Which two developing countries contain over one-third of the worlds 15- to 24-year-olds?

Overview

Adolescent pregnancy is a global phenomenon with clearly known causes and serious health, social and economic consequences. Globally, the adolescent birth rate (ABR) has decreased, but rates of change have been uneven across regions. There are also enormous variations in levels between and within countries. Adolescent pregnancy tends to be higher among those with less education or of low economic status. Further, there is slower progress in reducing adolescent first births amongst these and other vulnerable groups, leading to increasing inequity. Child marriage and child sexual abuse place girls at increased risk of pregnancy, often unintended. In many places, barriers to obtaining and using contraceptives prevent adolescents from avoiding unintended pregnancies. There is growing attention being paid to improving access to quality maternal care for pregnant and parenting adolescents. WHO works with partners to advocate for attention to adolescent pregnancy, to build an evidence base for action, to develop policy and programme support tools, to build capacity and to support countries to address adolescent pregnancy effectively.

Scope of the problem

Every year, an estimated 21 million girls aged 15–19 years in developing regions become pregnant and approximately 12 million of them give birth (1).

Globally, ABR has decreased from 64.5 births per 1000 women in 2000 to 42.5 births per 1000 women in 2021. However, rates of change have been uneven in different regions of the world with the sharpest decline in Southern Asia (SA), and slower declines in the Latin American and Caribbean (LAC) and sub-Saharan Africa (SSA) regions. Although declines have occurred in all regions, SSA and LAC continue to have the highest rates globally at 101 and 53.2 births per 1000 women, respectively, in 2021 (4).

There are enormous differences within regions in ABR as well. In LAC, for example, Nicaragua recorded the highest estimated ABR at 85.6 per 1000 adolescent girls in 2021, compared to 24.1 per 1000 adolescent girls in Chile (4). Even within countries, there are enormous variations, for example in Zambia the percentage of adolescent girls aged 15–19 who have begun childbearing (women who either have had a birth or are pregnant at the time of interview) ranged from 14.9% in Lusaka to 42.5% in the Southern Province in 2018 (5). In the Philippines, this ranged from 3.5% in the Cordillera Administrative Region to 17.9% in the Davao Peninsula Region in 2017 (6).

While the estimated global ABR has declined, the actual number of childbirths to adolescents continues to be high. The largest number of estimated births to 15–19-year-olds in 2021 occurred in SSA (6 114 000), whereas far fewer births occurred in Central Asia (68 000). The corresponding number was 332 000 among adolescents aged 10–14 years in SSA, compared to 22 000 in South-East Asia (SEA) in the same year (4).

Context in which adolescent pregnancies occur

Studies of risk and protective factors related to adolescent pregnancy in LMICs indicate that levels tend to be higher among those with less education or of low economic status (7). Progress in reducing adolescent first births has been particularly slow amongst these vulnerable groups, leading to increasing inequity.

Several factors contribute to adolescent pregnancies and births. First, in many societies, girls are under pressure to marry and bear children.As of 2021, the estimated global number of child brides was 650 million: child marriage places girls at increased risk of pregnancy because girls who are married very early typically have limited autonomy to influence decision-making about delaying child-bearing and contraceptive use Second, in many places, girls choose to become pregnant because they have limited educational and employment prospects. Often in such societies, motherhood – within or outside marriage/union – is valued, and marriage or union and childbearing may be the best of the limited options available to adolescent girls.

Contraceptives are not easily accessible to adolescents in many places. Even when adolescents can obtain contraceptives, they may lack the agency or the resources to pay for them, knowledge on where to obtain them and how to correctly use them. They may face stigma when trying to obtain contraceptives. Further, they are often at higher risk of discontinuing use due to side effects, and due to changing life circumstances and reproductive intentions. Restrictive laws and policies regarding the provision of contraceptives based on age or marital status pose an important barrier to the provision and uptake of contraceptives among adolescents. This is often combined with health worker bias and/or lack of willingness to acknowledge adolescents’ sexual health needs.

Child sexual abuse increases the risk of unintended pregnancies. A WHO report dated 2020 estimates that 120 million girls aged under 20 years have experienced some form of forced sexual contact. This abuse is deeply rooted in gender inequality; it affects more girls than boys, although many boys are also affected. Estimates suggest that in 2020, at least 1 in 8 of the world’s children had been sexually abused before reaching the age of 18, and 1 in 20 girls aged 15–19 years had experienced forced sex during their lifetime.

The WHO report titled Violence against women prevalence estimates 2018notes that “adolescents aged 15–19 years (24%) are estimated to have already been subjected to physical and/or sexual violence from an intimate partner at least once in their lifetime, and 16% of adolescent girls and young women aged 15–24 have been subjected to this violence within the past 12 months.”

Preventing adolescent pregnancy and childbearing as well as child marriage is part of the SDG agenda with dedicated indicators, including indicator 3.7.2, “Adolescent birth rate (aged 10–14 years; aged 15–19 years) per 1000 women in that age group,” and 5.3.1, “Proportion of women aged 20–24 years married before the age of 18 years.”

Strategies and interventions related to adolescent pregnancy have focused on pregnancy prevention. However, there is growing attention being paid to improving access to and quality of maternal care for pregnant and parenting adolescents. Available data on access paints a mixed picture. Access to quality care depends on the geographic context and the social status of adolescents. Even where access is not limited, adolescents appear to receive a lower quality of both clinical care and interpersonal support than adult women do.

WHO response

WHO works with partners to advocate for attention to adolescents, build the evidence and epidemiologic base for action, develop and test programme support tools, build capacity, and pilot initiatives in the small but growing number of countries that began to recognize the need to address adolescents’ sexual and reproductive health. As a result of these collective efforts, adolescent health has moved to the centre of the global health and development agenda. In this changed context, WHO continues its work on advocacy, evidence generation, tool development and capacity building, while working with partners within and outside the United Nations system to support countries to address adolescent pregnancy effectively in the context of their national programmes.

Adolescent pregnancy is a global phenomenon with clearly known causes and serious health, social and economic consequences to individuals, families and communities. There is consensus on the evidence-based actions needed to prevent it. There is growing global, regional and national commitment to preventing child marriage and adolescent pregnancy and childbearing. Nongovernmental organizations have led the effort in several countries. In a growing number of countries, governments are taking the lead to put in place large-scale programmes. They challenge and inspire other countries to do what is doable and urgently needs to be done – now.

References

1. Sully EA, Biddlecom A, Daroch J, Riley T, Ashford L, Lince-Deroche N et al., Adding It Up: Investing in Sexual and Reproductive Health 2019. New York: Guttmacher Institute; 2020.
2. Darroch J, Woog V, Bankole A, Ashford LS. Adding it up: Costs and benefits of meeting the contraceptive needs of adolescents. New York: Guttmacher Institute; 2016.
3. United Nations, Department of Economic and Social Affairs, Population Division. Fertility among young adolescents aged 10 to 14 years. New York: UNDESA, PD, 2020.   
4. United Nations Department of Economic and Social Affairs. World Population Prospects, 2019 Revision: Age-specific fertility rates by region, subregion and country, 1950-2100 (births per 1,000 women) Estimates. Online Edition [cited 2021 Dec 10]. Available from: https://population.un.org/wpp/Download/Standard/Fertility/
5. Zambia Statistics Agency, Ministry of Health (MOH) Zambia, and ICF. Zambia Demographic and Health Survey 2018. Lusaka, Zambia, and Rockville, Maryland, USA: Zambia Statistics Agency, Ministry; 2018.
6. Philippine Statistics Authority (PSA) and ICF. Philippines National Demographic and Health Survey 2017. Quezon City, Philippines, and Rockville, Maryland, USA: PSA and CF; 2018.
7. Chung, W.H, Kim, ME., Lee, J. Comprehensive understanding of risk and protective factors related to adolescent pregnancy in low- and middle-income countries: A systematic review. Journal of Adolescence. 2018; 69: 180-188.