Into a New World: Young Women's Sexual and Reproductive Lives

Today's adolescents, the largest generation of 10-19-year-olds in history, are coming of age in a world that is very different from the one in which their parents grew up. Although the pace of change varies among and within regions of the world, society is in a state of widespread and rapid transformation, creating a dizzying array of new possibilities and new challenges for youth.

Improved modes of transportation and communication expose even youth in remote areas to people with different values and traditions, while an increasingly urban and industrialized world presents the allure of advancement and opportunity. But without adequate education and training, young people will be unable to meet the demands of modern workplaces, and without the guidance of parents and community and government leaders, adolescents may be ill equipped to assess the ramifications of their decisions.

Nevertheless, in the developing world, where widespread poverty endures, some families may forsake children's education if their labor is needed to help support the household. In most countries, 70-100% of children are enrolled in primary school, but the number of years of schooling that young people obtain is highly variable. For instance, while 80% of young women in a few developing countries get a basic education - at least seven years of schooling - 25% or fewer in many parts of Sub-Saharan Africa do.

Governments are moving toward the goal of making basic education widely available. Consequently, young women in virtually all countries are more likely than their mothers were to obtain a basic education, and in the developing world the differential can be considerable. For example, in Sudan, 46% of 15-19-year-olds have had seven or more years of schooling, compared with 5% of women aged 40-44. Nevertheless, disparities - primarily along socioeconomic and residential lines - persist. In many developing countries, urban young women are 2-3 times as likely as rural women to have a basic education.

While some of the hurdles of adolescence are the same for all young people, the teenage years are especially telling for women. Although some 10-19-year-olds are only beginning to experience the changes that come with puberty, many are entering sexual relationships or marriage. And each year, about 14 million young women aged 15-19 give birth. Teenage childbearing is most common in the developing world, where the proportion of women who have their first child by age 18 is often between one-quarter and one-half (Chart 1). By contrast, in the developed world - and in a small number of developing countries - fewer than one in 10 have an early first birth.

Early marriage and, especially, childbearing can have a profound and long-lasting impact on a woman's well-being, education and ability to contribute to her community. Yet, complex physical, familial and cultural factors that are often poorly understood determine who will marry and when; who will begin sexual activity before marriage; who will begin childbearing during adolescence; and who will bear children outside marriage. The available data demonstrate that while the needs and experiences of adolescents vary around the world, there are similarities that cross national and regional boundaries.

The Timing of Sex And Marriage Varies

Marriage marks an important transition in an individual's life, and the timing of the event can have a dramatic impact on a young person's future. While in many societies a woman's first sexual experience is likely to be with her husband, in others the beginning of sexual activity is not so closely linked to marriage. Differing expectations regarding relationships and sexual behavior— and a society's way of adapting to changes in these expectations— can have a profound impact on youth, their families and society as a whole.

At least half of young women in many Sub-Saharan African countries enter their first union• ;either a formal marriage that is religiously or legally sanctioned, or a cohabiting union that may or may not lead to formal marriage• ;by age 18, although no more than one in seven do so in a few countries in the region. In Latin America and the Caribbean, 20-40% of adolescent women enter a union, and in North Africa and the Middle East, the proportion is 30% or less. Across Asia, the likelihood of early marriage is quite variable; 73% of women in Bangladesh enter a union by age 18, compared with 14% in the Philippines and Sri Lanka, and only 5% in China. Women in developed countries are unlikely to marry before age 18; 10-11% do so in France, Great Britain and the United States, but only 3-4% marry this young in Germany and Poland.

Early marriage is less common than it was a generation ago, although considerable variation exists among and within regions. For instance, in Sub-Saharan Africa, the proportion of women who had married by age 18 has changed little in Ghana (39% of 40-44-year-olds vs. 38% of 20-24-year-olds) and CŸte d'Ivoire (49% vs. 44%), but has declined markedly in Kenya (47% vs. 28%). By contrast, substantial declines have taken place throughout Asia, and levels of early marriage have remained essentially stable in Latin America and the Caribbean.

Throughout the world, the timing of a first union is strongly associated with a woman's educational attainment. In much of Sub-Saharan Africa, Latin America and the Caribbean, rates of early marriage among women with less than a basic education are roughly three times those among women with at least seven years of schooling (Table 1). Large differentials according to educational attainment also are seen in developed countries, although rates of early marriage are relatively low there.

Entering sexual relationships and intiating childbearing during the teenage years is common among women in the developing world.
Country and survey year	% of women 20-24 married or in union before age 18		% of women who gave birth by age 202		% of married women 15-19 who do not want a child soon	% of women 15-19 who are in need of contraceptive protection3
	Fewer than 7 years of schooling1	7 or more years of schooling1	20- 24	40- 44
Sub-Saharan Africa
Botswana, 1988	15	8	55	50	62	29
Burkina Faso, 1992- 1993	65	25	62	58	66	16
Burundi, 1987	18	9	27	39	75	3
Cameroon, 1991	79	26	67	64	64	32
Central African Rep., 1994- 1995	60	42	61	59	59	23
Côte d'Ivoire, 1994	48	21	63	57	62	35
Ghana,1993	51	26	49	50	83	32
Kenya, 1993	52	18	52	59	66	22
Liberia, 1986	57	30	64	59	63	36
Madagascar, 1992	45	14	53	60	59	27
Malawi, 1992	63	25	63	56	73	u
Mali, 1987	80	61	67	62	68	28
Namibia, 1992	21	5	42	38	28	19
Niger, 1992	87	12	75	63	57	21
Nigeria, 1990	69	14	54	49	62	22
Rwanda, 1992	21	4	25	36	74	6
Senegal, 1992- 1993	54	6	52	54	64	13
Tanzania, 1991- 1992	58	28	57	65	64	24
Togo, 1988	50	16	56	59	74	33
Uganda, 1995	62	31	66	65	67	22
Zambia, 1992	60	31	61	68	68	30
Zimbabwe,1994	69	24	47	54	70	8
North Africa & Middle East
Egypt, 1992	49	6	29	40	64	4
Morocco, 1992	23	4	19	39	56	2
Sudan, 1989- 1990	41	9	26	61	59	4
Tunisia, 1988	12	4	13	36	70	2
Yemen, 1991- 1992	54	17	41	35	14	2
Asia
Bangladesh, 1993- 1994	82	40	66	85	71	18
China, 1992	8	2	14	22	73	u
India, 1992- 1993	66	21	49	58	65	15
Indonesia, 1994	49	10	33	51	70	3
Pakistan, 1990- 1991	38	7	31	38	57	8
Philippines, 1993	30	10	21	26	81	4
Sri Lanka, 1987	u	u	16	31	76	3
Thailand, 1987	25	8	24	28	76	4
Turkey, 1993	30	6	25	42	71	4
Latin America & Caribbean
Bolivia, 1993- 1994	34	18	38	38	91	12
Brazil, 1996	34	14	32	29	88	12
Colombia, 1995	42	15	36	34	83	11
Dominican Republic, 1991	64	18	33	52	66	12
Ecuador, 1987	42	15	35	39	80	8
El Salvador, 1985	48	16	u	u	82	10
Guatemala, 1987	48	10	50	48	79	12
Mexico, 1987	46	13	35	41	63	5
Paraguay, 1990	33	13	37	34	74	11
Peru, 1991- 1992	43	9	27	36	90	10
Trinidad & Tobago, 1987	42	33	30	40	87	11
Developed countries
France, 1994	29	7	6	13	18 4	u
Germany, 1992	3	3	6	13 5	87 4	u
Japan, 1992	6	0	3	2	77 6	u
Poland, 1991	12	3	14	11	u	u
Great Britain, 1991	27	6	15	16	u	u
United States, 1995	41	6	22	24	70	12
1. Figures are based on 10 or more years of education for the developed countries except Great Britain (11 or more) and the United States (12 or more). 2. In North Africa, the Middle East and Asia, never-married women are assumed to have had no births. 3. "In need" refers to sexually active women who do not want a child soon and are not using a modern method: the pill, diaphragm, condom, IUD, spermicides, sterilization, injectables and implants. Information on fertility preferences is available only for married women; unmarried women are assumed not to want a child soon. Women who were pregnant at the time of the survey but had not wanted to be are considered to be in need. 4. Refers to 20-24-year-olds. 5. Refers to 35-39-year-olds. 6. Refers to 18-19-year-olds; the value is based on 22 women. u=unavailable.

Cultures around the world have varying attitudes toward sexual activity among unmarried people. In North Africa, the Middle East and most Asian countries, young women are expected to abstain from intercourse until they marry, and available evidence suggests that most conform to that norm. However, in much of Sub-Saharan Africa, unmarried teenage women commonly have sexual relationships, which often lead to formal unions; in the United States and some European countries, sexual relationships among teenagers are common also but may not lead to marriage. Many of the same societies that restrict or condemn sexual behavior for single women tolerate or even encourage it for unmarried men. As a result, men are more likely than women to initiate sexual activity outside marriage, and they do so at a younger age.

Delaying marriage beyond adolescence has advantages for women, but leaves them vulnerable to certain hazards as well. A woman who postpones marriage may be able to pursue her education further, may have a greater role in deciding when and whom she will marry, and may have more influence over what happens within her marriage and family. However, she also may become more likely to engage in premarital sexual behavior, which carries the risk of unintended pregnancy and infection with sexually transmitted diseases (STDs). Faced with an unintended pregnancy, a woman who remains unmarried has to decide whether to bear a child out of wedlock or to seek an abortion; in countries where induced abortion is illegal or not easily accessible, many women will resort to clandestine procedures. Both married and unmarried sexually active women may contract STDs, but the risk is greater for those who are not married because they are more likely to have multiple partners.

Childbearing Frequently Begins at an Early Age

In some societies, women are encouraged to begin their families during adolescence. Fairly large proportions of women have their first child by age 18 in most of Sub-Saharan Africa (for example, about one-fifth in Namibia and one-half in Niger); fewer than one-fifth do so in most of Asia (except in India and Bangladesh, where the proportions are roughly 30% and 50%, respectively). In Latin America and the Caribbean, 12-28% of women first give birth at ages 15-17; in North Africa and the Middle East, 3-27% begin childbearing this early.

Women with a basic education are about half as likely as those with less schooling to begin a family before age 18; in North Africa and the Middle East, the proportions of young teenagers giving birth are lower, but the difference according to educational attainment is larger. Education is associated with differences in adolescent childbearing in developed countries, as well; in the United States, teenagers with less than 12 years of schooling are about six times as likely as those with more schooling to give birth by age 18.

While the majority of adolescents who have a child are married, a substantial proportion are not. In much of Sub-Saharan Africa, one-third of births to women aged 15-19 occur among unmarried adolescents; the proportion is quite low (4-6%) in Burkina Faso, Mali, Niger and Nigeria, but exceeds three-quarters in Botswana and Namibia. Typically in Latin America and the Caribbean, 12-25% of adolescent births are to unmarried women. Nonmarital childbearing is a growing trend in the developed world; in France, Germany, Great Britain and the United States, more than half of adolescents who give birth are unmarried.

Survey data indicate that the proportion of teenage mothers who had not planned to give birth varies widely within and between regions. In Latin America and the Caribbean, between one-fourth and one-half of young mothers say that their birth was unplanned; in North Africa and the Middle East, the proportion ranges from about 15% to 30%. Some 10-16% of teenage births in India, Indonesia and Pakistan are unplanned, compared with 20-45% in the rest of Asia. The variation is even greater in Sub-Saharan Africa - from 11-13% in Niger and Nigeria to 50% or more in Botswana, Ghana, Kenya, Namibia and Zimbabwe. A large share of adolescent births in developed countries also are unplanned - for example, 66% in the United States.

As access to education has increased and the benefits of postponing childbearing have become more widely known, adolescent childbearing has declined in some countries where it once was common (Table 1). Women aged 20-24 in parts of Asia are about 80% as likely as those aged 40-44 to have had their first child during adolescence; elsewhere in the region, they are only one-half to two-thirds as likely to have done so. Adolescent childbearing has fallen by about one-quarter to one-half in North Africa and the Middle East.

By contrast, smaller declines have occurred in Sub-Saharan Africa, and in some countries, adolescents are more likely to give birth than they were a generation ago. In Latin America and the Caribbean, changes in levels of teenage childbearing have varied. For example, there has been a 37% decline in the Dominican Republic, no change in Bolivia and a slight increase in Brazil.

Delaying childbearing benefits young women by giving them more time to acquire education and develop skills that will enhance their ability to care for their families and compete in the job market. It also can have a dramatic impact on the rate of population growth both within a country and globally. In many developing countries, a woman who has her first child by age 18 will have an average of seven children. Postponing the first birth until her early 20s reduces the average number of births she has to about five.

Teenagers' Birth Control Use Is Generally Low

While some teenagers are eager to begin childbearing, most do not wish to have a child soon; even among those who are married, at least two-thirds in most countries want to delay childbearing or postpone a second birth (Table 1). Yet many factors beside a young woman's fertility desires influence whether she will use birth control: her marital status, her family's expectations and community's norms, and her access to contraceptive and health care services.

Consequently, no more than 20% of married teenagers use a method in most Sub-Saharan countries, although 60% or more of them indicate they do not want a child soon. Levels of use are similarly low in North Africa and the Middle East, but they vary quite a bit in Asia: Fewer than 5% of married adolescents in India and Pakistan practice contraception, compared with about 40% of those in Indonesia and Thailand. With few exceptions, countries in Latin America and the Caribbean have levels of use ranging from 30% to 53%.

Sexually active unmarried teenagers are much more likely than their married peers to practice contraception in Sub-Saharan Africa; they are as likely as their married counterparts to do so in Latin America and in the United States. Of the roughly 260 million women aged 15-19 worldwide, married and unmarried, about 11% (29 million) are sexually active and do not want to become pregnant but are not using a modern method of birth control (the pill, injectable, IUD, implant, sterilization, diaphragm, condom or spermicides). The proportion who need contraceptive protection, or better protection, is especially large in Sub-Saharan Africa (for example, about one-third of all adolescent women in CŸte d'Ivoire and Ghana) and is also fairly high in Bangladesh and India (slightly less than one in five). About one in 10 women in much of Latin America and the Caribbean are at risk of having an unintended pregnancy because they are not using a method or are using a traditional contraceptive.

Adolescents who wish to practice contraception face many obstacles when seeking a method. The level of knowledge of modern methods, for example, varies among adolescent women in the developing world and is particularly low in Sub-Saharan Africa• ;less than one-half in Burkina Faso, Burundi, Madagascar, Mali, Niger, Nigeria and Tanzania. Familiarity with the condom is lowest - no more than one-third of young women in many countries know about this method.

Teenagers who are knowledgeable about birth control methods may not know where to obtain them. This is a greater obstacle in rural than in urban areas. Additionally, in some countries where sexual activity among unmarried adolescents is commonly viewed as wrong, young women's access to contraceptive services is legally restricted.

Even when young women are familiar with a modern method and have access to it, they may not know how to use it properly. In part because teenagers often lack knowledge about or skill in using contraceptives, they are more likely than older women to become pregnant within the first year after beginning to use a method.

Despite their frequently low levels of contraceptive use, teenagers today are more likely than those of the 1970s to be using a modern method. Increases in use are most notable among married teenagers in several Asian countries: Prevalence has doubled or tripled in Indonesia, the Philippines and Thailand, and it has increased 10-fold in Bangladesh (Table 2).

Table 2: The use of modern contraceptives is increasing among married adolescent women.
Country	% of married women aged 15-19 using a modern method
	1970s	1990s
Bangladesh	2	20
Bolivia	2*	10
Brazil	46*	46
Colombia	21	34
Egypt	6*	13
Ghana	2*	7
Indonesia	11	32
Kenya	1	5
Mexico	11	24†
Philippines	5	10
Thailand	15	40†
United States‡	59	65
Zimbabwe	28*	30
*The mid- or late 1980s. †1987. ‡Percentage is of all sexually active women aged 15-19; the earlier period is 1982.

Modern contraceptive methods are the choice of most married adolescents who use birth control in North Africa, the Middle East and Asia. Traditional methods - mostly periodic abstinence - prevail in Sub-Saharan Africa and are used by large minorities of married teenagers in Latin America and the Caribbean.

In no developing country do more than 8% of married adolescent women use the condom, the only contraceptive method that also is effective in preventing the spread of HIV and other STDs. But in some areas, messages about the condom's role in disease prevention are beginning to be heeded. In several Latin American countries and in the United States, sexually active unmarried adolescents are twice as likely as married teenagers to use the condom.

Sexual Activity Entails Many Health Risks

Childbirth - especially the birth of a first baby - carries potential health risks for all women. For a woman younger than 17 who has not reached physical maturity, the risks are heightened. Young adolescents, especially those not yet 15, are more likely than older women to experience premature labor, miscarriage and stillbirth, and they are up to four times as likely as women older than 20 to die from pregnancy-related causes. Furthermore, their infants have a greater chance than babies born to adult women of being underweight at birth and of dying by age one.

Throughout the world, some pregnant adolescents receive no prenatal care; the proportion exceeds one-half in Bangladesh, Bolivia and Egypt. Even in affluent populations, many teen agers get no care or seek services only late in their pregnancy.

Another threat to young women's reproductive health lies in the decision to terminate an unwanted pregnancy in settings where abortion is illegal or difficult to obtain. In such situations, adolescents may seek out providers who will perform the procedure clandestinely; often these practitioners are unskilled and work under unsanitary conditions.

In several countries of Sub-Saharan Africa, adolescents represent between one-fourth and one-third of women suffering from abortion-related complications; in Kenya and Nigeria, they make up more than half of women with the most severe abortion complications. Even where abortion is legally available, young women may face an increased risk of complications if they delay obtaining one, as some do because they do not recognize or they deny the early signs of pregnancy, or they lack the resources to pay for an abortion.

Infections of the reproductive tract also have a major impact on a woman's health and fertility. Many such infections develop when women give birth or have an abortion under nonsterile conditions, and others are contracted through sexual intercourse with an infected partner. Each year, a sizable proportion of women and men aged 15-49 contract an STD• ;less than 10% in developed and some developing countries, but from 11% to 25% in most developing regions. Young women are especially susceptible to STDs because they have fewer protective antibodies than older women do, and the immaturity of their cervix increases the likelihood that exposure to an infectious agent will result in transmission of the disease.

In societies where women have little power to make decisions about their lives, an adolescent who fears infection by her partner may be unable to refuse his demands for sex or to insist that he use condoms. And while unmarried women have a greater risk of acquiring STDs, even married women may be at risk if their husbands had many sexual relationships before marrying or continue to have more than one sexual partner.

STDs in women often cause no symptoms initially; as a result, women may be unaware that they are infected and therefore may not seek treatment. Untreated STDs can have devastating health effects, including fertility impairments, chronic pelvic pain, cervical cancer and adverse effects on infants born to women who had the infection during pregnancy.

Additionally, half of HIV infections occur among people younger than 25. Many pregnant teenagers in some Sub-Saharan countries test positive for the virus - for example, 20-27% in some areas of Botswana, Nigeria and Rwanda.

Certain cultural practices are associated with reproductive health risks among adolescents. In some societies, many girls undergo female genital mutilation, in which part or all of the genitalia are removed. Complications can occur from the cutting itself, and lifelong effects may include chronic pain during intercourse, recurrent pelvic infections and difficult labor. In many Asian, Latin American and Caribbean countries, males traditionally have their first sexual experience with a prostitute.

Finally, youth the world over experience sexual abuse, incest and rape. In many regions, young people - particularly those who are poor or homeless and who lack the skills to compete for nonexploitive employment - are victims of sexual exploitation for commercial gain.

Young Women Need A Helping Hand

Today's adolescents are the next generation of parents, workers and leaders. To fill these roles to the best of their ability, they need the guidance and support of their family and their community, and the attention of a government committed to their development. As economic modernization, urbanization and mass communications change the expectations and behavior of adolescents, adaptation to new ways will likely be inconvenient and sometimes painful. But adaptation is inevitable and inescapable.

Most countries recognize the necessity and value of education for young women. Women who have even a primary education delay marriage and childbearing by about one and one-half years compared with those who have no schooling; those with a secondary education postpone these events further. Education also contributes to the health of a woman's children and family, and facilitates her use of information and services. Governments and other social institutions therefore must find new ways to enable families to enroll girls in school and to encourage young women to stay in school and complete their basic education.

Few developed or developing countries have given adequate attention to the particular reproductive health needs of adolescent women• ;in some cases because of a lack of resources, in others because of a fear of engendering controversy. The extent and nature of reproductive health needs is individual and depends on a woman's age and circumstances (Table 3). And because patterns of marriage and sexual behavior vary among regions of the world (Table 4) or among cultural groups, the proportion of young women with specific needs varies as well. However, the need for accurate information and education is universal - both for girls and young women and for the boys and young men who will become their sexual partners and husbands.

Table 3: Regardless of sexual activity or childbearing status, all young women need reproductive health services.
Sexual activity and childbearing status	Services needed during adolescent years
	Sexuality education	Contraceptive services	STD screening and treatment	Prenatal care	Delivery services	Programs for students who are pregnant or mothers
Not sexually active	X
First sex before marriage	X	X	X
First sex within marriage	X	X	X
Pregnant or a parent	X	X	X	X	X	X

Table 4: The patterns of marriage and sexual behavior among young women vary in different regions of the world.
% of women who by age 20	Sub- Saharan Africa	Asia, North Africa, Middle East	Latin America, Caribbean countries*	Five developed
Are not sexually active	17	52	44	23
Have had first intercourse	83	†	56	77
Before marriage	38	†	28	67
Within marriage	45	48	28	10
Have had a child	55	32	34	17
*France, Germany, Great Britain, Poland and the United States.†Comparable national information is not available on sexual activity among unmarried women for all countries in these regions.

Young children and teenagers often learn about sexual matters from peers, siblings, parents and the media, but the information they obtain through these channels is usually limited and may be erroneous. Formal instruction, tailored to the age and background of the youth involved, is an important source of accurate information about sexuality, pregnancy, childbearing, contraception and STD prevention. Formalized curricula are common in developed countries, where the length of schooling is extensive. But they are much less prevalent in developing countries and typically are not implemented at the national level; furthermore, given the short duration of schooling common in many countries, and the high dropout rates among disadvantaged adolescents, community-based educational programs are a necessary supplement to school initiatives.

Comprehensive sexuality education programs not only cover biological facts, but also provide young people with practical information and skills regarding dating, sexual relationships and contraceptive use. Although programs often encounter religious or political opposition, most studies show that they do not encourage sexual activity; rather, they are associated with the postponement of first sex and, among young people who are sexually active, with the use of contraceptives.

Governments, along with other appropriate institutions and even the media, have a role to play in improving women's ability to protect themselves against unwanted pregnancies and STDs. Special efforts are needed to educate and motivate men to cooperate with their sexual partners in the use of contraceptives to prevent unwanted pregnancies and of condoms to prevent the spread of disease. Making available services to diagnose and treat STDs, as well as information about the risk of infection, also is critical. Adolescent women require access to a range of contraceptive services that are responsive to their specific circumstances, including their marital status, number of partners and fertility intentions.

Some young women who experience an unwanted pregnancy will seek an abortion, whether or not it is legally available. In countries where it is, services must be financially and geographically accessible to all young people. Where the procedure is not available legally, many women will seek clandestine abortions; these women must have access to adequate care if they suffer complications from the procedure, and postabortion care must include contraceptive counseling, to help women avoid another unwanted pregnancy.

In many developing countries, services for pregnant and parenting women of any age are inadequate. Adolescents in particular, however, need to be informed about the importance of prenatal care, and services have to be accessible to them. They also need social support during pregnancy, and after giving birth, they need support and health care for themselves and their infants. Teenage mothers may require assistance with breastfeeding, advice about nutrition or information about immunizations. Many will need contraceptive counseling and services to help them delay their next pregnancy.

Privacy and confidentiality are important aspects of service provision for adolescents, who may be uncomfortable discussing sexual matters or may fear condemnation from their families or communities if they reveal their sexual activity. Care provided specifically for adolescents must be sensitive to young women's limited access to transportation and their often meager financial resources. The degree to which the service environment welcomes young women will determine the extent to which adolescents avail themselves of reproductive health care.

The future rests heavily on the welfare of adolescent women - on how well they fulfill their roles as mothers, as contributors to the economy, as teachers of the next generation and as sources of strength for their communities and nations. As they work toward claiming their full and legitimate place in the world, young women face hardship and challenge. But the challenge for communities and nations - to give young women the helping hand they need and deserve - is even greater.

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© copyright 2005, The Alan Guttmacher Institute