Adolescent pregnancies and abortions
Many unwanted pregnancies are known to occur world-wide during adolescence, due in part to the fact that young women become sexually active before they are fully aware of the need for contraception and how to get appropriate services. It is also known that socio-economic and cultural factors influence the age at which young women engage in their first sexual intercourse, and whether or not they are likely to practice any form of contraception. In view of the fact that in many countries, adolescent sexuality is neither easily accepted nor discussed by the family, the school and the society at large, adolescents might be denied appropriate, adequate and meaningful education on sex and/or family life, as well as proper access to reproductive health care and contraceptive services.
Fertility rates in adolescents aged 15-19 years vary between continents and between socio-economic strata. In African countries, the rates range between 23 and 236 per 1000 per year; in Latin America, between 54 and 153 per 1000; in developed countries around 30 per 1000, with the lowest rates (below 20/1000) found in parts of Europe and Eastern Asia. In general, the rates tend to be highest among the less educated and the poor adolescents in society, who are precisely those least equipped to negotiate sexual behavior with sex partners, and who might perceive pregnancy and motherhood as means to recognition in society.
WHO estimates that in most countries in the African Region, some adolescents become sexually active at the age of 12-13 years, without any preparation about sexuality and contraception. By 15 years of age, 56% of them have regular, unprotected pre-marital sexual intercourse that could lead to unintended pregnancies and unsafe abortions. Worse still, the African region accounts for two-thirds of HIV infections occurring among 15-24 year olds world-wide. Post-abortion and post-partum sepsis, as well as delayed or inadequate treatment of STDs, give rise to high infertility rates in the region, with some countries having rates as high as 25% infertility in couples.
Induced abortion is said to be the oldest and probably the most widely used method of fertility control. One of the resolutions of the 1967 World Health Assembly recognized the fact that abortion constituted an important health problem for women in many countries. It has been demonstrated in various regions of the world that women of all ages and social classes experience spontaneous abortion, and also use induced abortion to terminate undesired pregnancies. While older multiparous women seek abortion as a means to limiting additional births, younger unmarried females use abortion to delay childbearing. WHO estimates that about 15%, but as high as 50% in some areas, of maternal deaths results from unsafe abortions globally. Although WHO does not consider the medical termination of pregnancy to be a family planning method, it believes that the level of induced abortion or of maternal deaths resulting from abortion clearly indicate that there are unmet needs for family planning world-wide. The risk of maternal death has been found to be significantly less when women have access to safe legal abortion services. About 10-15% of all suspected pregnancies end up in spontaneous abortion (miscarriage) which, though less fatal than unsafely-induced abortion, still often requires treatment and hospitalization.
Each country would need to determine the strategies best suited to it, for the improvement of female reproductive health. However, the African Region of WHO has developed a reproductive health strategy for the region for 1998-2007, and has set targets to guide countries in the different programmatic areas of reproductive health. The strategic framework of the plan calls for advocacy and social mobilization for the promotion of healthy reproductive behavior, as well as for equitable access to quality reproductive health services to all, including adolescents. Some of the targets are the following: 1) reduce maternal deaths resulting from unsafe abortions to less than 10% of the maternal mortality rate; 2) reduce the incidence of pregnancy and STDs in adolescents by 30%; 3) reduce unwanted pregnancies among adolescents by 30% of current national levels; 4) provide all persons (including adolescents) with the necessary knowledge of and tools for reproductive health, to ensure appropriate timing and spacing of births, and the prevention of sexually transmitted infections; 5) for a country like Seychelles with a high contraceptive prevalence rate (over 25%), increase the contraceptive prevalence rate by 20%.
In conclusion, the need for induced abortion and the incidence of unplanned pregnancy, unsafe abortions and the related morbidity and mortality can be reduced, if not prevented, by making family planning services available for all, as an integral part of health care, and by providing accurate information to women (including adolescents), to health care providers and to the community at large.
Stella Anyangwe, MD, PhD
WHO Liaison Officer, Ministry of Health, Victoria, Seychelles
References
Earlier onset of puberty and adolescence and its impact on teenage sexuality
During the human life span there are three dynamic periods of growth: antenatally (i.e. during pregnancy), then during the first postnatal year and finally during puberty and adolescence. The last is the longest of these three periods, lasting from age10 to age 20. It is a complex period of physical, emotional, mental and social maturation. For this reason adolescence has been identified as an age category at which an otherwise healthy population is at risk due to the cascade of maturational processes. Puberty is a part of adolescence, but refers only to the physical growth and maturation of gonads. For girls this occurs between 10 and 16 years of age. The events of normal puberty are judged by certain parameters, which are not applicable to adults. Sequences of pubertal maturation start with a spurt in body growth, followed by development of secondary sexual characteristics and finally menarche: the first menstruation.
From the beginning of this century a so-called secular trend to earlier puberty and earlier menarche has been noted all over the world as a result of better nutrition and health care. In the mid-19th century, the mean age at menarche was between 17 and 18. Thus young women gained their reproductive capabilities in their late teens or early twenties. Nowadays, all that happens during the early teens, as the average age at menarche nowadays is 12-13. So, human beings are constantly changing in a biological sense. This advancement in biological puberty, as a result of which physical sexual maturity now occurs many years in advance of the intellectual maturity required to handle sexuality, has raised fundamental sociological problems. It is said that we are "servants" of our hormones because sexuality is associated with the onset of puberty.
No single aspect of adolescence alarms adult society more than the prospect of young people engaging in sexual activities and risking pregnancy. Complaints have been registered since earliest recorded history. In the 8th century BC, the Egyptian historian, Hesiod, lamented, "I see no hope for the future of our people if they are dependent on the frivolous youth of today". Obviously, the sexual behaviour of young people has constantly been changing, reflecting the times and society in which they live. However, throughout history, marriage and the establishment of a family during the late teenage years or in early adulthood, have been the norm rather than the exception. Only in relatively recent times have many cultures departed from this practice. Most so-called developed countries now predicate a socio-cultural system where marriage, sexuality and pregnancy are only established during the third decade of life, mainly because of the longer period required to complete one’s education and become economically independent. While such social conventions may hold great merit, they often generate conflicts within teenagers who must content with the paradoxical messages they receive from their biological clock and their parental and societal guidance.
Added to this, the much earlier onset of puberty, and consequently sexuality, often brings disastrous consequences, including unwanted teenage pregnancies, infection with HIV and other sexually transmitted diseases and emotional trauma. Teenage sexuality and pregnancies in the USA have been identified as one of the major problems of the nation. Estimates are that between 30% and 70% of girls in their early teens are sexually active, with fewer that 45% of these regularly using appropriate contraceptive means; the overall teenage pregnancy rate in the USA has increased by 23% over a 20-year interval (1).
Seychelles has not escaped this sensitive social problem. In a research project on high risk pregnancy conducted by the author in the early 80’s in Seychelles (2), the data showed that out of a total of 4665 deliveries during 1980-82, 1255 (27%) were to teenagers. Although most of these teenagers were primigravidas, 14% were multigravidas and 23% of all the teenage gravidas were between 12 and16 years of age. The outcome of these teenage pregnancies was marred by one or more complications in 47% of cases, either during the antenatal period or during delivery. Progress has been made since then, but teenage mothers were still responsible for 14% of all deliveries in 1996 and 33% of first births, and of the 228 teenagers who delivered a baby in 1996, there were still 22 (10%) who were multigravidas3. From 1982 to 1996, age specific fertility rates for 15 to19-year-olds remained between 60 and 78 per 1000 per year despite the fact that family life education was part of the curriculum in all primary and secondary schools (3,4).
Sex, like fire and water, is a powerful force, and any powerful force must be handled wisely. Sexual health education and guidance is becoming the first step to promoting reproductive health. However, if the links between attitudes, beliefs, self-esteem, interpersonal skills, sexuality, contraception and reproductive health are not understood, sexual health education programs are bound to fail. Sexual and reproductive health is not only the absence of disease; it includes being able to develop positive aspects of sexuality. Many programs and experiences have been evaluated all over the world but it is difficult to choose a single effective formula for the whole world because sexual education programs may require very different approaches in different cultural and religious settings.
In Seychelles the most recent approaches have included widespread training of health workers, teachers and other professionals in adolescent reproductive health and interpersonal communication skills. In addition peer educators and counselors have been trained to work with the youth of this country and more attention is being paid to the development of interpersonal skills and self-esteem in the personal and social education program in schools. Training programs in parenting are now being introduced. It may be that some of these efforts are beginning to bear fruit: the age specific fertility rate for 15 to 19-year-olds, having never fallen below 60/1000 over the previous 20 years, fell to 49/1000 in 1997 (5).
A very appropriate remark on the issue of sexual health education may be quoted from Dr. Esther Sapire’s book, "Contraception and Sexuality in Health and Disease". Quote: ‘Sex education is a battle against sexual illiteracy’ (6). If we were to teach arithmetic as we teach about sexuality, business activities would collapse. Ignorance cannot be the basis for a good marriage nor for the successful practice of a profession and we must provide young people with a sound basis for both. In order to act responsibly, a person needs all the relevant knowledge he can understand. Knowledge is not permission, but it may protect, whereas ignorance cannot.
The World Health Organization declares that adolescents are the adults of tomorrow and to ignore their needs is difficult, unwise and unjust. It is difficult because there are so many adolescents, unwise because what happens to them affects what happens to the whole of mankind (both now and in the future) and unjust because they are members of the human family and should not be deprived of the rights other members enjoy.
Seychelles’ experience in educating and guiding adolescents in all aspects of their lives, including their sexuality, has given very rewarding results, but must be continued and improved and must rely on team work, including health professionals, parents, schools, religions, social workers and peer leaders.
Vesna Dramusic MD, PhD
Consultant in Obstetrics and Gynecology, Victoria Hospital, Seychelles
References