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Adolescent Sexual and Reproductive Health Globally

Adolescent Sexual and Reproductive Health Globally. Shifting the Paradigm. Robert Wm. Blum, M.D., M.P.H., Ph.D. Professor, Director, WHO Collaborating Centre Division of General Pediatrics & Adolescent Health University of Minnesota. Prepared for Tulane University School of Public Health

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Adolescent Sexual and Reproductive Health Globally

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  1. Adolescent Sexual and Reproductive Health Globally Shifting the Paradigm Robert Wm. Blum, M.D., M.P.H., Ph.D. Professor, Director, WHO Collaborating Centre Division of General Pediatrics & Adolescent Health University of Minnesota Prepared for Tulane UniversitySchool of Public Health November 19, 2001

  2. Social andDemographic Trends

  3. Population and Age One fifth of the world’s population is between 10-19 years of age 914 million rising to 1.13 billion by 2025; Between 1975-1995 the proportion has fallen from 22% to 20%;

  4. Demographic Trends • Today, 30% of the world’s population is between the ages of 10-24 years; • 83.5% of the world’s young people live in developing countries; • In a number of countries in sub-Saharan Africa there are 5 times the number of people <15 years than over 55; • In many developing countries young people make up 20-25% of the population; in Japan and France it is 13% and 14%, in China, 16%.

  5. Percent of the population 10-19 years old Population and Age Asia19% Europe13% Japan12% LatinAmerica21% Africa23%

  6. Changes in World Population 1950-2025 25+ years 15-24 years 0-14 years

  7. Social Trends Impacting Adolescent Health • Migration: • Between countries • Within countries: rural to urban • Young women; • The rising value of education; • Delay in the age of marriage; • Ethnic minorities are disadvantaged the world over.

  8. Countries by Urban and Rural Areas Young Population in Developing 1990-2025 Urban Rural

  9. Consequences of Urbanization • Disintegration of traditional family and social structures; • Rise in unemployment; • Rise in juvenile violence; • Rise in youth suicide.

  10. Secondary School School enrollment rates in secondary school, by region and year, ages 12-17 East Asia/Pacific Near East/North Africa Latin America/Caribbean South Asia Sub-Saharan Africa 1975 1985

  11. Education and Marriage On average, there is a 30% spread in teen marriage when girls with more years of schooling are compared with less Education Region > 6 years < 6 years Sub-Saharan Africa 38.4 71.4 Near East/North Africa 18.5 49.8 Asia 19.8 56.0 Latin America/Caribbean 30.0 62.1

  12. Education, Age and Birth Births before age 20 by region and education Education Region > 6 years < 6 years Sub-Saharan Africa 37.0 63.8 Near East/North Africa 8.6 35.0 Asia 17.1 45.7 Latin America/Caribbean 21.3 53.1 Percentage of women aged 20-24 who gave birth before age 20, by region, according to residence and years of education, 1980s-90s.

  13. Consequences of Education • Delay in age of marriage; • Rise in out-of-wedlock births; • Rise in clandestine abortions; • Rise in number of sexual partners with associated risks of AIDs and other STDs.

  14. Mortality and Adolescent Reproductive Health

  15. Maternal Mortality Persists as a Leading Cause of Death in Developing Countries • 40-50% of all maternal deaths are due to abortion complications; • Cephalopelvic disproportion, hemorrhage, toxemia and sepsis are all associated with maternal deaths; • Ritual genital mutilation results in increased maternal death; • In Eastern Europe 25% of all maternal deaths are due to abortion complications.

  16. N – 12 E – 50 Europe W – 14 E – 55 S – 12 Asia W – 230 N - 1100 SC– 410 SE– 300 Africa W - 1100 E - 1300 S - 360 Maternal Mortality NorthAmerica 11 Caribbean 110 CentralAmerica 110 SouthAmerica 200 Oceana 260 0-100 101-200 201-500 1000+ By subregion, 1995 – deaths per 100,000 live births

  17. Maternal Mortality Ratio by Age of Mother Pakistan ‘91-92 (Hazara) Bangladesh, ‘87(rural) Egypt, ‘92 Bolivia, ‘92 (La Paz), China, ‘89(30 provinces)

  18. Adults and Children living with HIV/AIDs W. Europe 540,000 E. Europe + C. Asia 700,000 NorthAmerica 920,000 E. Asia + Pacific 640,000 Caribbean 390,000 N. Africa + Middle East 400,000 LatinAmerica 1,400,000 Sub SaharanAfrica 25,300,000 Australia +New Zealand 15,000 December, 2000; By subregion, 1995 – deaths per 100,000 live births

  19. Adolescent Reproductive Health and Behavior

  20. Earlier Age of Sexual Debut • 40% of teens in El Salvador and Brazilhave had intercourse by age 15; • 50% of all Nigerian females have had intercourse by 16 years of age; • In North America and Northern Europe, 40% to 60% of young people have initiated their sexual careers by age 16.

  21. Adolescent Sexual Activity 51- 60% Burkina Faso 54.1% Ghana 59.0% <20% Philippines 8.1% Rwanda 14.2% Peru 18.4% 31- 40% Paraguay 30.1% Senegal 35.4% 61- 70% Zambia 60.5% Niger 60.9% Uganda 61.6% Central African Republic 62.0% Mali 66.0% Cote d’Ivorie 68.1% Cameroon 68.5% 21- 30% Kazakstan 20.5% Brazil (NE) 22.5% Bolivia 22.9% Guatemala 25.0% DominicanRepublic 26.9% Colombia 29.6% Haiti 29.0% Zimbabwe 29.7% 41- 50% Namia 42.4% Kenya 46.1% Tanzania 49.9% Percent of Adolescents who have ever had sex.

  22. In many countries of the world the age of marriage is rising as the age of menarcheis declining.

  23. In Bangladesh, the age of marriage has increased by 4 years (from age 14 to 18) since 1975.

  24. Marriage and Birth Proportion of 15-19 year old mothers unmarried at first birth. Region Percent Sub-Saharan Africa 32% Latin America 17% Asia <1% Middle East <1% North Africa <1%

  25. Premarital Sex Region Country Percent Africa Niger 5% Botswana 81% Latin America Dominican Republic 10% Brazil 40% Asia >10% Middle East >10%

  26. Worldwide 15 million babies are born to adolescent mothers annually.

  27. Pregnancy, birth and abortion rates Women, aged 15-19, mid-1990s* • Birth Control • Abortion

  28. Contraceptive Type Used Proportion of sexually active women aged 15-19 who used a contraceptive method§ at last intercourse • Condom + • Other • Condom • Pill • Long Acting § Users reporting more than one method were classified by the most effective. *Aged 18-19; **Aged 16-19; +Statistical standards for Canada do not allow condom, long-acting and other methods to be tabulated separately.

  29. Adolescent Births in Select Industrialized Countries (1999) Births per 1000 Women Ages 15-19

  30. Adolescent Abortions in Select Industrialized Countries (1999) Per 1000 Women Ages 15-19

  31. Rising out of Wedlock Births • In the 30 years from 1965-1995 out of wedlock births increased from one-in-ten to three out of four adolescent births in the United States; • Nearly identical trends have been seen in Chile.

  32. A Desire to Limit Family Size • In the decade 1975 to 1985 the ideal family size declined by one-third in many developing countries; • Use of contraception continues to rise among adolescents in industrialized countries; • There is a growing awareness of contraceptive alternatives among adolescents in developing countries.

  33. Knowledge of Contraception Over 90% of 15 -19 year old women in most developing countries know about some form of contraception.

  34. 11- 20% Kenya 12.5% Madagascar 13.7% Senegal 15.8% Tanzania 16.5% Uganda 16.9% Bolivia 14.8% DominicanRepublic 14.2% Haiti 14.3% 21- 30% Peru 22.7% Columbia 25.6% Brazil (NE) 22.5% Zimbabwe 20.5% Namibia 22.5% Mali 25.6% Ghana 22.4% C. AfricanRepublic 20.4% Burkina Faso 21.3% <10% Malawi 7.9% Niger 8.4% Rwanda 7.5% Zambia 3.5% Guatemala 6.1% Paraguay 9.2% 31- 40% Nigeria 30.7% Cote d’Ivoire 34.9% Kazakstan 39.0% 40% + Cameroon 52.7% Contraceptive Use Contraceptive use is much less than knowledgeable. Percent of sexually active 15-19 year olds using any method of contraception

  35. Use of a Modern Method of Contraception Adolescents in sub-Saharan Africa are least likely to use a modern method; Use of a modern method of contraception is strongly linked to marital status.

  36. Barriers to Contraception • Cost of oral contraception; • Ineffective barrier contraception; • Laws prohibiting contraception among unmarried women or adolescents; • Lack of availability.

  37. What works? What doesn’t work?

  38. Knowledge (just know) Shifting Models & Approaches Teen Teen

  39. Peer Influence (peer education) Shifting Models & Approaches Knowledge (just know) Teen Teen

  40. Shifting Models & Approaches Knowledge (just know) Teen Teen Peer Influence (peer education) Risk Behaviors Linked (comprehensive strategy)

  41. Shifting Models & Approaches Knowledge (just know) Teen Teen Peer Influence (peer education) Risk Behaviors Linked (comprehensive strategy) Resistance Skills (just say no)

  42. Shifting Models & Approaches Knowledge (just know) Teen Teen Environmental Factors (mentorship) Peer Influence (peer education) Risk Behaviors Linked (comprehensive strategy) Resistance Skills (just say no)

  43. Knowledge (just know) Peer Influence (peer education) Shifting Models & Approaches Family Factors (family involvement) Teen Teen Environmental Factors (mentorship) Risk Behaviors Linked (comprehensive strategy) Resistance Skills (just say no)

  44. Evaluation research has repeatedly shown that problem reductioninterventions alone directed at youth arerarely effective.

  45. Ineffective Strategies for Teen Pregnancy Prevention • Providing information alone; • Scare tactics; • Short-term interventions; • Abstinence only; • Contraception only; • School-based services.

  46. The 5 Assets of Youth • Caring and Compassion; • Character; • Competence in academic, social and vocational arenas; • Confidence; • Connection.

  47. Program Elements that Promote Youth Assets • Programs that incorporate more elements of positive youth development appear to be more effective in achieving their goals; • Programs that strengthen adult-adolescent relationships appear to have better outcomes; • Long-term programs with a strong youth participation component are most effective.

  48. Nothing is more practical than a good theory.

  49. We see that youth development is central to effective youth health programs.

  50. Positive youth development has as a basic tenet that youth are resources to be developed not problems to be fixed. Pittman

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