent and 27 per cent, respectively,in Asia and the Pacific, and 17per cent and 5 per cent, respectively, inLatin America and the Caribbean(World Health Organization, 2011b).Also, most comprehensive sexuality educationis delivered through school-basedcurricula. However, not all adolescentsattend school and not all remain in schooluntil they initiate sex. Married girlsbetween the ages of 10 and 14 and whoare not in school have virtually no accessto sexuality education, further increasingtheir vulnerability to pregnancy.ConclusionThe determinants of adolescent pregnancyare complex, multidirectional,multidimensional and vary significantlyacross regions, countries, age and incomegroups, families and communities.Pressures from all levels conspireagainst girls and lead to pregnancies, intendedor otherwise. National laws may prevent a girlfrom accessing contraception. Communitynorms and attitudes may block her access tosexual and reproductive health services or condoneviolence against her if she manages toaccess services anyway. Family members mayforce her into marriage where she has littleor no power to say “no” to having children.Schools may not offer sexuality education,so she must rely on information (often inaccurate)from peers about sexuality, pregnancy“I was 14 years old and was in high schoolwhen I had to stop going to school becausemy family did not have money to pay myschool fees. My mother used to send mysister and me to the market to beg forsomething to bring home to eat. One day, webegged two gentlemen for some money. Theygave 2,000 Congolese Francs [about $2] tomy sister to buy food to take home. Once mysister left, they took me to a pub and boughtme a sweet drink, but it had something in itthat put me to sleep. I woke up in a healthcenter, where nurses told me that I hadbeen raped. I became pregnant.”Chada, 16, Democratic Republic of the Congoand contraception. Her partner may refuse touse a condom or may forbid her from usingcontraception of any sort. And menarche maybe wrongly seen by her family or older husbandas readiness for childbearing. No matter howmuch a girl wishes to claim her childhood, goto school and reach her full potential, the forcesworking against her can be overwhelming.THE STATE OF WORLD POPULATION 201355

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4Taking actionMultilevel interventions that aim todevelop girls' human capital, focuson their agency to make decisionsabout their reproductive health,and promote gender equality andrespect for human rights have haddocumentable impact on preventingpregnancies.sYouth peer providers from the AMNLAE teenprogramme in Nicaragua.© Mark Tuschman/Planned Parenthood GlobalTHE STATE OF WORLD POPULATION 201357

Sexual and reproductive health and fullenjoyment of rights are central to adolescents’transition into adulthood and are vital to adolescents’identity, health, well-being and personalgrowth, development and fulfillment of theirpotential in life.Fully engaged, educated, healthy, informedand productive adolescents can help break multigenerationalpoverty and can contribute to thestrengthening of their communities and nations.Countries with a large share of their populationswho are adolescents or young people have anopportunity to reap a substantial demographicbonus for their nations’ economies, development,resilience and productivity. This requires investingin adolescents’ and young people’s humancapital and expanding the range of choicesand opportunities available to them. But manyadolescents, especially girls, are denied the investmentsand opportunities that would enable themto realize their full potential. For example, 26per cent of the world’s adolescent girls and 17per cent of boys between the ages of 11 and15 are not in school.Adolescent pregnancy is a symptom of underinvestmentin girls’ human capital and thesocietal pressures and structural inequities thatprevent girls from making decisions about theirhealth, sexual behaviour, relationships, marriageand childbearing and that critically influencewhether they will be able to take full advantageof opportunities for education, employment andpolitical participation (UNFPA, 2012d).Preventing pregnancy thus requires dismantlingthe many barriers to adolescents’ realizationof their full potential and their ability to enjoytheir rights. Paving the way to a safe and successfultransition to adulthood involves engaginggirls—and boys—in decision-making from the“I think it is far too earlyin my life to have a childconsidering the time andthe love a child needs.”Anders, 17, Denmarkindividual level to the policy-making level,enabling them to acquire the skills and thepower to voice their perspectives and priorities.Actions that support this transition from adolescenceto adulthood are also ones that can reducethe number of pregnancies to girls.Because adolescent pregnancy is the result ofdiverse underlying societal, economic and otherforces, preventing it requires multidimensionalstrategies that are oriented towards’ girls empowermentand tailored to particular populations ofgirls, especially those who are marginalized andmost vulnerable.Addressing unintended pregnancy amongadolescents requires holistic approaches. Becausethe challenges are great and complex, no singlesector or organization can face them on its own.Only by working in partnership, across sectors,and in collaboration with adolescents themselves,can constraints on their progress be removed.Investing in girlsMany of the actions by governments and civilsociety that have lowered adolescent fertilitywere designed to achieve other objectives, suchas keeping girls in school, preventing HIV infection,or stopping child marriage. All of these58 CHAPTER 4: TAKING ACTION

actions have in some way contributed to girls’human capital development, imparted informationor skills to empower girls to make decisionsin life and upheld or protected girls’ basichuman rights.The protective effects of educationIn 2006, Duflo et al. (2006) studied the impactof three school-based HIV-prevention interventionsin Kenya: the training of teachers in theGovernment’s HIV/AIDS-education curriculum;the encouragement of students to debate the roleof condoms and write essays on how to protectthemselves from HIV/AIDS; and a measure toreduce the cost of education. The study involved70,000 students from 328 primary schools andlooked at the effectiveness of these interventionson childbearing, seen by the study’s authors asa proxy for risky behaviours that may result inpregnancy. After two years, the study foundthat the teacher-training programme had littleimpact on students’ knowledge, self-reportedsexual activity or condom use. The condomdebates and essays were found to increasepractical knowledge and self-reported use ofcondoms, but yielded no concrete data relatedto pregnancy and childbearing. However, thereduction in the cost of education—by providingfree school uniforms for students in thesixth grade—reduced dropout rates andadolescent childbearing.Kenya abolished school fees in 2003. Sincethen, the main financial barrier to accessingprimary education has been the cost of schooluniforms, which cost about $6 each. The dropoutrate among girls who received free uniformsdecreased 15 per cent. This decrease translatedinto a 10 per cent reduction in adolescentchildbearing. Reducing the cost of educationhelped girls stay in school longer and alsotGirls in a boardingschool in Nyamuswa,Tanzania.© Mark Tuschman/Project ZawadiTHE STATE OF WORLD POPULATION 201359

decreased the chances of their marrying and havingchildren.In a later study in Kenya, Duflo et al. (2011)found that simply providing children with schooluniforms was sufficient to increase enrolment,reduce the drop-out rate by 18 per cent and lowerthe pregnancy rate by 17 per cent. “The childrenalready enrolled in sixth grade classes were givena free uniform. Implementers also announcedthat students still enrolled in school the followingyear would be eligible for a second uniform, anddistributed uniforms again the following year.”(Duflo et al., 2011) The reduction in the numberof pregnancies, however, occurred “entirelythrough a reduction in the number of pregnancieswithin marriage” as “there was no change inthe out-of-wedlock pregnancy rate.” This findingsuggests that education’s protective power lay inits ability to reduce child marriage rates, which inturn helped reduce adolescent pregnancy. Dufloet al. concluded that “giving girls…the opportunityto go to school if they want to do so is anextremely powerful (and inexpensive) wayto reduce teen fertility.”Girls reap many immediate and long-term benefitsfrom education, which, during adolescence, isa necessary first step for girls to overcome a historyof disadvantage in civic life and paid employment(Lloyd, 2009). Enhancing the quality andrelevance of learning opportunities for adolescentscan prepare and empower girls for a range of adultroles beyond the traditional roles of homemaker,mother, and spouse, with benefits not just for thegirls, but also for their families and communities.Being in school along with boys during adolescencefosters greater gender equality in the dailylives of adolescents. Education for adolescent girlshelps them avoid early pregnancies, and lowerstheir risk of HIV/AIDS.While primary education is a basic need forall, secondary education offers greater prospectsof remunerative employment, with girls receivingsubstantially higher returns in the workplacethan boys when both complete secondary school.Gupta et al. (2008) found that “educationcontinues to be the single most important predictorof age at marriage over time.” Schoolenrolment has a protective value in that schoolgirls are “seen as children and not of marriageableage” (Marcus and Page, 2013). According to onestudy in Kenya (Duflo et al., 2011), “once oneleaves school, sex and marriage are expected.”Decades of research have shown that educationand schooling are key factors for not onlyreducing the risk of early sexual initiation,pregnancy, and early childbearing, but also forincreasing the likelihood that adolescents willuse condoms and other forms of contraception ifthey do have sexual intercourse (Blum, 2004).Other actions, such as conditional cash transfers,aimed at keeping girls in school have alsoprotected girls from pregnancy. Conditionalcash transfers are regular monthly or bi-monthlypayments, which are contingent on familiesavailing themselves of basic services, such asschool, primary health care, sexual and reproductivehealth services, or free awareness-raisingor education sessions.Malawi, for example, piloted a conditionalcash transfer programme to encourage girlsin the Zomba district to stay in school or toencourage recent dropouts to resume their education.Zomba has a high dropout rate, loweducational attainment, and the country’s highestHIV prevalence rates among women ages15 to 49. Through the Zomba programme,households received a $10 monthly transfer,equivalent to about 15 per cent of the60 CHAPTER 4: TAKING ACTION

average household income. About 70 per centof the transfer went to the parents, and 30per cent went to the girl herself. In addition,the programme paid a girl’s secondary school feedirectly to the school, as soon as her enrolmentwas confirmed. Households received transfersonly if girls attended school for at least 75per cent of the days school was in session inthe previous month (Baird et al., 2009). Somegirls were randomly assigned to receive unconditionalcash transfers: no conditions, only cash.Unconditional transfers had a more powerfuleffect than conditional transfers on reducing theincidence of marriage and adolescent childbearing(Baird et al., 2011).More than three in five girls who had droppedout returned to school because of the conditionalcash transfers. In addition, 93 per cent ofthe girls who had not previously dropped outand participated in the programme were still inschool at the end of the school year, comparedwith 89 per cent of the girls who had not previouslydropped out and did not participate inthe programme.PROGRESS BEING MADEJAMAICAA governmentfoundation enables pregnantgirls to continue theireducation and returnto school after theygive birth.EGYPTGirl-friendly spacescombining literacy training,life-skills training andrecreation programmeschanged girls' perceptionsabout early marriage.UKRAINEIncreasing adolescents'access to contraceptionreduced abortions bytwo-thirds.INDIAA life-skills programmefor young marriedwomen resulted inincreased use ofcontraception.KENYAFree school uniformsincreased enrolments,reduced drop-out rates,and lowered pregnancyrate by 17 per cent.THE STATE OF WORLD POPULATION 201361

Baird et al. (2009) also found that the initiativemay have affected sexual behaviour andsuggested that “as girls and young womenreturned to (or stayed in) school, they significantlydelayed the onset (and, for those alreadysexually active, reduced the frequency) of theirsexual activity. The programme also delayedmarriage—which is the main alternative forschooling for young women in Malawi—andreduced the likelihood of becoming pregnant.”For programme beneficiaries who were out ofschool at baseline, the probability of gettingmarried and becoming pregnant declined by40 per cent and 30 per cent, respectively.A 2012 review, Adolescent Fertility in LowandMiddle-Income Countries: Effects andSolutions, found that “the evidence base supportingthe effectiveness of conditional cashtransfers was relatively strong in comparison toother interventions.” Evidence of these transfers’impact on education is especially strong.A recent analysis of transfers in developingcountries found that on average they improvesecondary school attendance by 12 per cent(Saavedra and Garcia, 2012).Enhancing knowledge, building skillsIn Zimbabwe, a programme designed to preventHIV infection among young people also had theunintended but welcome effect of reducing thenumber of adolescent pregnancies (Cowan et al.,2010). Across 30 communities in seven districtsin the south-eastern part of the country, professionalpeer educators worked with young peoplein and out of school to enhance knowledge anddevelop skills. At the same time, communitybasedprogrammes aimed to improve knowledgeof parents and other stakeholders about reproductivehealth, improve communication betweenparents and their children, and build communitysupport for adolescent reproductive health. Theprogramme also included training for nurses andother staff in rural clinics to improve availabilityand accessibility of services for young people.At the end of the programme, a survey of 4,684young people between the ages of 18 and 22showed some improvement in knowledge levelsbut no impact on self-reported sexual behaviours.However, young women who participatedin the programme were less likely to report thatthey had become pregnant compared to those ina control group.The Empowerment and Livelihood forAdolescents programme in Uganda aimed toprevent HIV among adolescent girls and helpthem enter the labour market. Through the programme,implemented by the non-governmentalorganization BRAC, girls in 50 communitiesreceived life-skills training to build knowledge,improve negotiating skills and reduce riskybehaviours and vocational training to help themstart small-scale enterprises. After two years, theaverage fertility rate of girls participating in theprogramme was three percentage points lowerthan girls not in the programme—translatinginto a 28.6 per cent reduction—and the likelihoodof girls engaging in income-generatingactivities rose 35 per cent (Bandiera et al., 2012).In Guatemala, Mayan girls are the country’smost disadvantaged group, with limited education,frequent childbearing, social isolation andchronic poverty. Many are married as children(Catino et al., 2011). The Population Counciland other groups launched a project in 2004to strengthen support networks for Mayan girlsbetween the ages of eight and 18 in rural areasand help them successfully navigate adolescenttransitions. The project, Abriendo Oportunidades62 CHAPTER 4: TAKING ACTION

(“Open Opportunities”), established communitybasedgirls clubs and safe spaces where girls couldcome together, gain life and leadership skills andbuild social networks. As a result of the initiative,100 per cent of participating girls completed sixthgrade, compared with 81.5 per cent of all girlsnationwide. Seventy-two per cent of the girls inthe programme were still in school at the endof the two-year programme, compared to 53per cent of all indigenous girls nationwide.An evaluation showed that 97 per cent of theprogramme’s participants remained childless, comparedwith the national average of 78.2 per centfor girls ages 15 to 19 (Segeplan, 2010). Sincethen, the programme has expanded to more than40 communities and has reached more than 3,500indigenous girls. The programme now offers separateservices for girls between the ages of eight and12 and those between the ages of 13 and 18, witheach group benefiting from age-specific services.In many developing countries, adolescentpregnancy occurs mainly within child marriage.Eighteen is the minimum legal age for marriagefor women without parental consent in 158 countries(UNFPA, 2012). However, in 146 countries,state or customary law allows girls younger than18 to marry with the consent of parents or otherauthorities; in 52 countries, girls under age 15can marry with parental consent.Laws are important but are infrequentlyenforced. A recent UNICEF paper reported, forexample, that in India, where 47 per cent of girlsare married before 18, only 11 people were convictedof perpetuating children marriage in 2010,despite a law forbidding it (UNICEF, 2011a).Because of the challenges in enacting andenforcing laws, some governments are takingother measures that empower girls at risk of childmarriage through, for example, life-skills training,provision of safe spaces for girls to discusstheir futures, the provision of information abouttheir options, and the development of supportnetworks. Such interventions seek to equip girlswith knowledge and skills in areas relevant totheir lives, including sexual and reproductivehealth, nutrition, and their rights under the law.Girls are empowered when they are able to learnskills that help them to develop a livelihood,communicate better, and negotiate and makedecisions that directly affect their lives. Safespaces and the support they offer help girlsovercome their social isolation, interact withpeers and mentors, and assess alternatives tomarriage (UNFPA, 2012).An example of such a programme is BerhaneHewan, a two-year programme in Ethiopiathat began in 2004. The Berhane Hewanprogramme set out to protect girls from forcedt Life-skills class,Ethiopia.© Mark Tuschman/Planned ParenthoodGlobalTHE STATE OF WORLD POPULATION 201363

© Mark Tuschman/Planned Parenthood Globalmarriage and support those who are alreadymarried through the formation of groups ledby female adult mentors. The programme providedeconomic and other incentives for girls tostay in school, including non-formal education,such as literacy and numeracy skills development,for girls who are not in school; andengagement with communities in the discussionof issues such as child marriage (Erulkar,A. S., and Muthengi, E., 2009). An estimated41 per cent of women between the ages of 20and 24 in Ethiopia report having been marriedbefore age 18 (UNFPA, 2012).Through the Berhane Hewan programme,peers, the community and individuals successfullycame together to improve the social,educational and health status of vulnerablegirls (Bruce et al., 2012). The programmecoupled community education and engagementwith financial incentives. Participantswere given school supplies, worth about$6 a year, as well as a goat or sheep, worthabout $25, upon completion of the two-yearprogramme. The programme reached morethan 12,000 girls in the Amhara region,which has the country’s highest incidence ofchild marriage. Girls who attended the programme—especiallythose between the ages of10 and 14—were more likely to have stayedin school and were less likely to have marriedthan their counterparts who did not participatein the programme.64 CHAPTER 4: TAKING ACTION

In India, Pathfinder International implementeda government programme, Prachar(“Promote”) to change behaviours with the aimof delaying marriage and promoting healthytiming and spacing of pregnancies amongadolescents and young couples in Bihar. ThisIndian state has the highest prevalence of childmarriage (63 per cent) and the highest share (25per cent) of girls between the ages of 15 and19 who have begun childbearing (PathfinderInternational, 2011).The Prachar programme included life-stagespecifictraining in sexual and reproductivehealth to unmarried girls between the ages of12 and 19 and to boys between 15 and 19.Women change-agents conducted home visitsto young married women, and men changeagentsconducted home visits to boys. Parentsand mothers-in-law were engaged throughcommunity meetings, and mothers-in-law alsoparticipated in the home visits. Young coupleswere invited to participate in “newlywed welcomeceremonies,” which offered information,education and entertainment to improve knowledgeabout sexual and reproductive health, buildlife skills and promote couples’ communicationand joint decision-making.At the conclusion of the programme’s firstphase, young married women were nearly fourtimes more likely to use contraception as youngmarried women not participating in the programme.Also, participants were 44 per centless likely to be married and 39 per cent lesslikely to have had a child than girls outsidethe programme area.The Ishraq (“Enlightenment”) programmein Egypt began in 2001 with the aim of transforminggirls’ lives by changing gender normsand community perceptions about girls’ roles insociety, while bringing them safely and confidentlyinto the public sphere. The programmeestablished girl-friendly spaces in communitiesto enable girls to meet, learn and play,and combined literacy classes, life-skills trainingand sports (Brady et al., 2007). While anevaluation of the programme did not addressadolescent pregnancy, it did address a numberof factors associated with child marriage andearly pregnancy. Specifically, literacy improved(92 per cent of participants who took the governmentliteracy exam passed) as did schoolenrolment (nearly 70 per cent of programmeparticipants entered or re-entered school).After the programme, participants expresseda desire to marry later. Additionally, theprogramme was associated with increasedself-confidence: 65 per cent felt “strong andable to face any problem.”Consistent long-term, multi-level sexual andreproductive health programming can also contributeto prevention of adolescent pregnancy.An example of one developed country that hasachieved very low levels of adolescent pregnancyand abortion is the Netherlands, which hasa pragmatic and comprehensive approach tofamily planning, especially for young people. Ithas resulted in one of the lowest abortion ratesworldwide (UNFPA, 2013d). Since 1971, familyplanning has been included in the nationalpublic health insurance system, providing freecontraceptives. Sexuality education is universaland comprehensive, and girl’s empowerment isamong the highest worldwide. Sexually activeyoung people display some of the highest ratesof contraceptive use of any youth population,and as a consequence, the country’s abortionrate is one of the lowest in the world (Kettingand Visser, 1994; Sedgh et al., 2007).THE STATE OF WORLD POPULATION 201365

The right to age-appropriate,comprehensive sexualityeducationCurriculum-based comprehensive sexualityeducation provides young people with ageappropriate,culturally relevant and scientificallyaccurate information. It also provides youngpeople with structured opportunities to exploreattitudes and values and to practise skills theywill need to be able to make informed decisionsabout their sexual lives.Adolescents and young people have a rightto comprehensive and non-discriminatorysexuality education through several humanrights agreements and documents, includingthe Convention on the Rights of the Child,the International Covenant on Economic,Social and Cultural Rights; the InternationalCovenant on Civil and Political Rights; theConvention on the Elimination of All Formsof Discrimination against Women; and theConvention on the Rights of Persons withDisabilities. Comprehensive sexuality educationis essential for the realization of other humanrights (UNFPA, 2010).In a review of 87 comprehensive sexualityeducation programmes including 29 fromdeveloping countries, UNESCO (2009) foundthat nearly all of the programmes increasedknowledge, and two-thirds had a positiveimpact on behaviour: Many adolescents delayedsexual debut, reduced the frequency of sex andnumber of sexual partners, increased condomor contraceptive use, or reduced sexual risktaking.More than one-quarter of programmesimproved two or more of these behaviours.Another study concluded: “There is now clearevidence that sexuality education programmescan help young people to delay sexual activityand improve their contraceptive use when theybegin to have sex. Moreover, studies to date providean evidence base for programmes that gobeyond just reducing sexual activity—namely,unintended pregnancy and sexually transmittedinfections—to instead address young peoples’sexual health and well-being more holistically”(Boonstra, 2011).There are two main approaches to sexualityeducation: advocating abstinence only or providingage-appropriate, comprehensive programmes.Two large reviews (Oxford, 2007; Kirby,2008) found that abstinence-only programmesare not effective at stopping or delaying sex.Comprehensive sexuality education “teachesabout abstinence as the best method for avoidingsexually transmitted diseases and unintendedpregnancy but also teaches about condoms andcontraception to reduce the risk of unintendedpregnancy and of infection with sexually transmitteddiseases, including HIV. It also teachesinterpersonal and communication skills andhelps young people explore their own values,goals and options” (Advocates for Youth, 2001).Looking at comprehensive programmes,UNESCO found that “nearly all of the programmesincreased knowledge, and two-thirdshad a positive impact on behaviour…” includingdelaying sexual debut. In the United States,the highest rates of adolescent pregnancy tendto be in states where abstinence-only educationpredominates. The lowest rates occur in stateswhere information about sexuality and contraceptionis provided in a non-judgmental manner(Szalavitz, 2013).In reviewing the progress and achievementsof comprehensive sexuality education since the1994 International Conference on Populationand Development, the international community66 CHAPTER 4: TAKING ACTION

has learned a number of lessons about comprehensivesexuality education. One is thateven in the face of the HIV/AIDS pandemic,governments have been slow to implementcomprehensive sexuality education, and evenslower to reach the most vulnerable youngpeople (Haberland and Rogow, 2013).A second lesson is that comprehensive sexualityeducation can be effective beyond theprevention of high-risk behaviours. Researchshows that programmes that tend to have thegreatest impact on adolescent pregnancy andsexually transmitted infections are those thatemphasize critical thinking about gender andpower in relationships (Haberland and Rogow,2013). These findings offer promise for a newgeneration of programmes that can have aconcrete, positive impact on the well-beingof young people.New research shows that comprehensive sexualityeducation programmes are more likely tohave an impact on reducing adolescent pregnancyand sexually transmitted infections whenthey address gender and power issues. Studiesfrom both developing and developed countriesconfirm that young people who believe in genderequality have better sexual health outcomesthan their peers. In contrast, those youngpeople who hold less egalitarian attitudestend to have worse sexual health outcomes(International Sexuality and HIV CurriculumWorking Group, 2011).Gender equality and human rights are key topreventing the spread of HIV and to enablingyoung people to grow up to enjoy good health.For example, young people who, compared totheir peers, adopt egalitarian attitudes aboutgender roles are more likely to delay sexualdebut, use condoms, and practice contraception;they also have lower rates of sexuallytransmitted infections and unintended pregnancyand are less likely to be in relationshipscharacterized by violence. Another study foundthat a targeted programme to increase girls’understanding of the risks of intergenerationalsex reduced pregnancy by 28 per cent (Dupas,2011).Most comprehensive sexuality educationis delivered through school-based curricula.However, not all adolescents attend school andnot all remain in school until they initiate sex.Married girls between the ages of 10 and 14and who are not in school thus have virtuallyno access to sexuality education. It is thereforeimportant to make additional efforts to meetthe needs of adolescents who are out of school.Curriculum- and group-based sexuality andHIV education programmes can reach thosewho are not in school if they are implementedby providers of health and other services foryouth, community centres, or other localinstitutions accessible to adolescents (Kirbyet al., 2006).According to UNESCO (2013), 57 millionchildren of primary school age and 69 millionchildren of lower-secondary school age do notattend school. Most of them live in developingcountries, and slightly more than halfare girls. Two approaches with potential forreaching large numbers of out-of-school adolescents—althoughnot necessarily as stand-aloneprogrammes for preventing pregnancy—involvethe use of the mass media and interactive radioinstruction.Recent reviews of mass media campaigns thatpromoted adolescent sexual health, mostly indeveloping countries, found that they commonlyincreased knowledge, and the majorityTHE STATE OF WORLD POPULATION 201367

t Contraceptioninformation atCEMOPLAF centrein Ecuador.© Mark Tuschman/Planned ParenthoodGlobalinfluenced behaviours such as condom use(Gurman and Underwood, 2008; Bertrandet al., 2006). Some reduced the number ofpartners for women, decreased their frequencyof casual sex or sex with “sugar daddies” andincreased abstinence.In Zambia, the HEART (Helping EachOther Act Responsibly Together) campaign,designed for and by adolescents ages 13 to 19,helped raise awareness about HIV preventionand condom use and sought to create a socialcontext in which prevailing social norms couldbe discussed, questioned and reassessed toreduce sexual transmission of HIV. An evaluationfound that, compared with those who didnot view the programming, viewers were87 per cent more likely to use condoms, and67 per cent more likely to have used a condomthe last time they had sex. Condom use is abehaviour that can help prevent pregnancy(AIDSTAR-One, n.d.).Brazil’s Programme for Sexual and EmotionalEducation: A New Perspective is framed withina perspective of rights and is focused on preventingunsafe sexual practices and promotingpositive approaches that address what it meansto have a “healthy and pleasurable sex life.” Theprogramme, which also addresses gender equity,uses an integrated approach that reaches adolescentsin and out of the classroom and involvesteachers, health care providers, families andthe community. Adolescents are also reachedthrough radio programmes, school newspapers,plays and informational workshops. An evaluationthat polled 4,795 youth in 20 publicschools in the state of Minas Gerais found thatafter the programme, the group receiving sexualityeducation had a higher percentage usingcondoms with either a casual partner or a steadypartner and a higher percentage using a moderncontraceptive, compared with a control group.Additionally, the programme did not result inan increase in sexual activity (Andrade et al.,2009).Media campaigns have been more effective atreaching urban adolescents (both in and out ofschool) than rural adolescents, although theirreach is expanding with the increasing availabilityof social media and mobile communicationstechnologies.However, just as the media can be part of thesolution by advocating for prevention, they mayalso glamourize sex and adolescent childbearing,as in MTV’s Teen Mom 2 television series in theUnited States.Advertising campaigns are another way ofeducating or informing the public. Some ofthese campaigns rely on fear or scare tactics to68 CHAPTER 4: TAKING ACTION

change behaviour through the threat of impendingdanger or harm (Maddux et al., 1983). Feartactics present a risk, identify who is vulnerableto that risk and urge a particular action, suchas taking steps to prevent an adolescent pregnancy.Research on fear-based messaging that,for example, encourages people to stop smokingor lose weight, shows these campaigns have littleeffect when they provide strong fear messageswith no recommended action or when the recommendedaction is not easily taken oris perceived to be ineffective. Such approachesare also ineffective when there are no acknowledgmentsof barriers to action and how they canbe overcome, and no support for recipients sothey believe that they are capable of taking theaction. For these approaches to work, the perceivedefficacy of action must be greaterthan the perceived threat.Content delivery systems are also evolving,as many programmes launch online curricula(Haberland and Rogow, 2013). Despite thecurrent lack of compelling evidence that this‘‘The way the media puts itis that everyone should havesex! Everything is about sex . . .commercials . . . everything. Ofcourse, people start living by itand people get careless.’’17-year-old girl, Swedendelivery mechanism offers measurable advantagesin outcomes, the potential for low-cost, globalreach suggests the likelihood of an increasingnumber of Internet-based programmes in thefuture. Investment in rigorous research to assessits effects is needed. Meanwhile, some existingprogrammes, such as Afluentes in Mexico andButterfly in Nigeria, are using computer-basedprogrammes to provide training or technicalsupport to teachers.Life-skills programmes offer another way foradolescents to acquire information that can helpthem prevent a pregnancy. UNICEF (2012)finds that about 70 countries have nationallevellife-skills training programmes, whichvary across country and cultural context. Ingeneral, however, life-skills training focuses onbuilding five core skills: decision-making andproblem-solving; creative thinking and criticalthinking; communication and interpersonalskills; self-awareness and empathy; and copingwith emotions and stress. Much of the focus oflife-skills training has been on the developmentof protective psychological skills, communicationskills and knowledge to avoid risk.For 10 years starting in 1996, the Life SkillsProgramme in Maharashtra, India, includedweekly hour-long sessions, some of whichfocused on health, child health and nutrition.The programme was designed to reach unmarriedgirls between the ages of 12 and 18, withan emphasis on girls who were out of schooland working. It involved parents in programmedevelopment and teachers to lead the classes.An evaluation showed significant impact: Inthe area covered by the programme, the medianage of marriage rose from 16 to 17, and thecontrol group was four times more likely tomarry before age 18 than the programme group.THE STATE OF WORLD POPULATION 201369

s Youth peereducators ofGeração Bizin Maputo,Mozambique.© UNFPA/PedroSá da BandeiraAdditionally, the proportion of marriages of girlsbefore age 18 fell to 61.8 per cent compared to80.7 per cent for girls outside the programme(Pande et al., 2006).Attitudes of boys and men have a significantimpact on the health, rights, social status andwell-being of girls and thus on girls’ vulnerabilityto pregnancy. In many countries, UNFPAsupports programmes to work with boys, maleadolescents and youth on sexuality, family lifeand life-skills education to question currentstereotypes about masculinity, male risk-takingbehaviour (especially sexual behaviour) and topromote their understanding of and supportfor women’s rights and gender equality. In somecountries, UNFPA has partnered with nationalinstitutions to raise awareness of the impact ofnegative attitudes and harmful practices ongirls and women through school-based, ageappropriate,comprehensive sexuality educationor with civil society organizations to engagemen and boys in dialogue about their attitudestowards issues such as child marriage, contraceptionand matters of sexual and reproductivehealth and reproductive rights.Investing in services foradolescents and young peopleAdolescents—married or unmarried—often lackaccess to contraceptives and information abouttheir use. Barriers include a lack of knowledge ofwhere to obtain them, fear about being rejectedby service providers, opposition by a male partner,community stigma about contraception oradolescent sexuality, inconvenient locations orclinic hours, costs, and concerns about privacyand confidentiality.To make it easier for adolescents to learnabout preventing pregnancy and sexually transmittedinfections, including HIV, or to obtaincontraceptives, an increasing number of countrieshave established youth-friendly sexual andreproductive health services. Youth-friendly servicestypically ensure adolescents’ privacy, are inlocations—and are open at hours—that are convenientto young people, are staffed by providerswho are trained in meeting young people’s needs,and offer a complete package of essential services.Nicaragua, for example, is increasing disadvantagedadolescents’ and young people’s access tosexual and reproductive health services, including70 CHAPTER 4: TAKING ACTION

contraception, through its Competitive VoucherScheme. Vouchers for free services are distributedby local non-governmental organizationsto adolescents and youth in Managua’s markets,outside public schools, on the streets and inclinics. Outreach workers also distribute vouchersdoor to door. Each voucher is valid for threemonths and may be transferred to another adolescentin greater need. It can be used to coverone consultation and one follow-up visit for:counselling, family planning, pregnancy testing,antenatal care, treatment of sexually transmittedinfections, or any combination of services. Theprogramme also trained clinic staff in counsellingfor adolescents, issues of adolescent sexuality,and identifying and addressing sexual abuse(Muewissen, 2006).Preliminary findings from an evaluationshowed that vouchers were associated withgreater use of sexual and reproductive healthcare, knowledge of contraceptives, knowledgeof sexually transmitted infections and increaseduse of condoms.Through Mozambique’s Geração Biz (BusyGeneration) programme, the ministries of health,education and youth and sports jointly provideyouth-friendly sexual and reproductive healthservices, school-based information campaignsabout contraception and HIV prevention andcommunity-based information to reach youngpeople who are not in school. Through a networkof 5,000 peer counsellors, Geração Bizprovides non-judgmental, confidential informationand services to Mozambique’s youth. Themulti-sectorial nature of the programme thatengages policymakers, health care providers,educators and community stakeholders as wellas youth themselves is a key contributing factorto an increase in adolescents’ and young people’sknowledge about and use of contraception(Hainsworth et al. 2009).The Development Initiative SupportingHealthy Adolescents (DISHA) programme inIndia combines community-level mentoringand community dialogue with the scaling upof health services and comprehensive sexualityeducation, contraceptive education and provision,and life skills training. In 176 villages,the programme has created youth groups andresource centres where adolescents can learnabout sexual and reproductive health, receive servicesand enrol in training for future livelihoods.The programme also trains local health providersin youth-friendly care, organizes volunteers todistribute modern methods of family planning,deploys peer educators, organizes counsellingsessions, and provides a forum for young peopleand adults to come together to talk about youth’srole in society.Using a quasi-experimental design with acomparison group, the evaluation showed thatthe age of marriage among programme participantsrose from 15.9 years to 17.9 years; andmarried youth exposed to DISHA were nearly“Once a condom broke, and we onlydiscovered it afterwards. My girlfriendpanicked, which I fully understand. But Iactually think we managed the situationwell. We found a pharmacy where webought emergency contraception.”Lasse, 18, DenmarkTHE STATE OF WORLD POPULATION 201371

ADOLESCENT ABORTION RATES DROP BYTWO-THIRDS IN UKRAINEOne million abortions were reported each year in Ukraine in theearly 1990s. Since then, the number has decreased by more than 80per cent, mainly because of increased access to contraceptives andfamily planning information and services.The abortion rate among adolescents between the ages of 15and 17 has also declined, from 7.74 abortions per 1,000 girls, to 2.51today. This decrease is attributed to Government efforts to increaseaccess to youth-friendly health services and to legislation, policiesand programmes that prioritize young people’s sexual and reproductivehealth.One such programme, the Government’s “Reproductive Healthof the Nation,” aims to preserve the reproductive health of thepopulation and positively influence reproductive health amongadolescents. Another, the national Youth of Ukraine programmepromotes healthy lifestyles as a national priority.UNFPA, the World Health Organization and UNICEF are supportingthe Ministry of Health’s development of a comprehensiveregulatory and institutional framework for youth-friendly healthservices.Access to quality family planning services, including counsellingon modern methods of contraception, has improved, and awarenessabout the health benefits of family planning has grown. TheGovernment has entered into partnerships with pharmaceuticalcompanies and pharmacies to broaden the range of available contraceptivesand reduce their price, and the Ministry of Health hasstrengthened its capacity to support and promote family planninginitiatives, including those available to adolescents and youth.Viktoriya Verenych, an obstetrician-gynaecologist at a youthfriendlyclinic in Kyiv, says that over the past five years, she hasnoticed a trend of earlier sexual debut among her clients.“It is very important that at this point in their lives, they haveaccess to qualified counselling on prevention of unwanted pregnancies,HIV and sexually transmitted infections,” Verenych says. “Thiscounselling must be provided in a youth-friendly manner.”60 per cent more likely to report the current useof a modern contraceptive compared to similaryouth not exposed to the programme. Likewise,attitudes towards child marriage changed. At thestart of the programme, 66 per cent of boys and60 per cent of girls believed that the ideal age ofmarriage for girls was 18 or older. After the programme,the comparable figures were 94 per centof boys and 87 per cent of girls (Kanesathasan etal., 2008).Access to emergency contraception is especiallyimportant for adolescents, especially girls, whooften lack the skills or the power to negotiateuse of condoms and are vulnerable to sexualcoercion, exploitation and violence. Emergencycontraception is a method to prevent pregnancywithin five days of unprotected intercourse,failure or misuse of a contraceptive (such as aforgotten pill), rape or coerced sex. It disruptsovulation and reduces the likelihood of pregnancyby up to 90 per cent. It cannot preventimplantation of a fertilized egg, harm a developingembryo or end a pregnancy.Barriers to adolescents’ accessing emergencycontraception include lack of knowledge aboutit, reluctance of health care workers to provideit, cost, community opposition to its use andlegal restrictions.In 22 countries, a dedicated and registeredemergency contraceptive pill is unavailable(International Consortium for EmergencyContraception, 2013). Even in countries whereemergency contraception is available, adolescentsmay be reluctant to obtain it from traditionalhealth outlets, such as clinics, which may bestaffed by judgmental providers. To make iteasier for adolescents to obtain emergency contraception,the non-governmental organizationPATH developed a project in Cambodia, Kenya,72 CHAPTER 4: TAKING ACTION

and Nicaragua to strengthen the capacity ofpharmacies to provide youth-friendly reproductivehealth services with a focus on emergencycontraception. The initiative trained pharmacystaff and peer educators to provide accurate, upto-dateinformation on emergency contraceptionand other reproductive health services.An assessment of the initiative found thatthe project increased the capacity of pharmacypersonnel to provide high-quality reproductivehealth services to youth. Data suggest thatpharmacy staff gained knowledge of emergencycontraceptive pills, sexually transmitted infectionsand modern methods of contraception.RESPONDING TO THE NEEDS OF ADOLESCENTS AND YOUTH IN COLOMBIAOn the second floor of a modern building, the youth-friendlyhealth centre in Duitama, Colombia, has a few white walls, butmost have been painted by local adolescent graffiti artists. OfDuitama’s 111,000 inhabitants, about one quarter are betweenthe ages of 10 and 24.Every month, more than 600 young people take advantageof the centre’s services, which include everything from dentistryto sexual and reproductive health and psychotherapy.“It’s not only about health, it’s also about communication,”says Nubia Stella Robayo, a nurse specializing in maternal andperinatal health services for adolescents.“Most of the girls have financial problems,” Robayo says.“Eighty per cent of their pregnancies were unplanned.” Andmost of the girls and boys who come to the centre for the firsttime are not using contraceptives.Robayo says many of the girls she sees think that their bodiesare too immature to become pregnant, so they think they donot need to worry about using a condom. This is especially thecase among girls from surrounding rural areas. The confusionabout sexuality and pregnancy, she says, points to a need forbetter sexuality education and information.“When I first heard about youth-friendly services, I thoughtit was a fabulous idea and I said ‘we have to do it’,” says LucilaEsperanza Perez, the centre’s manager, who says preventingadolescent pregnancy is the main goal. Perez herself had hadtwo children by the time she was 20 and knows first-handthe challenges adolescent pregnancy can pose. “We wanted acentre where young people could receive the information theyneed to manage their sexual and reproductive lives," Perezsays. “And young people were consulted from the beginning ofthe project; they have been the true managers.”A service is considered youth-friendly when it meets theneeds of adolescents and youth, recognizes their rights, andbecomes a place where they can be informed, guided andtaken care of, she explains. Health, she adds, is a state of physical,mental, spiritual and social well-being.Catherine, 19, is 32 weeks pregnant and gets her antenatalcheck-ups at the centre. “Pregnancy is hard if it is notplanned,” she says, “as there are too many goals and dreamsto be deferred.”Catherine says the nurses and doctors at the centre makeher feel appreciated. “The nurses and doctors speak to youwith affection, and they are always receptive to any question orsituation you may have,” she says.Juan, 20, has joined one of the centre’s peer groups, whereyoung people have an opportunity to share their experiencesand knowledge with other young people in schools andthroughout the community. His peer group also leads workshops,forums and other activities that bring young peopletogether to discuss issues ranging from responsible sexualityto gender-based violence. Sometimes as many as 1,000 youngpeople turn up for events.While more and more young people are using the centre’sservices, and adolescent pregnancies are starting to decrease,Perez says “there is a lot to do” to help even more peopleprevent pregnancies and address other problems that affectDuitama’s youth, such as preventing sexual violence andstopping substance abuse.THE STATE OF WORLD POPULATION 201373

In all three countries, knowledge of emergencycontraception by pharmacy staff increased considerably.Before the training, initial assessmentdata showed that up to 30 per cent of pharmacystaff were providing emergency contraceptivepills correctly; after the training, that figure roseto about 80 per cent (Parker, 2005).Ending sexual coercion andviolenceSexual violence usually refers to sexual intercoursethat is physically forced, especially rape.Sexual coercion is more broadly the act of forcingor attempting to force another individualthrough violence, threats, verbal insistence,deception, cultural expectations or economic circumstanceto engage in sexual behaviour againsthis or her will (Baumgartner et al., 2009).Definitions that aggregate all forms of sexualcoercion and sexual violence make it difficultto establish a relationship between adolescentpregnancy and sexual violence, such as rape, orsexual coercion which adolescents may or maynot identify as violence.Almost 50 per cent of allsexual assaults around the worldare against girls below age 16.Stopping coercion and violence against adolescents—oranyone—is an imperative everywhereand requires continuous actions on many fronts,from strengthening criminal justice systemsso that perpetrators are brought to justice andthat survivors are supported, to training healthcare providers to recognize and report it and tochanging the attitudes of men and boys so thatcoercion and violence are prevented.India, Haiti and the Democratic Republic ofthe Congo are three countries that have recentlymoved to strengthen laws against sexual violence,but to date there has not been an evaluation ofsuch laws either there or elsewhere as to howwell they protect girls from rape and unwantedpregnancy (Heise, 2011). However, much likelaws prohibiting child marriage, their efficacyresides in enforcement and the public’s supportfor them. But also like child marriage laws, lawsthat penalize sexual and gender-based violencesend a strong message that protecting the rightsof vulnerable young people and especially adolescentgirls is a national priority.A review of evidence on interventions to reduceviolence against adolescent girls (Blanc et al.,2012) notes that violence-prevention initiativesare typically implemented within the broader contextof programmes that address life skills, createsafe spaces for girls, and change notions of masculinityamong boys and young men. Or they areembedded in broader youth-focused programmesthat address sexual and reproductive health.These programmes have, for example, workedthrough sports associations (Brady and Khan,2002), life-skills and peer-support programmes(Askew et al., 2004; Ajuwon and Brieger, 2007;Jewkes et al., 2008), female mentorship/guardianprogrammes (Mgalla et al., 1998), programmespromoting HIV prevention and reproductivehealth education, (Hallman and Roca 2011) andworkshops targeting men (Peacock and Levack,2004). Others have modified in-school sexualityeducation or life-skills curricula to include widerdiscussion of gender-based violence and sexualcoercion (Ross et al., 2007).This review points out, however, that whilethese initiatives have succeeded in empoweringgirls, building communication skills and74 CHAPTER 4: TAKING ACTION

developing gender-equitable attitudes, a declinein partner violence was noted only in cases whenactions also focused on economic empowerment,gender and sexual health, and group solidarity(Pronyk et al., 2006; Jewkes et al., 2008) and/orengaged men and boys (Verma et al., 2008).Investing in girls who are pregnantor have childrenMuch can be done to reduce the harmful health,social and economic effects of pregnancy on girlsand ensure that opportunities for education, jobs,livelihoods and participation in the affairs of theircommunities are not lost, for both married andunmarried adolescents.Ensuring access to services for pregnantadolescents or new mothers often means providingfinancial support for health care anddiet, advice about breastfeeding, help returningto school or training, shelter and servicesif they have been rejected by their familiesand contraceptive or birth-spacing informationand services.Critical factors for improving maternal healthfor adolescents include access to and use of antenatalcare to identify and treat underlying healthissues, including malaria, HIV or anaemia, providingobstetric care to ensure the safe delivery ofyoung mothers and their infants, treating complicationsfrom unsafe abortion, providing postnataland newborn care, and making contraceptionavailable to allow birth spacing (Advocates forYouth, 2007).But for millions of adolescents around theworld, access to services is limited by a range ofeconomic, social and geographical factors as wellas availability. Personal autonomy—or the lack ofit—is a key determinant of access and use. Thisobstacle is particularly daunting for girls whoare in marriages and have little say in decisionsregarding their own health and little or no accessto money needed for transportation to clinicsor to pay for care (World Health Organization,2007). Girls may also not seek care if they believeproviders of services will be judgmental or refuseto accommodate them.In general, adolescents seek care later, andreceive less. Pregnant girls often lack knowledgeabout which services exist, when care should besought and how to find care at the right time.Girls who do not receive antenatal care are less“When I was 17, I got a boyfriend at school. Iasked my girlfriends about sex and they saidyou cannot get pregnant the first 10 days afteryour period. But I got pregnant. The boy wasso scared he ran away, and my parents wantedto kill me. Luckily, a teacher from my schoolcame along and helped me break the news tomy parents. The teacher also told them that Icould go back to school after giving birth. Atfirst, my parents didn’t accept, but afterwardsthey were convinced. Now, I finished school at20 years old and I want to be a teacher. I wishthe topic is more discussed at school so thatgirls don’t make the mistake I did.”Phoebe, 20, UgandaTHE STATE OF WORLD POPULATION 201375

likely to be prepared for an emergency before,during or after childbirth. Rural women maybe several kilometres walk from the nearesthealth care facility (World Health Organizationand UNFPA, 2006). They may be much furtherfrom a facility that can provide emergencyobstetric care.Brazil is one country that has taken stepsto increase pregnant girls’ access to antenatal,delivery and postnatal care. The Institute ofPerinatology of Bahia, IPERBA, is a referralcentre for high-risk pregnancies in Bahia, animpoverished state in the northeastern part ofthe country. IPERBA’s multidisciplinary teamaddresses many dimensions of childbearing:sensitive patient-centred childbirth, preventingmother-to-child transmission of HIV and syphilis,and assistance to survivors of gender violence.The hospital is also well-known for offeringspecialized care for pregnant adolescents. It dealswith more than a thousand cases per year, representing23 per cent of all childbirths there.The Better Life Options Programme inIndia takes a holistic approach in its servicesfor pregnant adolescents in urban slums ofDelhi, rural Madhya Pradesh and ruralGujarat. The programme integrateseducation, livelihoods, life skills, literacytraining, vocational training and reproductivehealth, with the overall aim tobroaden girls’ life options (World HealthOrganization, 2007). The programme alsopromotes social change through the educationof parents, family and communitydecision makers. An evaluation found thatgirls participating in the programme weremore likely than girls not in the programmeto follow antenatal nutritional regimens(iron and folate supplements) and deliver ina hospital or at home with a skilled birthattendant.The longer girls stay out of school, the lesslikely they are to return. To enable pregnant adolescentsor new mothers to stay in or return toschool, they need supportive national and localschool policies. But even with supportive policies,many may not resume their education. Forexample, despite progressive legislation in SouthAfrica allowing young women to return to schoolpost pregnancy, only around a third actually reenterthe schooling system (Grant and Hallman,2006). To improve this picture, some girls willneed child care, financial support and individualized,one-on-one support and counselling to helpthem deal with their new responsibilities andfeeling different from their peers.The Women’s Centre of Jamaica Foundationassists girls 17 and younger who have droppedout or have been forced out of school due to apregnancy. Teen mothers are allowed to continuetheir education at the Centre location nearestto them for at least one school term, and thenreturn to the formal school system after the birthof their babies. There are seven main centres and“I had my first child when I was14 and the second one at 17. Tosurvive with my children, I workin people’s gardens for 700Rwandan francs [about $1] a dayor wash people’s clothes.”Emerithe, 18, Rwanda76 CHAPTER 4: TAKING ACTION

eight outreach centres which offer, among otherservices, continuing education for adolescentmothers. Compared with adolescent mothers notparticipating in the Centre’s programme, the rateof repeat pregnancies has been lower among girlsin the programme, and more girls have continuedtheir education, including sitting exams andre-entry into the formal education system.Reaching girls 10 to 14 years oldA number of initiatives have reached or targetedadolescent girls age 14 or younger, whose needs,circumstances and vulnerabilities are verydifferent from those of older adolescents. Themore successful interventions have promotedgender equality, helped keep girls in school orreduced poverty and the economic incentives forchild marriages among the most disadvantagedsegments of society (Blum et al., 2013).Several of the more successful initiativesinclude India’s Life Skills Programme inMaharashtra, Ethiopia’s Berhane Hewanprogramme and Guatemala’s OpenOpportunities programme, mentioned above.Another successful initiative is Rwanda’s FAMProject, an interactive training programme targetedto 10 to 14-year-olds that deals with issuessuch as puberty, fertility, gender norms, communicationsand relationships. Developed bythe Institute for Reproductive Health and implementedin Rwanda in conjunction with CatholicRelief Services, the project increased knowledgeand improved child-parent communicationsabout sexuality and gender roles.Through Nepal’s “Choices Curriculum,”developed by Save the Children, children’s clubsteach very young adolescents about genderequality and raise awareness about issues such asdiscrimination and gender-based violence.However, many countries have given littleattention to this age group apart from taking stepsto keep them in school. Policymakers may assumethat adolescents ages 10 to 14 are under theprotection of a parent or guardian and thus deviseprogrammes that depend on parents’ engagement.But for some young adolescents, parents may notbe present in their lives.Engaging boys and menThe gender-related attitudes expressed by menand boys directly affect the health and well-beingof women and girls.Promoting gender equality by empoweringwomen and engaging men is fundamental toachieving a number of development objectives,such as reducing poverty and improving sexualand reproductive health. Men’s and boys’relationships with women and girls can supportor hamper these objectives (UNFPA, 2013b).A review of actions to engage men and boys inrectifying gender inequities in health interventionsfound that well-designed programmes withmen and boys can lead to changes in attitudes andbehaviours in areas such as sexual and reproductivehealth, maternal and newborn health, HIVprevention and gender socialization (World HealthOrganization, 2007). Integrated programmes,especially ones that combine community outreach,mobilization and mass media campaigns withgroup education, are the most effective at changingbehaviour (UNFPA, 2013b).Reaching out to young men is an especiallygood investment because they are more responsiveto health information and to opportunitiesto view gender relations differently. Researchshows that unhealthy perceptions of sex, includingseeing women as sexual objects, viewing sexas performance-oriented and using pressure orTHE STATE OF WORLD POPULATION 201377

force to obtain sex, begin in adolescence. Formsof gender discrimination affect girls and women,but dominant perceptions of masculinity amongyoung men and adolescent boys are a drivingforce for male risk-taking behaviour, includingstreet violence and unsafe sexual practices(UNFPA, 2013b). Strengthening opportunitiesfor boys and young men to participate insupporting gender-equality efforts will have animpact not only on women and girls but also ontheir own lives. They are more likely to grow intofuture generations of men who live by genderequitableprinciples.With UNFPA support, Nicaragua took a“gender-transformative approach” to preventingsexual violence and pregnancy through aninitiative, Que Tuani No Ser Machista. Gendertransformativeprogrammes challenge andtransform rigid gender norms and relations andgenerally entail moving beyond the individuallevel to also address the interpersonal, sociocultural,structural and community factors thatJAMAICA OFFERS A MODEL FOR PREVENTING ADOLESCENT PREGNANCYAND SUPPORTING YOUNG MOTHERS“Becoming pregnant at such a young age was a terrifying experience.I did not know what to do when I found out,” said 17-year-oldJoelle as she recounted the emotional turmoil of being pregnantduring her teenage years.“It was going to be my final year in high school. I would havebeen graduating and making my parents proud,” she recalled. “Iwas so horrified, ashamed and devastated to see that all the things Iwanted would not happen.”Joelle was one of two girls who candidly shared their experiencewith the First Lady of Burkina Faso, Chantal Compaoré, and herteam, who were in Kingston, Jamaica to learn about the strategiesthe Government has employed to address adolescent pregnancy inthe country.The Adolescent Mothers Programme of the Women’s CenterFoundation of Jamaica that Joelle is enrolled in is a centrepiece ofthese strategies, a UNFPA “good practice” programme and a modelfor other countries grappling with the issue of teen pregnancy.Joelle described the organization and the counsellors who arecaring for her during this difficult period as “firefighters who rescuedme from the mental burning building I was in.”Getting resultsSince 1978, Jamaica’s Programme for Adolescent Mothers hasbeen providing continuing education, counselling and practical skillstraining for mothers under age 17. Through the programme, theycan pursue their education at the nearest Women’s Centre for atleast one semester and then return to the formal school systemafter their babies are born.The Foundation operates seven main centres and nine outreachstations across Jamaica, and provided continuing education to1,402 adolescent mothers in the 2011–2012 school year, morethan half of whom successfully returned to the formal schoolsystem. The Centre also offers a range of other services such asday care facilities and walk-in counselling for women and men ofall ages. This includes counselling for “baby fathers,” their parentsand the parents of teen mothers.Putting family planning at the coreFamily planning is an integral element of the counselling programmeoffered at each branch of the Women’s Centre of Jamaica,and UNFPA has partnered with the organization for years to helpreduce the risk of unintended second pregnancies among mothersthey counsel.With the knowledge and consent of their parents, the youngmothers are provided with sexual and reproductive health informationand offered a contraceptive method of their choice, whichhelps them to delay a second pregnancy and enables them to completetheir education. With support from UNFPA, the Women’s78 CHAPTER 4: TAKING ACTION

influence gender-related attitudes and behaviours(Promundo, 2010).Through group education and advocacy campaigns,the Nicaraguan initiative prompted boysbetween ages 10 and 15 in 43 communities toreflect on what it means to be macho and why,and encouraged them to question gender normsand stereotypes. Group education includedexercises that encouraged boys to express theirfeelings, especially about what it means to bea young man. An estimated 3,000 teenagers“I am always imagining what my life wouldbe like if I had met someone before I waspregnant, someone who taught me tobe assertive, someone who talked to meabout relationships, the advantages anddisadvantages of engaging in sex so young.Maybe I would not be in this situation.”Swinton, 20, pregnant at 15, ZimbabweCentre distributed more than 10,000 male condoms and 6,000female condoms between 2008 and 2011 alone.Over the years, the Centre has succeeded in keeping thesecond pregnancy rate of the adolescent mothers enrolled inits programme below 2 per cent. It has also been effective inhelping students complete their secondary education and evenadvance to university.Back to school: The success of advocacyIn Jamaica, the immediate consequence of teenage pregnancyis expulsion from school, so reintegrating adolescent mothersinto the formal education system has been a priority.These efforts have recently paid off in a landmark achievementwhen the “Policy on the Re-Integration of AdolescentMothers into the Formal Education System” was approvedby the Cabinet in May 2013. This policy breakthrough, spearheadedby the Women’s Centre of Jamaica Foundation and theMinistry of Education, with support from UNFPA, will allowall school-aged mothers to continue their education after thebirth of their child.As of September 2013, when the new policy went into effect,teenage mothers no longer face the risk of being denied entryback to school. Schools are now mandated to accept adolescentmothers back into the formal education system after they givebirth. Moreover, the young moms will have the choice to attend anew school or to return to the one they left.“The education of our girls is a strength of Jamaican culture andhistory,” says Ronald Thwaites, Jamaica's Minister of Education.“We want to give every girl an education, no matter what her circumstances,even if she has become pregnant and had a child. Wewant to lift her up, make sure she gets the best opportunity. Weare a nation of second chances.”Innovation fosters success: Engaging men, nurseriesWhile addressing the young mothers’ challenges is the mainpriority, engaging men and providing them with informationand counselling has also been a central element in the Women’sCentre’s successful strategy.As part of the Centre’s ongoing peer counselling services,UNFPA has supported the training of 50 young men in theClarendon and Manchester regions of Jamaica. Through variousactivities, they help to sensitize their peers on sexual and reproductivehealth issues including family planning, HIV preventionand sexual and reproductive health services. The young menattend Centres or outreach sites close to their homes and providetheir respective outreach managers with reports on their activities.THE STATE OF WORLD POPULATION 201379

ICPD AND THE ROLE OF MENThe Programme of Action of the International Conference onPopulation and Development calls on leaders to “…promote the fullinvolvement of men in family life and the full integration of womenin community life,” ensuring that “men and women are equalpartners” (paragraphs 4.24, 4.29). It notes that “[s]pecial effortsshould be made to emphasize men’s shared responsibility andpromote their active involvement in responsible parenthood, sexualand reproductive behaviour, including family planning; prenatal,maternal and child health; prevention of sexually transmitted diseases,including HIV; [and] prevention of unwanted and high-riskpregnancies” (paragraph 4.27).participated in the first phase (2009-2010), andup to 20,000 in the second phase (2010-2011).Engaging boys through mass media andinnovative technologiesGlobally, mass-media campaigns have shownsome level of effectiveness in sexual and reproductivehealth (including HIV prevention, treatment,care and support), gender-based violence, fatherhoodand maternal, newborn and child health.Effective campaigns generally go beyond merelyproviding information to encouraging boys andmen to talk about specific issues, such as violenceagainst women. Some effective campaigns alsouse messages related to gender-equitable lifestyles,in a sense promoting or reinforcing specific typesof male identity. Mass-media campaigns on theirown seem to produce limited behavioural changebut show significant change in behaviouralintentions (Bard et al., 2007).UNFPA supported the development ofBreakaway, an electronic football game aimed atraising awareness among boys between the agesof eight and 16 about violence against girls andwomen. In Breakaway, the player encountersreal-life situations that resonate with a boy’s oryoung man’s experience such as peer pressure,competition, collaboration, teamwork, bullying,and negative gender stereotypes. The game givesplayers choices that allow them to make decisions,face consequences, reflect, and practice behavioursin a game and story format. Through the interactivefootball match, players learn that things arenot as they seem, and their choices and actionswill affect the lives of everyone around them. Firstreleased and distributed locally in Africa aroundthe FIFA World Cup in June 2010, the game isnow disseminated globally through the Internet inEnglish, French, Spanish and Portuguese. A numberof UNFPA Country Offices and partners aresupporting use of the tool through disseminationand outreach opportunities.ConclusionMany of the actions by governments, civil societyand international organizations that have helpedgirls prevent pregnancy were not specificallydesigned for that purpose. Multidimensionalinterventions that aim to develop girls’ humancapital, focus on their agency to make decisionsabout their reproductive health and sexuality, andpromote gender equality and respect for humanrights, have had documentable impact on preventingpregnancies.Most of the programmes featured in this chapterhave been evaluated and have been deemed effectiveat supporting some aspect of girls’ safe andhealthy transition from adolescence to adulthood.Some categories of intervention—such as providingcomprehensive sexuality education—havealso been broadly evaluated as being effective inincreasing knowledge about sexual and reproductivehealth, including contraception, changing80 CHAPTER 4: TAKING ACTION

ehaviours of boys and girls, or increasing use ofcontraception.Yet there are many innovative initiatives, notfeatured in this chapter, that aim to reduce theprevalence of child marriage, keep girls in school,change attitudes about gender roles and genderequality and increase adolescents’ access to sexualand reproductive health, including contraception,that have not yet been evaluated but warrantfurther study to determine their effectiveness inimproving girls’ lives.Two important lessons may be drawn fromcountries’ experiences described in this chapter:investing in girls empowers them in many ways,including enabling them to prevent pregnancy;and dismantling the barriers to girls’ enjoyment oftheir rights and addressing the underlying causesof adolescent pregnancy can positively transformgirls’ lives and futures.The most vulnerable girls, including those whoare extremely poor, ethnic minorities or fromindigenous populations, and very young adolescentswho have been forced into marriage,require additional support but are often left outof development or sexual and reproductive healthprogrammes. In most cases, contextual data andinformation about these girls are scarce ornon-existent, and little is known about their vulnerabilitiesand challenges, so it is not surprisingthat few governments or civil society organizationshave formulated policies, programmes or laws thatcan protect or empower them.A growing number of governments are investingin adolescents in ways that empower them toprevent a pregnancy, but fewer have invested insystems and services that support a girl who hasbecome pregnant or who has had a child and thatcan help protect her health and the health of herchild and help her realize her potential in life.TOWARDS A NEW BEGINNING IN THE PHILIPPINESBefore Geah became pregnant at 17, she considered herself a typicalteenage girl who would hang out with friends and boyfriend, againstthe wishes of her parents who thought she should stay home, focus onher studies and finish school.Though her pregnancy was unexpected, she said, she was excitedand happy to know that soon she would have a baby, just like someof her friends did. Her boyfriend was happy about it too, but becausehe did not have a job and depended on his parents, he could not offermuch help to her.One day, Geah went to a health centre in Bago for a check-up. One ofthe workers there knew Geah and informed her mother, who was furiouswhen she found out about the pregnancy but nevertheless promised tosupport her and took her regularly to a clinic for antenatal care.During the pregnancy, Geah remained in school but dropped outafter giving birth.Several months later, she and her parents and younger brother wereinvited to participate in a course to teach parents and family membersabout adolescent health and development, to equip them withknowledge and skills to understand the challenges faced by adolescentmothers and to help them cope with the stressors. The course washosted by the Salas Youth ACCESS Center, established by the CityGovernment of Bago through the City Population Office in partnershipwith Rafael Salas Foundation and with funding assistance from UNFPAin the Philippines.ACCESS is staffed by trained youth peer counsellors and caters tothe needs of both in-school and out-of-school youth.Geah said that after the training, her parents understood her situationbetter and gave her more support and encouragement. The lines ofcommunication with her parents also improved, she said.Support from her parents and ACCESS enabled her to return to school.ACCESS also provided contraceptives to help her delay her next pregnancyuntil after she completes her education, which she says will help herget a good job and make enough money to provide for her family.—Angie Tanong, Commission on PopulationTHE STATE OF WORLD POPULATION 201381

82 CHAPTER 5: CHARTING THE WAY FORWARD

5Charting theway forwardAdolescents are shaping humanity'spresent and future. Depending onthe opportunities and choices theyhave during this period in life, theycan enter adulthood as empoweredand active citizens, or be neglected,voiceless and entrenched in poverty.© Mark Tuschman/Educate Girls IndiaTHE STATE OF WORLD POPULATION 201383

t Youth-friendly healthcentre in Guatemala.© Mark Tuschman/Planned ParenthoodGlobalMillions of girls become pregnant every yearin developing countries and to a lesser extentin developed countries. The impact on theirhealth, economic prospects, rights and futures isindisputable, as is the impact on their children,families and communities.Most countries have taken action aimed atpreventing adolescent pregnancy, and in fewercases, to support girls who have become pregnant.But many of the measures to date havebeen primarily about changing the behaviour ofthe girl, failing to address underlying determinantsand drivers, including gender inequality,poverty, sexual violence and coercion, childmarriage, exclusion from educational and jobopportunities and negative attitudes and stereotypesabout adolescent girls, as well as neglectingto take into account the role of boys and men.In 1994, the 179 governments representedat the International Conference on Populationand Development (ICPD) acknowledged thatpoor educational and economic opportunitiesand sexual exploitation are important factorsin the high levels of adolescent child-bearing.“In both developed and developing countries,adolescents faced with few apparent life choiceshave little incentive to avoid pregnancy andchildbearing.” But they also acknowledged thatthe reproductive health needs of adolescents as agroup had been “largely ignored,” and they calledon governments to make information and servicesavailable to help protect girls and young womenfrom unwanted pregnancies and to educate youngmen “to respect women’s self-determination.”Governments, in the ICPD Programme ofAction, also underscored the need to take actionsto promote gender equality and equity.The challenges girls were facing in 1994 persisttoday and are compounded by new pressuresstemming from the proliferation of mass andsocial media that can sometimes glorify adolescentpregnancy and reinforce negative attitudesabout girls and women. The ICPD Programmeof Action points the way forward in helping girlsface these ongoing and emerging challenges.But the challenges are not the same for alladolescent girls. While there is a growing bodyof evidence on the determinants of pregnancyand the impact on girls 15 or older, very littleresearch has been carried out about pregnanciesamong girls 14 or younger. Yet, from what we doknow, the impact of a pregnancy on a very youngadolescent girl is profound. Actions to preventpregnancy among older adolescents are underway in most countries today. But only a handfulof countries have made a deliberate effort toreach very young adolescents, who are typically84 CHAPTER 5: CHARTING THE WAY FORWARD

overlooked by policymakers and developmentprogrammes everywhere. A deeper understandingof the challenges confronting 10 to 14-year-oldsis urgently needed, and pregnancy prevention andsupport for very young adolescent mothers mustbe advanced to the top of the sexual and reproductivehealth and reproductive rights agenda ofgovernments, development institutions and civilsociety. It is with this group that the greatest needlies and that the obstacles have been thus farinsurmountable.1 Reach girls ages 10 to 14Intervene early with preventive measuresThe needs, vulnerabilities and challenges ofvery young adolescents—between ages 10 and14—are often overlooked by policymakers. Butinterventions at this critical stage of their development,characterized by profound physical,cognitive and social changes that occur in puberty,are needed to ensure girls’ safe and healthytransition through adolescence into adulthood.Governments, communities and civil societyshould seize opportunities arising during thisformative period to begin laying the foundationsfor girls’ sexual and reproductive health andreproductive rights—and enjoyment of all theirhuman rights in the long run. Strategic timingof preventive interventions, including the provisionof age-appropriate comprehensive sexualityeducation and steps to enable girls to attend andremain in school, allows for positive outcomesbefore the circumstances of young adolescents’lives are set.Give visibility to girls traditionally invisible topolicymakersEffective policymaking has been hampered inmany countries by a dearth of data and contex-“My uncle slept with me. I don’tgo to school anymore. At school,they do not accept girls whobecome pregnant.”Affoué, 13, Côte d’Ivoiretual information about very young adolescents.Researchers and policymakers should join forcesto fill this data void to ensure very young adolescentsare not overlooked by or excluded fromservices and to ensure their rights are protected.National censuses and future householdsurveys should include a basic set of questionsabout 10 to 14-year-olds. These questionsshould address whether biological parents arealive and living in the household, whether theadolescents are married or already parents themselves,how much education they have attainedand whether they are still in school, and whetherthey hold jobs or work outside the home. Wheresuch data exist, they should be easily accessible,and be analysed separately from data on olderadolescent girls.At the same time, data on younger and olderadolescent girls should be combined to identifyand highlight the trajectory from childhoodthrough adolescence to adulthood. Such an analysisreveals critical junctures in the lives of girlsthat are preceded by critical investment windows.Such data and analyses when presented tostakeholders can be used to inform policy andprogramme priorities, ensure properly weightedresource allocation, influence programme designTHE STATE OF WORLD POPULATION 201385

and even serve as a community-level advocacytool to ensure that younger and older adolescentsget their due.Programmes should ensure a match betweenneed and actual reach through the collectionof simple but high-quality monitoring data sothat 10 to 14-year-old adolescent girls at greatestrisk of school dropout, child marriage, sexualviolence and coercion, and early or unintendedpregnancy may be reached with appropriateinputs and interventions.Research on what younger (and older) maleand female adolescents need (and want) to knowand when they need to know it, with respectto the sequence of events in their lives and thecultures of which they are a part, would help todetermine the “age appropriateness” and contentof interventions in different communities(World Health Organization, 2011b).“We were in love, we thought it wasgoing to be forever, we wanted a baby…After we realized that we were pregnant,we got scared… you don’t know whatyou are facing or what is coming… Itdisrupted my schooling…I was nursingand I used to look at my classmatesthrough the window and kept on thinkingthat I could also be going to school.”Dunia, 34, pregnant at 17, Costa Rica2 Invest strategically inadolescent girls’ educationPreliminary findings from a new global reviewof countries’ progress in implementing theICPD Programme of Action show that higherliteracy rates for girls ages 15 to 19 are associatedwith significantly lower adolescentbirth rates (UNFPA, 2013e). Education of allchildren is a right in itself and increases theircapacity to participate socially, economicallyand politically in their communities’ affairs.When a girl stays in school and gets an education,especially during adolescence, she ismore likely to avoid child marriage and delaychildbearing. Of the 176 countries and seventerritories surveyed, 82 per cent indicated commitmentto ensuring equal access of girls toeducation at all levels, and about 81 per centindicated commitment to keeping more girlsand adolescents in secondary school. Whilethe commitment is widespread, much moremust be done to reach all girls. The surveyalso found that adolescent birth rates are lowerin higher-income groups, but in all incomegroups, higher literacy among young women isassociated with significantly lower adolescentbirth rates. Investing in girls’ education is alsoassociated with the overall empowerment ofgirls, enhances their status in their communities,improves their health and increases theirbargaining power in marriages.Specific actions to make it easier for girls toenrol in and remain in school longer include:waiving school fees; providing free uniforms,text books and supplies; offering free meals;awarding scholarships to girls from low-incomefamilies; using conditional cash transfers to getgirls in school, stay in school and do better inschool; recruiting and retaining female teachers;86 CHAPTER 5: CHARTING THE WAY FORWARD

and providing a safe environment for girls inthe classroom and en route to class and theirhomes. The quality of education and how girlsare treated by classmates, teachers and staff arealso important determinants of whether girls stayin school. Raising awareness among parents andfamilies about the long-term benefits of educatinggirls can also help keep girls in school.In many countries, girls who become pregnantare expelled and not allowed to returnafter giving birth, undermining their futuresand denying them one of their basic humanrights. The global survey of countries on theimplementation of the ICPD found that about40 per cent of countries were committed tofacilitating school completion of pregnant girls.Enabling girls to finish their education wouldrequire developing, promulgating and enforcingpolicies that allow girls to return to school aftera pregnancy or birth, providing child care, financialsupport and counselling to young mothers,or providing alternative education and skillstraining for girls who do not return to formalschooling. Such strategies also reduce secondpregnancies and improve the prospects for theyoung mother and her child.3 Adopt approaches groundedin human rights and meetinternational human rightsobligationsInterventions that respect human rights cantear down obstacles to girls’ enjoyment of theirrights to education, health, security and theirrights to be safe from violence, discriminationand poverty. Such approaches can help governmentsaddress many of the underlying causes ofadolescent pregnancy, including chronic genderinequality, inequitable access to services andopportunities, and child marriage. They canalso help transform the social and economicforces working against the adolescent girl intoeven more powerful forces that support herdevelopment, health, autonomy, well-beingand empowerment.Adopting human rights approaches alsoentails States’ fulfilling their obligations, asduty-bearers, under human rights instrumentssuch as the Convention on the Rights of theChild and the Universal Declaration of HumanRights. States are therefore accountable to theircitizens—the rights-holders—to ensure thatnational laws and policies enable everyone toexercise all their human rights and comply withhuman rights standards, including but not limitedto, recognizing and applying the “evolvingcapacity of the child” standard regarding accessto sexual and reproductive health care informationand services. Adolescents themselvesshould participate in the development andmonitoring of laws and policies that affect theirsexual and reproductive health.Mechanisms for reporting, investigating andfiling claims about reproductive rights violationswill accomplish little if adolescents areunable to access them or do not even knowthey exist. Developing effective and responsiveaccountability systems and making themknown to all stakeholders are therefore crucial.In addition, collecting and analysing age- andincome-disaggregated data related to adolescentpregnancies can help ensure that lawsand policies appropriately address needs andunmet demand for services from all segmentsof the population, especially marginalizedadolescents. Data are especially scarce for girlsages 10 to 14, yet these figures are particularlyimportant because they can yield insights intoTHE STATE OF WORLD POPULATION 201387

this often-overlooked group’s unique needs,vulnerabilities and challenges.At the ICPD, governments across the globerecognized the special needs of adolescents andyouth and the unique barriers they face in accessingquality reproductive health information andservices. Participating governments agreed toremove regulatory, legal, and social barriers thatinhibit adolescents’ access to services. They alsoagreed that health services must safeguard therights of adolescents to privacy and confidentiality,employing the evolving capacities standardfor autonomous decision-making.4 Ensure adolescents’ accessto comprehensive sexualityeducation, services and maternalhealth careExpand access to comprehensive sexualityeducationAge-appropriate, comprehensive sexuality educationprovides adolescents with vital informationabout preventing pregnancy and sexually transmittedinfections, including HIV, and can promotegender equality. The ICPD global survey showsthat about 76 per cent of countries were committedto age-appropriate sexuality education, about70 per cent were committed to revising curriculato make them more gender-sensitive and 69per cent supported life-skills training for youngpeople through formal education. Increasingaccess to age-appropriate comprehensive sexualityeducation—so that it reaches boys and girls andadolescents who are in or out of school, includingthose from indigenous peoples and ethnic minorities—wouldcontribute to improved health of girlsand boys, promote equitable gender relations, helpprevent pregnancy, and in turn help girls remainin school and realize their full potential.Strengthen gender equality and rightsaspects of the curriculumResearch shows that the comprehensive sexualityeducation programmes that have hadthe greatest impact on reducing adolescentpregnancy and sexually transmitted infectionswere those that addressed gender andpower issues (Haberland and Rogow, 2013).Studies show that young people who believein gender equality have better sexual healthoutcomes than their peers (InternationalSexuality and HIV Curriculum WorkingGroup, 2011).Comprehensive sexuality educationshould therefore address issues of genderand rights in a meaningful way. Youngpeople who, compared to their peers, adoptegalitarian attitudes about gender rolesare more likely to delay sexual debut, usecondoms, and practice contraception; theyalso have lower rates of sexually transmittedinfections and unintended pregnancy(Dupas, 2011).In addition, sexuality education is morelikely to be effective in protecting adolescents’health and preventing pregnancy if itis age-appropriate, comprehensive, based onevidence and core values and human rights,gender-sensitive, promotes academic growthand critical thinking, fosters civic engagement,and is culturally appropriate.The picture, however, remains soberingwith regard to reaching marginalizedadolescents, including those living inextreme poverty and married girls. Veryfew programmes reach these groups, especiallyadolescents who are not in school.Developing out-of-school programmes istherefore essential.88 CHAPTER 5: CHARTING THE WAY FORWARD

©Mark Tuschman/Packard FoundationEstablish, strengthen and increase access tohealth services that adolescents will useGirls need a range of support, programmes andservices, including health services. However, servicestailored to adolescents’ specific needsin many areas are limited, even though 78per cent of the countries surveyed indicatedthey are committed to increasing access tocomprehensive sexual and reproductive healthservices for adolescents—married or unmarried(UNFPA, 2013e). Even when adolescentfriendlyservices are available, adolescents maynot have access to them for reasons includinginconvenient locations or opening hours, cost orthe stigma they may experience in their communities.Moreover, adolescents will not use them ifthey are treated poorly by providers.Policymakers committed to increasing adolescents’access to and use of services should ensurethat providers are trained to work with youngpeople, respect confidentiality and offer complete,evidence-based and accurate information.Adolescent-friendly services should also offerlow-cost or free contraception, including maleand female condoms, emergency contraception,and a full range of modern methods, includinglong-acting reversible methods, according toadolescents’ preferences and needs.Improved service delivery must be coupledwith strong community mobilization and dedicatedoutreach so young people know whichservices are available to them and how theycan obtain them. Voucher schemes can helpdisadvantaged adolescents access services thatTHE STATE OF WORLD POPULATION 201389

they might not otherwise use because of cost.Community outreach is also necessary to raiseawareness, build support for services for adolescentsand reduce the stigma often associated withseeking contraception or being sexually activebefore a certain age or outside of marriage.Critically important is the reality that one sizedoes not fit all, given the diversity of young people’sneeds and the contexts of their lives. Somemay prefer accessing services through channelssuch as health facilities while others may prefer toaccess them through schools or from pharmaciesor other sources in the community. The key isto ensure common standards of high quality andconfidentiality, regardless of the channel, whileat the same time aiming to integrate, implementand constantly monitor an essential package ofservices for adolescents within existing healthservices so as to promote sustainability.Moreover, special efforts are needed to identifyand target the most vulnerable adolescent girls atrisk of early pregnancy and other poor sexual andreproductive health outcomes. Given that marriedgirls have a very high unmet need for contraceptioncompared to other age groups, targetingthem within existing family planning and contraceptiveefforts would go a long way in terms ofrealizing their rights, achieving equity and betterhealth outcomes, and efficiency within systems.When health services are of good quality,affordable and sensitive to the unique circumstancesof adolescents, buttressed withcommunity support, outreach, and innovativereferral mechanisms, young people will use them.At the same time, actions should be taken tochange male attitudes towards girls’ sexual andreproductive health and reproductive rights. Inmany instances, male partners restrict access toservices or refuse to use contraception, and atother times males are restricted from using reproductivehealth services, reinforcing biases thatreproductive health is solely the businessof females.UNFPA’s Adolescent and Youth Strategy prioritizesactions to improve the quality of sexualand reproductive health services, including HIVservices, for adolescents and youth. This includessupporting advocacy efforts to lift legal andpolicy barriers impeding access to health services;partnering with governments, civil society andyoung people to develop and strengthen nationalprogrammes delivering quality adolescent sexualand reproductive health services and strengtheningyoung people’s leadership and voice in theprocess.Increase girls’ access to and use of antenatalcare, skilled birth attendants and post-abortionservicesThe same stigma and economic, geographicaland social obstacles that keep girls from accessingcontraception may also keep pregnant girls fromaccessing services that can protect their health andthe health of their newborns.Ensuring that quality antenatal, delivery andpost-partum care is accessible, equitable andaffordable can mitigate the health risks to adolescentsand their children. Service providersshould therefore increase the numbers and reachof skilled health workers to provide antenatal,delivery, and post-partum care to adolescent girls.Access to emergency obstetric care is especiallyimportant since it would help prevent maternaldeath and morbidity, including obstetric fistulae.Adolescent girls between the ages of 15 and19 account for as many as 3.2 million unsafeabortions annually in developing countries (Shahand Ahman, 2012). With unsafe abortion comes90 CHAPTER 5: CHARTING THE WAY FORWARD

great risk of injury, illness and maternal death.Post-abortion services should therefore be madeavailable to adolescents. Where abortion is legal,it should be safe and accessible. Increasing adolescents’access to contraception can not only helpprevent abortion, but it can also help preventdeath and injury from complications frompregnancy and delivery (UNFPA, 2012a).Girls who give birth during adolescence are athigh risk of having a second pregnancy soon afterthe first. Service providers could help prevent orspace second pregnancies by offering contraceptionto girls who have given birth or who havehad an abortion. Increasing access to long-actingreversible methods of contraception can helpprevent unintended second pregnancies.“I went for an abortion, but theyasked me for 15,000 dirhams [about$1,800], which I did not have… I askedmy parents for help, but did not getit. When the pregnancy signs startedto show, they kicked me out of thehouse and there was nothing I coulddo about it.”18-year-old girl, Morocco5 Prevent child marriage, sexualviolence and coercionEnact and enforce laws to ban child marriageand address its underlying causesSince the 1994 ICPD, 158 countries haveimplemented laws to increase the legal age ofmarriage to 18, but laws that are not enforcedhave little impact on practice. Today, an estimated67 million girls globally were marriedbefore their 18th birthday (UNFPA, 2013e).The overwhelming majority of adolescent pregnanciesin developing countries occur withinmarriage. Ending child marriage would notonly help protect girls’ rights but would also goa long way towards reducing the prevalence ofadolescent pregnancy.Zero tolerance towards child marriage is thegoal. However, until that aspiration becomesa reality, millions of girls will become childbrides and mothers. These girls occupy a difficultand often neglected space within society,receiving scant, if any, attention from socialprotection programmes. While they are stillchildren—developmentally, biologically, physically,psychologically and emotionally—theirmarital status signals an end to their status aschildren and renders them adults in the eyesof their societies. Neither youth-oriented programmesnor those targeting adult women arelikely to address the unique circumstances ofmarried girls or the needs of girls at risk of childmarriage, unless they do so in a planned anddeliberate manner.Enacting laws that ban child marriage is agood first step. But unless laws are enforced andcommunities support these laws, they will havelittle impact. Stopping child marriage requirescombining a variety of interventions intomulti-sectoral, multi-level responses, especiallyat the community level, to change harmfulTHE STATE OF WORLD POPULATION 201391

© Mark Tuschman/Global Fund for Womensocial norms and to empower girls. Timing iskey; these interventions, especially schoolingand asset-building for girls, must be directed atyoung adolescents (10 to 14 years old)—beforeor around the time of puberty—in order tocounter pressures on girls for marriage andchildbearing for social and economic security.Programmes have yielded demonstrable resultsat the community level even in a short amountof time.Specifically, governments, civil society, communityleaders and families that are seriousabout ending child marriage should consider:• Helping girls go to and stay in school andlearn skills so they can develop a livelihood,communicate better, negotiate, and makedecisions that directly affect their lives;• Initiating programmes for community leaders,religious leaders and parents to increase theirsupport for girls’ rights and education, latermarriage and for changing harmful normsand practices;• Supporting programmes that give girls alternativesto child marriage, including safe spacesfor girls to build agency, help them overcomesocial isolation, allow them to interact withpeers and mentors, gain critical life skills andconsider aspirations that do not involve childmarriage and early motherhood;• Offering conditional cash transfers to keepgirls in school and unconditional cash transfersto prevent child marriage and pregnancy;• Providing information about life optionsand development of life plans and supportnetworks;• Promulgating, enforcing and building communitysupport for laws on the minimumage of marriage;92 CHAPTER 5: CHARTING THE WAY FORWARD

• Registering all births and marriages so thatcases of child marriage may be more easilyidentified, and enforcing existing registrationlaws;• Training law enforcement officials to identifyand handle cases of child marriage and holdperpetrators accountable under the law.Protect girls from violence and coercionAn unknown number of girls around the worldbecome pregnant as the result of sexual violenceor as a result of sexual coercion. In addition, girlswho are pregnant are at risk of gender-based violence,typically committed by male partners orothers known to them. In some places, perpetratorscan avoid punishment and family shame bymarrying their victims.However, stopping sexual violence and sexualcoercion requires more than enacting and enforcinglaws and prosecuting perpetrators, no matterwho they are. Preventive measures are also necessary.As with many of the determinants ofadolescent pregnancy, long-term solutions mustbe multidimensional and address underlyingproblems, such as gender inequality, negative attitudesof boys and men towards girls, norms thatperpetuate violence and impunity, poverty thatcompels girls to engage in sex as a survival strategy,and inadequate protection of human rights.But in the short run, governments and othersshould consider:• Sensitizing boys as well as girls about sexualviolence, gender-based violence and sexualcoercion through youth-focused initiatives,including sports, life-skills and peer-supportprogrammes, mentoring organizations, HIVpreventionand reproductive health education,social networks and discussion groups for boysand men;• Modifying sexuality education or life-skillscurricula to include wider discussions ofviolence, coercion, human rights and healthyand respectful relationships;• Pursuing in-school interventions to changemisconceptions and build awareness of adolescents’rights and issues of gender equality;• Improving the response of the health sectorand law enforcement by enhancing providerknowledge, attitudes, and practices, includingthe ability to detect and respond to cases ofviolence;• Taking legal and policy measures to preventsexual violence, provide rehabilitation andredress to survivors, and investigate, prosecuteand punish offenders;• Adding an awareness-raising component onsexual coercion and violence to programmesfocused on adolescent economic empowermentor in programmes that engage men and boys;• Supporting programmes that build disadvantagedgirls’ economic, social and health assetsto reduce their vulnerability to sexual violenceor the need to engage in transactional sex tosupport themselves;• Investigating, prosecuting and punishingperpetrators of violence to the fullest extentof the law.“As I look back… I remembermany goals I wanted for myselfbut could not achieve.”Jessica, 39, pregnant at 18, USATHE STATE OF WORLD POPULATION 201393

©UNFPA/Matthew Cassel6 Support multilevel programmesAddress all sources of girls’ vulnerabilityActions to prevent pregnancy must be takenat multiple levels. Narrowly focused interventionsare not enough, and efforts centred onchanging a girl’s behaviour fail to reflect themultidimensional nature of the challenge.Keeping girls on healthy, safe and affirminglife trajectories requires comprehensive, strategic,and targeted investments in adolescentsthat address the multiple sources of their vulnerabilities,which vary by age, income group,place of residence and many other factors. Italso requires deliberate efforts to recognizethe diverse circumstances of adolescents andidentify girls at greatest risk of adolescentpregnancy and poor reproductive health outcomes.Such multi-sectoral programmes areneeded to build girls’ assets across the board—in health, education and livelihoods—butalso to empower girls through social supportnetworks and increasing their status at home,in the family, in the community and in relationships.These programmes should not onlycross sectors but should also operate at severallevels of influence, from the individual and thecommunity up to the national government.Such investments will take significant time andresources. But if they reach girls early, theycan significantly improve the lives of girlsand increase their contributions to theirfamilies and communities.Policymakers and programme managersshould leverage new opportunities offered bylarger scale efforts in other sectors, especiallyeducation, health and poverty reduction. Strongcoordination across these different sectors willbe needed to promote greater synergy andmaximize impact from these efforts. Actions areneeded to prevent adolescent pregnancy as wellas to ameliorate the impact on the girl.7 Engage men and boysAdopt gender-transformative approachesMany countries have adopted gender-sensitiveapproaches to achieve an array of developmentgoals, such as improving sexual and reproductivehealth. These approaches take into accountthe specific needs and realities of men, women,boys and girls but do not necessarily seek totransform or influence gender relations. Gendertransformativeprogrammes—those that seek tochallenge the underlying social norms that makeup the way gender roles and responsibilities areperceived—have been shown to have a greaterimpact on sexual and reproductive health programmes.By addressing the root causes of genderinequality, gender-transformative approaches aremore likely to achieve long-term change in areasincluding sexual and reproductive health, includingthat of adolescent girls. Initiatives that do94 CHAPTER 5: CHARTING THE WAY FORWARD

not address social norms risk treating symptomsrather than addressing the underlying causes ofinequality (UNFPA, 2013b). Without workingwith men and boys, discrimination, violence andinequality will continue.Engage boys before their attitudes aboutgender and sexuality are cementedWorking with adolescent boys is essential toequip them with the tools they need to leadmore gender-equitable lives. Sufficient opportunitiesand knowledge must be afforded forhow young people, particularly boys and youngmen, can challenge gender norms, stereotypesand harmful practices. Furthermore, reachingadolescent boys through age-appropriate comprehensivesexuality education, which allowsthem to reflect and question predominantnorms around masculinity and femininity, is acritical way to better ensure future generationsof gender-equitable men.Boys should be involved in the developmentof age-appropriate tools and approachesfor the promotion of gender equality andadolescent sexual and reproductive health andreproductive rights. Communicating positivemessages—that change is possible and thatboys can positively influence not only theirown lives but also that of girls—can increaseboys’ participation and responsiveness.As part of age-appropriate comprehensivesexuality education curricula, young people,in particular boys and young men, should beprovided with guidance and opportunities toreflect on dominant versions of “manhood”and the expectations that come with it, aswell as build empathy and foster principles ofrespect and equality. Research demonstratesthat boys start to cement their perceptionsabout sexuality and intimate relationships inadolescence and often carry those understandingsinto adulthood.Engage fathers tooFathers play a critical role in helping their childrentransition successfully from adolescenceto adulthood and are in a position to be positiverole models, encouraging boys to becomegender-sensitive adults.8 Lay the groundwork to supportadolescent health and rights after2015In the post-2015 development agenda,support goals, targets and indicators forempowering girls, ending child marriage andensuring sexual and reproductive healthA little more than two years remain to realizethe United Nations Millennium DevelopmentGoals (MDGs).Governments, civil society organizations, theUnited Nations and other major stakeholdersare already formulating a sustainable developmentagenda that will build on and succeedthe MDGs after 2015. What has already beenagreed by the United Nations System Task Teamon the Post-2015 Agenda is that the successorframework must be grounded in principles ofhuman rights, equality and sustainability.In December 2012, UNFPA recommendedthat the post-2015 agenda recognize and embedgender equality, within the framework of humanrights, across its goals, since it is essential forelimination of inequality and necessary toenhance sustainability of development efforts(UNFPA, 2013f).In a human rights-based approach to development,people, including women and youngTHE STATE OF WORLD POPULATION 201395

people, are not considered passive recipients ofgoods, services or commodities, but, rather, asrights-holders, and therefore should be empowered.As active agents of their own development,rights-holders drive the sustainability of development.They are enabled to make choices, toinfluence policymaking processes and to holdtheir governments accountable.The State, as the main duty-bearer, has correspondingobligations to respect, protect andfulfil human rights, including reproductiverights. Human rights approaches also call for theestablishment and strengthening of independentnational human rights accountability systems.UNFPA also recommended that the post-2015 agenda uphold the rights of young peopleand call for investment in quality education,decent employment opportunities, effective livelihoodskills, access to sexual and reproductivehealth and comprehensive sexuality education tostrengthen young people’s individual resilienceand create the circumstances under which theyare more likely to reach their full potential.Adolescents and youth, particularly poor, ruraland indigenous girls, lack adequate access to thesexual and reproductive health information andservices needed to avoid unintended pregnancies,unsafe abortions and sexually transmittedinfections, including HIV. Unmet need forcontraception remains high, and demand is rising.Many adolescent girls are exposed to childmarriage, forced sexual relationships and otherharmful practices, such as female genital mutilation/cuttingand human trafficking. Thesepractices are human rights violations and havedamaging psychosocial effects, reducing girls’opportunities to complete their education,develop employable skills and participate fully incommunity and national development.In May 2013, a 27-member High-LevelPanel of Eminent Persons on the Post-2015Development Agenda released a report withrecommendations on the way forward (UnitedNations, 2013). The Secretary-General appointedthe panel whose report focused on thedimensions of economic growth, social equalityand environmental sustainability. The reportstated that “new goals and targets need to begrounded in respect for human rights” and thatthe post-2015 agenda should feature “a limitednumber of high-priority goals and targets…supported by measurable indicators.”Among the panel’s proposed universal goalsare the empowerment of girls and women andthe achievement of gender equality, with endingchild marriage as an accompanying indicatorof success.Another proposed goal is the provision ofquality education and lifelong learning, ensuringthat every child, “regardless of circumstance,”has access to lower secondary education. A proposedgoal of ensuring healthy lives includesan indicator for ensuring universal sexual andreproductive health and rights.In addition, national, regional and other consultationsthat have been taking place since late2012 have also resulted in recommendations forincluding women’s empowerment, equality, sexualand reproductive health, and the rights of adolescents,particularly girls, in the post-2015 agenda.Governments that are committed to empoweringadolescents, upholding their right toeducation and health, including sexual andreproductive health—all of which can have atremendous impact on adolescent pregnancy—should consider supporting goals and indicatorsproposed by the High-Level Panel of EminentPersons on the Post-2015 Development Agenda.96 CHAPTER 5: CHARTING THE WAY FORWARD

Towards empowered adolescentgirls and fulfilled potentialAdolescents are shaping humanity’s present andfuture. Depending on the opportunities andchoices they have during this period in life, theycan enter adulthood as empowered and activecitizens, or be neglected, voiceless and entrenchedin poverty.When adolescent pregnancy occurs, it canderail a girl’s healthy development and preventher from achieving her full potential and enjoyingher basic human rights. The impact canreverberate throughout her life and carry overto the next generation.Experience from effective programmes showsthat what is needed is a transformative shift awayfrom narrowly focused interventions, targetedat girls or at preventing pregnancy, and towardsbroad-based approaches that build girls’ humancapital, focus on their agency to make decisionsabout their lives (including matters of sexual andreproductive health), and present real opportunitiesfor girls so that pregnancy is not seen as theirdestiny. This new paradigm should instead targetthe circumstances, conditions, norms, valuesand structural forces that perpetuate adolescentpregnancies on the one hand and that isolate andmarginalize pregnant girls on the other.Interventions that have the power to reducevulnerability to early pregnancy, especially amongthe poorest, least-educated and marginalizedgirls, are those that are grounded in principlesof equity, equality and rights. Investments ingirls—in building their human capital and theiragency—can yield enormous social and economicreturns, to individuals, their families, communitiesand nations.Girls need access to sexual and reproductivehealth services and information. They also needto be unburdened from the economic and socialpressures that too often translate into a pregnancyand the poverty, poor health and unrealizedhuman potential that come with it. Girls whohave become pregnant need support, not stigma.Engagement by all stakeholders—families,communities, schools, health care providers andmore—is essential to bring about change byreshaping social norms, traditions and practicesthat perpetuate adolescent pregnancy and compromisegirls’ futures. Cooperation among allstakeholders can mobilize political will for investmentsto empower adolescent girls and buildtheir agency.s Youth peerprovider workswith local healthcentres to reachEthiopian youthand adolescentswith contraceptiveinformation andsupplies.© Mark Tuschman/Planned ParenthoodGlobalTHE STATE OF WORLD POPULATION 201397

Everyone has a role to play. The media andentertainment industries can help throughpositive images of adolescent girls and women.Governments can rededicate themselves to theelimination of child marriage and gender-basedviolence. Parents should be attuned to thegender-discriminatory messages they transmitto their children. Opinion leaders, communityleaders, teachers and health care providers shouldreinforce the messages that all children are ofequal worth and have rights to health, education,participation and equal opportunity.Policymakers must involve girls—and boys—in the design, implementation, and evaluationof measures intended to help girlsprevent pregnancy or managetheir lives if they become pregnant.Speaking with, and listeningto, girls and gaining in-depthunderstanding of their needs,challenges and vulnerabilities areimperative. According to the 179governments that endorsed theICPD Programme of Action in1994, actions intended to benefitadolescents “have proven mosteffective when they secure thefull involvement of adolescents inidentifying their reproductive andsexual health needs and in designingprogrammes that respond tothose needs.”Building a gender-equitable society in whichgirls are empowered, educated, healthy and protectedfrom child marriage, live in dignity andsecurity and are able to make decisions abouttheir futures and exercise their rights is essential.UNFPA strives to uphold every girl’s right togrow up unencumbered by gender inequalityand discrimination, violence, child marriageand pregnancy so they may make a safe, healthyand successful transition from adolescence intoadulthood. Childhood must never be derailedby motherhood.“Pregnancy is not like going to a partyand then it’s over… it affects our studiesand brings family conflicts… Beforeyou even think about having sexualrelationships, you should always thinkabout the consequences… the future.It is important to be prepared… and toknow what we want, and then we canmake decisions.”Valeria, 15, Nicaragua98 CHAPTER 5: CHARTING THE WAY FORWARD

IndicatorsMonitoring ICPD goals: selected indicators page 100Demographic indicatorspage 106Notespage 109THE STATE OF WORLD POPULATION 2013 99

Monitoring ICPD goals:selected indicatorsMonitoring ICPD Goals – Selected IndicatorsIndicators of Mortality Indicators of Education Reproductive Health IndicatorsInfantmortalityTotal per1,000 livebirthsLife expectancyM/FMaternalmortalityratioPrimary enrolment(gross) M/FProportionreaching grade 5M/FSecondaryenrolment(gross) M/F% Illiterate(>15 years)M/FBirths per1,000womenaged15-19ContraceptivePrevalenceAnymethodModernmethodsHIVprevalencerate (%)(15-49)M/FCountry,territory orother areaAlbania 27 99 11 16 69 10 13 98 95 71 68Algeria 97 95 4 32 61 52 98 97 72 74Angola 450 49 165 156 18 93 78 15 12Antigua and Barbuda 100 67 11 87 85 85 85Argentina 77 99 68 13 79 70 100 99 80 88Armenia 30 100 28 21 55 27 14 95 98 85 88Aruba 36 17 93 96 70 74Australia 1 7 99 16 5 72 68 97 98 85 86Austria 4 99 10 4 70 68Azerbaijan 43 89 41 47 51 13 15 88 86 87 85Bahamas 47 99 41 13 94 96 82 88Bahrain 20 97 12 9 62 31 99 100 92 97Bangladesh 240 31 133 42 61 52 14 43 51Barbados 51 100 50 12 90 97 83 95Belarus 4 100 21 7 73 56Belgium 8 99 11 4 70 69 3 99 99 90 87Belize 53 94 90 15 55 52 16 100 91 64 65Benin 350 84 114 108 13 8 27 27 13Bhutan 180 58 59 48 66 65 12 89 92 54 62Bolivia (Plurinational State of) 190 71 89 52 61 34 20 91 91 70 70Bosnia and Herzegovina 8 100 17 9 46 12 9 89 91Botswana 160 99 51 41 53 51 87 88 57 66Brazil 56 99 71 24 80 77 6 95 97Brunei Darussalam 24 10 18 5 98 100Bulgaria 11 99 48 11 69 40 30 99 100 84 82Burkina Faso 300 67 130 137 16 15 25 66 63 21 17Burundi 800 60 65 139 22 18 32 91 89 20 17Cambodia 250 71 48 51 51 35 17 96 95 39 36Cameroon, Republic of 690 64 127 115 23 14 24 100 87 44 39Canada 12 99 14 5 74 72 100 100Cape Verde 79 76 92 20 61 57 17 95 92 60 69Central African Republic 890 41 133 150 19 9 19 78 60 18 10Chad 1100 17 193 155 5 2 28 74 51 16 5Chile 25 100 54 7 64 93 93 83 87China 2 37 96 6 16 85 84 2China, Hong Kong SAR 3 3 3 80 75 95 100 72 74China, Macao SAR 4 3 5 87 88 80 77Colombia 92 99 85 23 79 73 8 90 90 73 79100 INDICATORS INDICATORSMaternal and Newborn Health Sexual and Reproductive Health EducationMaternal BirthsAdolescent Under age five Contraceptive Contraceptive Unmet need for Primary school enrolment, Secondary schoolmortality ratio attended by birth rate per mortality rate prevalence rate, prevalence rate, family planning, net per cent of primary enrolment, net per cent(deaths per skilled health 1,000 women per 1,000 women aged women aged per cent, school-age childrenof school-age children,100,000 live personnel, aged 15 to 19, live births, 15-49, any 15-49, modern 1988/2012 1999/20121999/2012births), 2010 per cent 1991/2010 2010-2015 methodmethod2005/20121990/2012 1990/2012male female male femaleAfghanistan 460 36 90 92 22 16 34 13

Monitoring Monitoring ICPD ICPD Goals goals: – Selected selected Indicators indicatorsIndicators of Mortality Indicators of Education Reproductive Health IndicatorsInfant Maternal Life and expectancy Newborn Health Maternal Primary enrolment Sexual Proportion and Reproductive Secondary Health% Illiterate Education Births per Contraceptive HIVmortality M/Fmortality (gross) M/F reaching grade 5 enrolment (>15 years) 1,000 PrevalenceprevalenceMaternal BirthsAdolescent Under age five Contraceptive Contraceptive Unmet need for Primary school enrolment, Secondary schoolTotal perratioM/F(gross) M/F M/Fwomenrate (%)mortality ratio attended by birth rate per mortality rate prevalence rate, prevalence rate, family planning, net per cent of primary1,000 liveagedAny enrolment, Modern net per cent(15-49)(deaths per skilled health 1,000 women per 1,000 women aged women aged per cent, school-age childrenbirths15-19method of school-age methodschildren,M/F100,000 live personnel, aged 15 to 19, live births, 15-49, any 15-49, modern 1988/2012 1999/20121999/2012Country, territorybirths), 2010 per cent 1991/2010 2010-2015 methodmethodor other area 2005/20121990/2012 1990/2012male femalemale femaleComoros 280 95 92 26 19 36 81 75Congo, DemocraticRepublic of the 540 80 135 180 18 6 24 34 32Congo, Republic of the 560 94 132 97 45 20 20 95 90Costa Rica 40 95 67 10 82 80 5Côte d'Ivoire 400 59 111 107 18 13 29 67 56Croatia 17 100 13 6 95 97 88 94Cuba 73 100 51 6 74 73 9 98 98 87 87Curaçao 13Cyprus 10 98 4 4 99 99 88 90Czech Republic 5 100 11 3 86 78 4Denmark 12 99 6 4 95 97 88 91Djibouti 200 78 27 83 18 17 57 51 28 20Dominica 100 48 96 97 80 89Dominican Republic 150 95 98 28 73 70 11 93 91 58 67Ecuador 110 89 100 21 73 59 7 99 100 73 75Egypt 66 79 50 24 60 58 12 99 96El Salvador 81 85 65 21 72 66 9 96 96 59 61Equatorial Guinea 240 128 143 10 6 59 59Eritrea 240 85 56 8 5 29 40 34 32 25Estonia 2 99 21 5 63 58 98 97 91 93Ethiopia 350 10 79 74 29 27 26 90 84 17 11Fiji 26 100 31 20 99 99 81 88Finland 5 99 8 3 98 98 93 94France 8 98 12 4 76 74 2 99 99 98 100French Guiana 84 14French Polynesia 41 8Gabon 230 144 65 31 19 28Gambia 360 56 104 100 13 9 22 68 71Georgia 67 97 44 22 53 35 12 96 94 84 80Germany 7 99 9 4 66 62 100 100Ghana 350 55 70 78 24 17 36 83 82 48 44Greece 3 12 4 76 46 99 99 98 98Grenada 24 100 53 12 54 52 96 99 84 84Guadeloupe 21 6Guam 52 11 67 58Guatemala 120 51 92 31 43 34 28 99 97 48 44Guinea 610 46 153 127 6 5 22 90 76 42 27Guinea-Bissau 790 44 137 156 14 10 6 77 73 11 6Guyana 280 87 97 34 43 40 29 81 85 71 81Haiti 350 26 69 67 35 31 37Honduras 100 66 108 32 65 56 17 97 98Hungary 21 99 19 6 81 71 7 97 98 92 92THE STATE OF WORLD STATE POPULATION OF WORLD POPULATION 2013 2012101 101

Monitoring ICPD Goals goals: – selected Selected indicators IndicatorsIndicators of Mortality Indicators of Education Reproductive Health IndicatorsInfant Maternal Life and expectancy Newborn Health Maternal Primary enrolment Sexual Proportion and Reproductive Secondary Health% Illiterate Education Births per Contraceptive HIVmortality M/Fmortality (gross) M/F reaching grade 5 enrolment (>15 years) 1,000 PrevalenceprevalenceMaternal BirthsAdolescent Under age five Contraceptive Contraceptive Unmet need for Primary school enrolment, Secondary schoolTotal perratioM/F(gross) M/F M/Fwomenrate (%)mortality ratio attended by birth rate per mortality rate prevalence rate, prevalence rate, family planning, net per cent of primary1,000 liveagedAny enrolment, Modern net per cent(15-49)(deaths per skilled health 1,000 women per 1,000 women aged women aged per cent, school-age childrenbirths15-19method of school-age methodschildren,M/F100,000 live personnel, aged 15 to 19, live births, 15-49, any 15-49, modern 1988/2012 1999/20121999/2012Country, territorybirths), 2010 per cent 1991/2010 2010-2015 methodmethodor other area 2005/20121990/2012 1990/2012male femalemale femaleIceland 5 15 3 99 99 88 89India 200 58 76 56 55 48 21 99 99Indonesia 220 80 66 31 62 58 11 98 100 74 74Iran (Islamic Republic of) 21 97 31 22 73 59 99 100 82 80Iraq 63 89 68 32 53 34 8 94 84 49 39Ireland 6 100 16 4 65 61 99 100 98 100Israel 7 14 4 97 98 97 100Italy 4 100 7 3 63 41 12 100 99 94 94Jamaica 110 98 72 25 69 66 12 83 81 80 87Japan 5 100 5 3 54 44 100 100 99 100Jordan 63 99 32 20 59 41 13 91 91 83 88Kazakhstan 51 99 31 30 51 50 12 100 100 90 90Kenya 360 44 106 77 46 39 26 84 85 52 48Kiribati 98 39 42 22 18 28 65 72Korea, DemocraticPeople's Republic of 81 100 1 28Korea, Republic of 16 100 2 4 80 70 99 98 96 95Kuwait 14 99 14 11 52 39 97 100 86 93Kyrgyzstan 71 98 31 42 48 46 12 96 96 81 80Lao People's Democratic Republic 470 37 110 45 38 35 27 98 96 43 39Latvia 34 99 15 9 68 56 17 95 96 83 83Lebanon 25 18 10 58 34 97 97 72 80Lesotho 620 62 92 82 47 46 23 74 76 23 37Liberia 770 46 177 85 11 10 36 42 40Libya 58 98 4 16 45 26Lithuania 8 17 7 63 50 18 94 93 91 91Luxembourg 20 7 3 94 96 85 88Madagascar 240 44 147 55 40 28 19 79 80 23 24Malawi 460 71 157 119 46 42 26 91 98 30 29Malaysia 29 99 14 5 49 32 96 96 66 71Maldives 60 95 19 13 35 27 29 94 95 46 52Mali 540 49 190 165 8 6 28 72 63 36 25Malta 8 100 20 7 86 46 93 94 82 80Martinique 20 7Mauritania 510 57 88 107 9 8 32 73 77 17 15Mauritius 5 60 100 31 13 76 39 4 74 74Mexico 50 95 87 17 71 67 12 99 100 71 74Micronesia (Federated States of) 100 100 52 40Moldova, Republic of 41 100 26 17 68 43 11 91 90 77 78Mongolia 63 99 20 31 55 22 99 98 74 79Montenegro 8 100 24 10 39 17 93 94Morocco 100 74 18 32 67 57 12 97 96 38 32Mozambique 490 54 193 116 12 11 19 93 88 18 17102 102 INDICATORS INDICATORS

Monitoring Monitoring ICPD ICPD Goals goals: – Selected selected Indicators indicatorsIndicators of Mortality Indicators of Education Reproductive Health IndicatorsInfant Maternal Life and expectancy Newborn Health Maternal Primary enrolment Sexual Proportion and Reproductive Secondary Health% Illiterate Education Births per Contraceptive HIVmortality M/Fmortality (gross) M/F reaching grade 5 enrolment (>15 years) 1,000 PrevalenceprevalenceMaternal BirthsAdolescent Under age five Contraceptive Contraceptive Unmet need for Primary school enrolment, Secondary schoolTotal perratioM/F(gross) M/F M/Fwomenrate (%)mortality ratio attended by birth rate per mortality rate prevalence rate, prevalence rate, family planning, net per cent of primary1,000 liveagedAny enrolment, Modern net per cent(15-49)(deaths per skilled health 1,000 women per 1,000 women aged women aged per cent, school-age childrenbirths15-19method of school-age methodschildren,M/F100,000 live personnel, aged 15 to 19, live births, 15-49, any 15-49, modern 1988/2012 1999/20121999/2012Country, territorybirths), 2010 per cent 1991/2010 2010-2015 methodmethodor other area 2005/20121990/2012 1990/2012male femalemale femaleMyanmar 200 71 17 63 46 46 19 49 52Namibia 200 81 74 42 55 54 21 84 88 44 57Nepal 170 36 81 44 50 43 28 78 64Netherlands 6 5 4 69 67 100 99 87 88New Caledonia 21 15 75 72New Zealand 15 96 29 5 99 100 94 95Nicaragua 95 74 109 20 72 69 11 93 95 43 49Niger 590 18 199 127 14 12 16 71 60 14 9Nigeria 630 34 123 122 14 9 19 60 55Norway 7 99 10 3 88 82 99 99 94 94Oman 32 99 12 9 32 25 98 97 94 94Pakistan 260 45 16 71 27 19 25 79 65 40 29Palestine 7 64 60 23 50 39 90 90 77 85Panama 92 89 88 18 52 49 98 97 65 71Papua New Guinea 230 43 70 62 32 24 27Paraguay 99 85 63 37 79 70 5 84 84 59 63Peru 67 85 72 26 69 50 6 97 97 77 78Philippines 99 62 53 27 49 36 22 88 90 56 67Poland 5 100 16 6 73 28 97 97 90 92Portugal 8 16 3 87 83 99 100 78 86Puerto Rico 55 8 84 72 4 81 86Qatar 7 100 15 8 43 32 95 95 87 96Réunion 43 5 67 64Romania 27 99 41 12 70 51 12 88 87 82 83Russian Federation 34 100 30 12 80 65 95 96Rwanda 340 69 41 74 52 44 21 89 92Saint Kitts and Nevis 100 67 86 89 84 88Saint Lucia 35 99 49 14 88 88 85 85Saint Vincent and the Grenadines 48 99 70 21 100 97 84 86Samoa 100 81 29 23 29 27 48 91 96 71 82San Marino 1 91 93São Tomé and Principe 70 81 110 63 38 33 38 97 98 30 34Saudi Arabia 24 100 7 12 24 97 97Senegal 370 65 93 75 13 12 29 77 81 24 19Serbia 6 12 100 22 13 61 22 7 95 94 90 91Seychelles 99 62 10 96 94 92 100Sierra Leone 890 61 98 187 11 10 27Singapore 3 100 6 2 62 55Slovakia 6 100 21 7 80 66Slovenia 12 100 5 3 79 63 9 98 98 92 93Solomon Islands 93 70 70 47 35 27 11 88 87 44 42Somalia 1000 9 123 131 15 1THE STATE OF WORLD STATE POPULATION OF WORLD POPULATION 2013 2012103 103

Monitoring ICPD Goals goals: – selected Selected indicators IndicatorsIndicators of Mortality Indicators of Education Reproductive Health IndicatorsInfant Maternal Life and expectancy Newborn Health Maternal Primary enrolment Sexual Proportion and Reproductive Secondary Health% Illiterate Education Births per Contraceptive HIVmortality M/Fmortality (gross) M/F reaching grade 5 enrolment (>15 years) 1,000 PrevalenceprevalenceMaternal BirthsAdolescent Under age five Contraceptive Contraceptive Unmet need for Primary school enrolment, Secondary schoolTotal perratioM/F(gross) M/F M/Fwomenrate (%)mortality ratio attended by birth rate per mortality rate prevalence rate, prevalence rate, family planning, net per cent of primary1,000 liveagedAny enrolment, Modern net per cent(15-49)(deaths per skilled health 1,000 women per 1,000 women aged women aged per cent, school-age childrenbirths15-19method of school-age methodschildren,M/F100,000 live personnel, aged 15 to 19, live births, 15-49, any 15-49, modern 1988/2012 1999/20121999/2012Country, territorybirths), 2010 per cent 2005/2010 2010-2015 methodmethodor other area 2005/20121990/2012 1990/20112male femalemale femaleSouth Africa 300 54 51 60 60 14 90 91 59 65South Sudan 123 4 1Spain 6 13 4 66 62 12 100 100 94 96Sri Lanka 35 99 24 11 68 53 7 93 93 86 91Sudan 730 70 86 9 29 50 42Suriname 130 87 66 23 46 45 92 93 52 63Swaziland 320 82 111 92 65 63 13 84 86 32 38Sweden 4 6 3 75 65 100 99 93 93Switzerland 8 4 4 82 78 99 100 83 81Syrian Arab Republic 70 96 75 21 58 43 99 100 68 68Tajikistan 65 88 27 73 28 26 100 96 91 81Tanzania, United Republic of 460 49 128 72 34 26 25 98 98Thailand 48 99 47 12 80 78 3 90 89 69 74The former YugoslavRepublic of Macedonia 10 100 20 11 97 99 82 81Timor-Leste,Democratic Republic of 300 30 54 49 22 21 32 91 91 37 41Togo 300 44 89 103 15 13 37 33 16Tonga 110 99 16 24 94 89 67 80Trinidad and Tobago 46 97 33 31 43 38 98 97 65 70Tunisia 56 95 6 17 63 7 100 99Turkey 20 91 38 18 73 46 6 100 98 81 76Turkmenistan 67 100 21 60 62 53 13Turks and Caicos Islands 26 77 84 72 69Tuvalu 93 28 31 22 24Uganda 310 58 159 86 30 26 34 93 95 17 15Ukraine 32 99 30 14 67 48 10 92 93 85 85United Arab Emirates 12 100 34 7 28 24 94 98 80 82United Kingdom 12 25 5 84 84 100 100 97 100United States of America 21 99 39 7 76 70 8 95 96 89 90United States Virgin Islands 52 11 78 73Uruguay 29 100 60 14 77 75 100 99 68 76Uzbekistan 28 100 26 53 65 59 14 94 91Vanuatu 110 74 92 28 38 37 98 97 46 49Venezuela (Bolivarian Republic of) 92 98 101 19 70 62 19 95 95 69 77Viet Nam 59 92 35 20 78 60 4Western Sahara 46Yemen 200 36 80 76 28 19 40 83 70 48 31Zambia 440 47 151 102 41 27 27 96 98Zimbabwe 570 66 115 53 59 57 15104 104 INDICATORS INDICATORS

Monitoring Monitoring ICPD ICPD Goals goals: – Selected selected Indicators indicatorsIndicators of Mortality Indicators of Education Reproductive Health IndicatorsInfant Maternal Life and expectancy Newborn Health Maternal Primary enrolment Sexual Proportion and Reproductive Secondary Health% Illiterate Education Births per Contraceptive HIVmortality M/Fmortality (gross) M/F reaching grade 5 enrolment (>15 years) 1,000 PrevalenceprevalenceMaternal BirthsAdolescent Under age five Contraceptive Contraceptive Unmet need for Primary school enrolment, Secondary schoolTotal perratioM/F(gross) M/F M/Fwomenrate (%)mortality ratio attended by birth rate per mortality rate prevalence rate, prevalence rate, family planning, net per cent of primary1,000 liveagedAny enrolment, Modern net per cent(15-49)(deaths per skilled health 1,000 women per 1,000 women aged women aged per cent, school-age childrenbirths15-19method of school-age methodschildren,M/F100,000 live personnel, aged 15 to 19, live births, 15-49, any 15-49, modern 1988/2012 1999/20121999/2012births), 2010 per cent 1991/2010 2010-2015 methodmethod2005/20121990/2012 1990/2012male femaleWorld andregional data 16 male femaleWorld 210 70 49 52 64 57 12 92 90 64 61More developed regions 8 16 24 7 71 62 9 97 97 90 91Less developed regions 9 240 53 57 63 57 13 91 89 61 57Least developed countries 10 430 106 99 38 31 23 83 79 36 30Arab States 11 140 76 48 44 53 44 17 89 83 64 58Asia and the Pacific 12 160 69 35 40 68 63 10 95 94 63 60Eastern Europe and32 98 32 26 67 53 11 94 94 86 85Central Asia 13Latin America and81 91 73 23 73 67 10 95 96 74 78the Caribbean 14Sub-Saharan Africa 15 500 48 117 110 28 21 25 80 77 27 21THE STATE OF WORLD STATE POPULATION OF WORLD POPULATION 2013 2012105 105

Monitoring ICPD Goals – Selected IndicatorsDemographic indicatorsMaleFemaleCountry,territory orother area106 106 INDICATORS INDICATORSAverageannual rateTotal of populationpopulation change,in millions, per cent2013 2010-2015Lifeexpectancyat birth(years),2010-2015Totalfertility Populationrate, per aged 10-19,woman, per cent,2010-2015 2010Afghanistan 30.6 2.4 59 62 5.0 23Albania 3.2 0.3 75 81 1.8 19Algeria 39.2 1.8 69 73 2.8 17Angola 21.5 3.1 50 53 5.9 21Antigua and Barbuda 0.1 1.0 73 78 2.1 18Argentina 41.4 0.9 73 80 2.2 16Armenia 3.0 0.2 71 78 1.7 15Aruba 0.1 0.4 73 78 1.7 15Australia 1 23.3 1.3 80 85 1.9 13Austria 8.5 0.4 78 84 1.5 11Azerbaijan 9.4 1.1 68 74 1.9 17Bahamas 0.4 1.4 72 78 1.9 16Bahrain 1.3 1.7 76 77 2.1 11Bangladesh 156.6 1.2 70 71 2.2 21Barbados 0.3 0.5 73 78 1.8 14Belarus 9.4 -0.5 64 76 1.5 11Belgium 11.1 0.4 78 83 1.8 11Belize 0.3 2.4 71 77 2.7 20Benin 10.3 2.7 58 61 4.9 21Bhutan 0.8 1.6 68 68 2.3 20Bolivia (Plurinational State of) 10.7 1.6 65 69 3.3 21Bosnia and Herzegovina 3.8 -0.1 74 79 1.3 14Botswana 2.0 0.9 48 47 2.6 22Brazil 200.4 0.8 70 77 1.8 17Brunei Darussalam 0.4 1.4 77 80 2.0 17Bulgaria 7.2 -0.8 70 77 1.5 10Burkina Faso 16.9 2.8 55 57 5.6 22Burundi 10.2 3.2 52 56 6.1 21Cambodia 15.1 1.7 69 74 2.9 21Cameroon, Republic of 22.3 2.5 54 56 4.8 22Canada 35.2 1.0 79 84 1.7 12Cape Verde 0.5 0.8 71 79 2.3 23Central African Republic 4.6 2.0 48 52 4.4 22Chad 12.8 3.0 50 52 6.3 22Chile 17.6 0.9 77 83 1.8 16China 2 1385.6 0.6 74 77 1.7 14China, Hong Kong SAR 3 7.2 0.7 80 86 1.1 11China, Macao SAR 4 0.6 1.8 78 83 1.1 11Colombia 48.3 1.3 70 78 2.3 18Comoros 0.7 2.4 59 62 4.7 20Congo, DemocraticRepublic of the 67.5 2.7 48 52 6.0 22Congo, Republic of the 4.4 2.6 57 60 5.0 20Country, territoryor other areaAverageannual rateTotal of populationpopulation change,in millions, per cent2013 2010-2015Lifeexpectancyat birth(years),2010-2015Totalfertility Populationrate, per aged 10-19,woman, per cent,2010-2015 2010Costa Rica 4.9 1.4 78 82 1.8 17Côte d'Ivoire 20.3 2.3 50 51 4.9 22Croatia 4.3 -0.4 74 80 1.5 11Cuba 11.3 -0.1 77 81 1.5 13Curaçao 0.2 2.2 74 80 1.9 14Cyprus 1.1 1.1 78 82 1.5 13Czech Republic 10.7 0.4 75 81 1.6 10Denmark 5.6 0.4 77 81 1.9 12Djibouti 0.9 1.5 60 63 3.4 21Dominica 0.1 0.4Dominican Republic 10.4 1.2 70 77 2.5 19Ecuador 15.7 1.6 74 79 2.6 19Egypt 82.1 1.6 69 73 2.8 19El Salvador 6.3 0.7 68 77 2.2 23Equatorial Guinea 0.8 2.8 51 54 4.9 20Eritrea 6.3 3.2 60 65 4.7 20Estonia 1.3 -0.3 69 80 1.6 11Ethiopia 94.1 2.6 62 65 4.6 23Fiji 0.9 0.7 67 73 2.6 18Finland 5.4 0.3 77 84 1.9 12France 64.3 0.5 78 85 2.0 12French Guiana 0.2 2.5 74 81 3.1 18French Polynesia 0.3 1.1 74 79 2.1 18Gabon 1.7 2.4 62 64 4.1 20Gambia 1.8 3.2 57 60 5.8 21Georgia 4.3 -0.4 70 78 1.8 13Germany 82.7 -0.1 78 83 1.4 10Ghana 25.9 2.1 60 62 3.9 21Greece 11.1 0.0 78 83 1.5 10Grenada 0.1 0.4 70 75 2.2 20Guadeloupe 0.5 0.5 77 84 2.1 15Guam 0.2 1.3 76 81 2.4 18Guatemala 15.5 2.5 68 75 3.8 22Guinea 11.7 2.5 55 57 5.0 21Guinea-Bissau 1.7 2.4 53 56 5.0 21Guyana 0.8 0.5 64 69 2.6 20Haiti 10.3 1.4 61 65 3.2 22Honduras 8.1 2.0 71 76 3.0 22Hungary 10.0 -0.2 70 79 1.4 11Iceland 0.3 1.1 80 84 2.1 14India 1252.1 1.2 65 68 2.5 19Indonesia 249.9 1.2 69 73 2.3 17Iran (Islamic Republic of) 77.4 1.3 72 76 1.9 17

Monitoring ICPD Goals Demographic – Selected Indicators indicatorsMaleFemaleAverageannual rateTotal of populationpopulation change,in millions, per cent2013 2010-2015Lifeexpectancyat birth(years),2010-2015Totalfertility Populationrate, per aged 10-19,woman, per cent,2010-2015 2010Iraq 33.8 2.9 66 73 4.1 21Ireland 4.6 1.1 78 83 2.0 12Israel 7.7 1.3 80 83 2.9 15Italy 61.0 0.2 80 85 1.5 9Jamaica 2.8 0.5 71 76 2.3 20Japan 127.1 -0.1 80 87 1.4 9Jordan 7.3 3.5 72 76 3.3 18Kazakhstan 16.4 1.0 61 72 2.4 15Kenya 44.4 2.7 60 63 4.4 21Kiribati 0.1 1.5 66 72 3.0 21Korea, Democratic People'sRepublic of 24.9 0.5 66 73 2.0 16Korea, Republic of 49.3 0.5 78 85 1.3 13Kuwait 3.4 3.6 73 75 2.6 13Kyrgyzstan 5.5 1.4 63 72 3.1 20Lao People's DemocraticRepublic 6.8 1.9 67 69 3.0 23Latvia 2.1 -0.6 67 77 1.6 11Lebanon 4.8 3.0 78 82 1.5 18Lesotho 2.1 1.1 49 50 3.1 24Liberia 4.3 2.6 59 61 4.8 21Libya 6.2 0.9 73 77 2.4 18Lithuania 3.0 -0.5 66 78 1.5 13Luxembourg 0.5 1.3 78 83 1.7 12Madagascar 22.9 2.8 63 66 4.5 22Malawi 16.4 2.8 55 55 5.4 22Malaysia 29.7 1.6 73 77 2.0 19Maldives 0.3 1.9 77 79 2.3 21Mali 15.3 3.0 55 55 6.9 21Malta 0.4 0.3 77 82 1.4 12Martinique 0.4 0.2 78 84 1.8 14Mauritania 3.9 2.5 60 63 4.7 21Mauritius 5 1.2 0.4 70 77 1.5 16Mexico 122.3 1.2 75 80 2.2 19Micronesia (Federated States of) 0.1 0.2 68 70 3.3 26Moldova, Republic of 3.5 -0.8 65 73 1.5 14Mongolia 2.8 1.5 64 71 2.4 18Montenegro 0.6 0.0 72 77 1.7 14Morocco 33.0 1.4 69 73 2.8 19Mozambique 25.8 2.5 49 51 5.2 21Myanmar 53.3 0.8 63 67 2.0 18Namibia 2.3 1.9 62 67 3.1 23Nepal 27.8 1.2 67 69 2.3 22Country, territoryor other areaAverageannual rateTotal of populationpopulation change,in millions, per cent2013 2010-2015Lifeexpectancyat birth(years),2010-2015Totalfertility Populationrate, per aged 10-19,woman, per cent,2010-2015 2010Netherlands 16.8 0.3 79 83 1.8 12New Caledonia 0.3 1.3 74 79 2.1 16New Zealand 4.5 1.0 79 83 2.1 14Nicaragua 6.1 1.4 72 78 2.5 22Niger 17.8 3.9 58 58 7.6 20Nigeria 173.6 2.8 52 53 6.0 21Norway 5.0 1.0 79 84 1.9 13Oman 3.6 7.9 75 79 2.9 14Pakistan 182.1 1.7 66 67 3.2 22Palestine 7 4.3 2.5 71 75 4.1 24Panama 3.9 1.6 75 80 2.5 17Papua New Guinea 7.3 2.1 60 64 3.8 21Paraguay 6.8 1.7 70 75 2.9 20Peru 30.4 1.3 72 77 2.4 19Philippines 98.4 1.7 65 72 3.1 21Poland 38.2 0.0 72 80 1.4 12Portugal 10.6 0.0 77 83 1.3 10Puerto Rico 3.7 -0.2 75 82 1.6 16Qatar 2.2 5.9 78 79 2.1 6Réunion 0.9 1.2 76 83 2.2 16Romania 21.7 -0.3 70 77 1.4 11Russian Federation 142.8 -0.2 62 74 1.5 11Rwanda 11.8 2.7 62 65 4.6 22Saint Kitts and Nevis 0.1 1.1Saint Lucia 0.2 0.8 72 77 1.9 18Saint Vincent and the Grenadines 0.1 0.0 70 75 2.0 19Samoa 0.2 0.8 70 76 4.2 22São Tomé and Principe 0.2 2.6 64 68 4.1 20Saudi Arabia 28.8 1.8 74 77 2.7 16Senegal 14.1 2.9 62 65 5.0 21Serbia 6 9.5 -0.5 71 77 1.4 13Seychelles 0.1 0.6 69 78 2.2 15Sierra Leone 6.1 1.9 45 46 4.7 21Singapore 5.4 2.0 80 85 1.3 13Slovakia 5.5 0.1 71 79 1.4 12Slovenia 2.1 0.2 76 83 1.5 10Solomon Islands 0.6 2.1 66 69 4.1 21Somalia 10.5 2.9 53 57 6.6 22South Africa 52.8 0.8 55 59 2.4 18South Sudan 11.3 4.0 54 56 5.0 21Spain 46.9 0.4 79 85 1.5 9Sri Lanka 21.3 0.8 71 77 2.4 15THE STATE OF WORLD STATE POPULATION OF WORLD POPULATION 2013 2012107 107

Monitoring Demographic ICPD indicators Goals – Selected IndicatorsCountry, territoryor other areaAverageannual rateTotal of populationpopulation change,in millions, per cent2013 2010-2015Lifeexpectancyat birth(years),2010-2015Totalfertility Populationrate, per aged 10-19,woman, per cent,2010-2015 2010Sudan 38.0 2.1 60 64 4.5 22Suriname 0.5 0.9 68 74 2.3 18Swaziland 1.2 1.5 50 49 3.4 24Sweden 9.6 0.7 80 84 1.9 12Switzerland 8.1 1.0 80 85 1.5 11Syrian Arab Republic 21.9 0.7 72 78 3.0 21Tajikistan 8.2 2.4 64 71 3.9 21Tanzania, United Republic of 49.3 3.0 60 63 5.2 21Thailand 67.0 0.3 71 78 1.4 14The former Yugoslav Republicof Macedonia 2.1 0.1 73 77 1.4 14Timor-Leste, DemocraticRepublic of 1.1 1.7 66 69 5.9 27Togo 6.8 2.6 56 57 4.7 21Tonga 0.1 0.4 70 76 3.8 22Trinidad and Tobago 1.3 0.3 66 74 1.8 14Tunisia 11.0 1.1 74 78 2.0 16Turkey 74.9 1.2 72 79 2.1 17Turkmenistan 5.2 1.3 61 70 2.3 20Turks and Caicos Islands 0.0 2.1Tuvalu 0.0 0.2Uganda 37.6 3.3 58 60 5.9 22Ukraine 45.2 -0.6 63 74 1.5 11United Arab Emirates 9.3 2.5 76 78 1.8 10United Kingdom 63.1 0.6 78 82 1.9 12United States of America 320.1 0.8 76 81 2.0 13United States Virgin Islands 0.1 0.1 77 83 2.5 14Uruguay 3.4 0.3 74 80 2.1 15Uzbekistan 28.9 1.4 65 72 2.3 21Vanuatu 0.3 2.2 70 74 3.4 20Venezuela (BolivarianRepublic of) 30.4 1.5 72 78 2.4 18Viet Nam 91.7 1.0 71 80 1.8 17Western Sahara 0.6 3.2 66 70 2.4 16Yemen 24.4 2.3 62 64 4.1 24Zambia 14.5 3.2 56 59 5.7 22Zimbabwe 14.1 2.8 59 61 3.5 23Male FemaleAverageannual rate Life TotalTotal of population expectancy fertilityWorld andpopulation change, at birth rate, perregional datain millions,2013per cent2010-2015(years),2010-2015woman,2010-2015Populationaged 10-19,per cent,2010World 7,162 1.1 68 72 2.5 16.7More developed regions 8 1,253 0.3 74 81 1.7 11.5Less developed regions 9 5,909 1.3 67 70 2.6 17.9Least developed countries 10 898 2.3 59 62 4.2 21.4Arab States 11 350 1.0 67 71 3.3 20.6Asia and the Pacific 12 3,785 1.9 69 72 2.2 17.6Eastern Europe and330 0.1 63 74 1.8 12.9Central Asia 13Latin America and612 1.1 71 78 2.2 18.7the Caribbean 14Sub-Saharan Africa 15 888 2.6 55 57 5.1 23.0108 INDICATORS108

Monitoring ICPD Goals – Selected IndicatorsNotes for indicators1 Including Christmas Island, Cocos (Keeling) Islandsand Norfolk Island.2 For statistical purposes, the data for China donot include Hong Kong and Macao, SpecialAdministrative Regions (SAR) of China, and TaiwanProvince of China.3 As of 1 July 1997, Hong Kong became a SpecialAdministrative Region (SAR) of China.4 As of 20 December 1999, Macao became a SpecialAdministrative Region (SAR) of China.5 Including Agalega, Rodrigues and Saint Brandon.6 Including Kosovo.7 On 29 November 2012, the United Nations GeneralAssembly passed resolution 67/19. Pursuantto operative paragraph 2 of that resolution, theGeneral Assembly decided to “…accord to Palestinenon-member observer State status in the UnitedNations…”. Includes East Jerusalem.8 More developed regions comprise Europe, NorthernAmerica, Australia/New Zealand and Japan.9 Less developed regions comprise all regionsof Africa, Asia (except Japan), Latin Americaand the Caribbean plus Melanesia, Micronesiaand Polynesia.10 The least developed countries according tostandard United Nations designation.11 Including Algeria, Bahrain, Djibouti, Egypt, Iraq,Jordan, Kuwait, Lebanon, Libya, Morocco, Oman,Palestine, Qatar, Saudi Arabia, Somalia, Sudan,Syrian Arab Republic, Tunisia, United Arab Emiratesand Yemen.12 Includes only UNFPA programme countries,territories or other areas: Afghanistan, Bangladesh,Bhutan, Cambodia, China, Cook Islands,Democratic People's Republic of Korea, Fiji, India,Indonesia, Iran (Islamic Republic of), Kiribati, LaoPeople's Democratic Republic, Malaysia, Maldives,Marshall Islands, Micronesia, Mongolia, Myanmar,Nauru, Nepal, Niue, Pakistan, Palau, Papua NewGuinea, Philippines, Samoa, Solomon Islands,Sri Lanka, Thailand, Timor-Leste, Tokelau, Tonga,Tuvalu, Vanuatu, Viet Nam.13 Includes only UNFPA programme countries,territories or other areas: Albania, Armenia,Azerbaijan, Belarus, Bosnia and Herzegovina,Bulgaria, Georgia, Kazakhstan, Kyrgyzstan, Republicof Moldova, Romania, Russian Federation, Serbia,Tajikistan, The former Yugoslav Republic ofMacedonia, Turkmenistan, Ukraine, Uzbekistan.14 Includes only UNFPA programme countries,territories or other areas: Anguilla, Antiguaand Barbuda, Argentina, Bahamas, Barbados,Belize, Bermuda, Bolivia (Plurinational State of),Brazil, British Virgin Islands, Cayman Islands,Chile, Colombia, Costa Rica, Cuba, Dominica,Dominican Republic, Ecuador, El Salvador,Grenada, Guatemala, Guyana, Haiti, Honduras,Jamaica, Mexico, Montserrat, Netherlands Antilles,Nicaragua, Panama, Paraguay, Peru, Saint Kitts andNevis, Saint Lucia, St. Vincent and the Grenadines,Suriname, Trinidad and Tobago, Turks and Caicos,Uruguay, Venezuela (Bolivarian Republic of).15 Includes only UNFPA programme countries,territories or other areas: Angola, Benin, Botswana,Burkina Faso, Burundi, Cameroon, Cape Verde,Central African Republic, Chad, Comoros, Congo,Côte d'Ivoire, Democratic Republic of the Congo,Equatorial Guinea, Eritrea, Ethiopia, Gabon, Gambia,Ghana, Guinea, Guinea-Bissau, Kenya, Lesotho,Liberia, Madagascar, Malawi, Mali, Mauritania,Mauritius, Mozambique, Namibia, Niger, Nigeria,Rwanda, Senegal, Seychelles, Sierra Leone, SouthAfrica, South Sudan, Swaziland, Togo, Uganda,United Republic of Tanzania, Zambia, Zimbabwe.16 Regional aggregations are weighted averagesbased on countries with available data.Technical notesData sources and definitionsThe statistical tables in The State of World Population 2013 includeindicators that track progress toward the goals of the Programme ofAction of the International Conference on Population and Development(ICPD) and the Millennium Development Goals (MDGs) in the areas ofmaternal health, access to education, reproductive and sexual health. Inaddition, these tables include a variety of demographic indicators.Different national authorities and international organizations mayemploy different methodologies in gathering, extrapolating or analyzingdata. To facilitate the international comparability of data, UNFPA relieson the standard methodologies employed by the main sources of data,especially the Population Division of the United Nations Department ofEconomic and Social Affairs. In some instances, therefore, the data inthese tables differ from those generated by national authorities.Regional averages are based on data about countries and territorieswhere UNFPA works, rather than on strict geographical definitionsemployed by the Population Division of the United Nations Departmentof Economic and Social Affairs. For a list of countries included in eachregional category in this report, see the “Notes for indicators.”Monitoring ICPD GoalsMaternal and newborn healthMaternal mortality ratio, per 100,000 live births. Source: WorldHealth Organization (WHO), UNICEF, UNFPA and World Bank. 2010.Trends in maternal mortality: 1990 to 2010: WHO. This indicator presentsthe number of deaths to women per 100,000 live births which resultfrom conditions related to pregnancy, delivery, the postpartum period,and related complications. Estimates between 100-999 are rounded tothe nearest 10, and above 1,000 to the nearest 100. Several of the estimatesdiffer from official government figures. The estimates are basedon reported figures wherever possible, using approaches that improvethe comparability of information from different sources. See the sourcefor details on the origin of particular national estimates. Estimates andmethodologies are reviewed regularly by WHO, UNICEF, UNFPA, academicinstitutions and other agencies and are revised where necessary,as part of the ongoing process of improving maternal mortality data.Because of changes in methods, prior estimates for 1995 and 2000may not be strictly comparable with these estimates. Maternal mortalityestimates reported here are based on the global database on maternalmortality, which is updated every 5 years.Births attended by skilled health personnel, per cent, 2005/2012.Source: WHO global database on maternal health indicators, 2013 update.Geneva, World Health Organization (http://www.who.int/gho).Percentage of births attended by skilled health personnel (doctors,nurses or midwives) is the percentage of deliveries attended by healthpersonnel trained in providing life-saving obstetric care, including givingthe necessary supervision, care and advice to women during pregnancy,labour and the post-partum period; conducting deliveries on their own;and caring for newborns. Traditional birth attendants, even if they receivea short training course, are not included.Adolescent birth rate, per 1,000 women aged 15-19, 1991/2010Source: United Nations, Department of Economic and Social Affairs,Population Division (2012). 2012 Update for the MDG Database:Adolescent Birth Rate (POP/DB/Fert/A/MDG2012). The adolescentbirth rate measures the annual number of births to women 15 to 19years of age per 1,000 women in that age group. It represents the riskTHE STATE OF WORLD STATE POPULATION OF WORLD POPULATION 2013 2012109 109

Monitoring ICPD Goals – Selected IndicatorsIndicators of Mortality Indicators of Education Reproductive Health Indicatorsof childbearing among adolescent Infant women Life expectancy 15 to 19 years Maternal of age. For Primary civil enrolment regional, Proportion and global Secondary rates and % trends Illiterate in contraceptive Births per Contraceptive prevalence and HIVregistration, rates are subject mortality to limitations M/F which depend mortality on the completenessof birth registration, 1,000 the live treatment of infants born alive but and comprehensive review’. The Lancet, 12 March aged 2013. Any World Modern and (15-49)(gross) M/F unmet reaching need grade 5 for enrolment family planning (>15 between1990 years) 1,000 and 2015: Prevalence a systematic prevalenceTotal perratioM/F(gross) M/F M/Fwomenrate (%)births15-19method methodsM/Fdead before registration or within the first 24 hours of life, the quality of regional data are based on United Nations Population Division/DESAthe reported information relating to age of the mother, and the inclusionof births from previous periods. The population estimates may sufferfrom limitations connected to age misreporting and coverage. For surveyand census data, both the numerator and denominator come from thespecial analyses of data from United Nations, Department of Economicand Social Affairs, Population Division. World Contraceptive Use 2012and 2013 updates for the MDG database (see http://www.un.org/en/development/desa/population/).same population. The main limitations concern age misreporting, birthomissions, misreporting the date of birth of the child, and samplingvariability in the case of surveys.EducationMale and female net enrolment rate in primary education (adjusted),male and female net enrolment rate in secondary education, 1999-2012. Source: UNESCO Institute for Statistics, data release of May 2012.Under age 5 mortality, per 1,000 live births. Source: United Nations,Department of Economic and Social Affairs, Population Division (2011). WorldPopulation Prospects: The 2010 Revision. DVD Edition - Extended Dataset inExcel and ASCII formats (United Nations publication, ST/ESA/SER.A/306).Under age 5 mortality is the probability (expressed as a rate per 1,000live births) of a child born in a specified year dying before reaching theAccessible through: stats.uis.unesco.org. The net enrolment rates indicatethe enrolment of the official age group for a given level of educationexpressed as a percentage of the corresponding population. The adjustednet enrolment rate in primary also includes children of official primaryschool age enrolled in secondary education. Data are for the most recentyear estimates available for the 1999-2012 period.age of five if subject to current age-specific mortality rates.Sexual and reproductive healthContraceptive prevalence. United Nations, Department of Economicand Social Affairs, Population Division (2013). 2013 Update for the MDGDatabase: Contraceptive Prevalence (POP/DB/CP/A/MDG2012). Thesedata are derived from sample survey reports and estimate the proportionof married women (including women in consensual unions) currentlyusing, respectively, any method or modern methods of contraception.Modern or clinic and supply methods include male and female sterilization,IUD, the pill, injectables, hormonal implants, condoms andfemale barrier methods. These numbers are roughly but not completelycomparable across countries due to variation in the timing of the surveysand in the details of the questions. All country and regional datarefer to women aged 15-49. The most recent survey data available arecited, ranging from 1990-2011. World and regional data are based onUnited Nations Population Division/DESA special analyses of data fromUnited Nations, Department of Economic and Social Affairs, PopulationDivision. World Contraceptive Use 2012 and 2013 updates for the MDGdatabase (see http://www.un.org/en/development/desa/population/).Unmet need for family planning. Source: United Nations, Departmentof Economic and Social Affairs, Population Division (2013). 2013Update for the MDG Database: Unmet Need for Family Planning (POP/DB/CP/B/MDG2012). Women with unmet need for spacing births arethose who are fecund and sexually active but are not using any methodof contraception, and report wanting to delay the next child. This isa subcategory of total unmet need for family planning, which alsoincludes unmet need for limiting births. The concept of unmet needpoints to the gap between women's reproductive intentions and theircontraceptive behavior. For MDG monitoring, unmet need is expressedas a percentage based on women who are married or in a consensualunion. The concept of unmet need for modern methods considersusers of traditional methods as in need of modern contraception. Forfurther analysis, see also Adding It Up: Costs and Benefits of ContraceptiveServices: Estimates for 2012. Guttmacher Institute and UNFPA, 2012and Alkema L., V. Kantorova, C. Menozzi, and A. Biddlecom “National,Demographic indicatorsTotal population, 2013. Source: United Nations, Department ofEconomic and Social Affairs, Population Division (2013). WorldPopulation Prospects: The 2012 Revision, CD-ROM Edition. These indicatorspresent the estimated size of national populations at mid-year.Average annual rate of population change, per cent. Source: UnitedNations, Department of Economic and Social Affairs, Population Division(2013). World Population Prospects: The 2012 Revision, CD-ROM Edition.Average annual rate of population change is the average exponentialrate of growth of the population over a given period. It is based on amedium variant projection.Male and female life expectancy at birth. Source: United Nations,Department of Economic and Social Affairs, Population Division (2013).World Population Prospects: The 2012 Revision, CD-ROM Edition. Theseindicators are measures of mortality levels, respectively, and representthe average number of years of life expected by a hypothetical cohort ofindividuals who would be subject during all their lives to the mortalityrates of a given period. Data are projections for the period 2010-2015and are expressed as years.Total fertility rate. Source: United Nations, Department of Economicand Social Affairs, Population Division (2013). World PopulationProspects: The 2012 Revision, CD-ROM Edition. The measure indicatesthe number of children a woman would have during her reproductiveyears if she bore children at the rate estimated for different age groupsin the specified time period. Countries may reach the projected levelat different points within the period. Projections are for the period2010-2015.Population aged 10-19, per cent. Source: United Nations, Departmentof Economic and Social Affairs, Population Division (2013). WorldPopulation Prospects: The 2012 Revision, CD-ROM Edition. The measureindicates the proportion of the population between the ages of 10and 19.110 110 INDICATORS INDICATORS

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