PREM Gender & Development
Why pay attention to adolescent reproductive health issues?
Level of adolescent birth rate remains a concern in some regions and groups. From 1997 to 2007, the
adolescent fertility rate has marginally declined in all regions. The largest decrease was observed in Latin
America and the Caribbean, where the rate dropped from 102 to 74. Progress was less dramatic in SubSaharan Africa, where the rate decreased from 141 to 134 (WB/IMF Global Monitoring Report, 2009). In
many low income countries, births among 15-24 year olds accounts for between 30 to 50 percent of all
births. In some countries such as India and Dominican Republic, births to 15-24 year olds constitute
more than half of all births.
Within countries, teenage motherhood is also closely associated with poverty. The proportion of women
(aged 15 to 24) who had a birth before age 15 is significantly higher in the poorest wealth quintile than
in the richest. Poor young women typically have less access to reproductive health services, but the
choice to have children very early also reflects low-income girls’ lack of access to schooling and limited
economic prospects.
Figure 1: Adolescent Fertility Rate, by income level and region
(Births per 1,000 women ages 15-19, 2007)
90.2
Low income
Lower middle
income
45.7
Latin America &
Caribbean
Middle
income
46.9
South Asia
67.0
35.0
27.0
Europe &
Central Asia
19.5
High income
72.6
Middle East &
North Africa
51.5
Upper middle
income
117.7
Sub-Saharan Africa
17.4
East Asia & Pacific
0
20
40
60
80
100
0
20
40
60
80
100
120
140
Source: World Development Indicators 2009, World Bank.
Sexual and reproductive health knowledge among young people and teenage girls’ use of maternal
health and family planning services is low; poor quality of these services is also a concern (World
Development Report 2007). For example, among sexually active youth in Nigerian schools, awareness of
the risk of pregnancy from the first sexual encounter was very low. Nor are young people able to identify
the time of month when the risk of pregnancy is highest. In Bangladesh few teenage mothers could
identify life-threatening conditions during pregnancy and only about 5 percent knew about conditions,
such as severe headaches, high blood pressure, and pre-eclampsia, that might threaten the life of the
mother during pregnancy or delivery. Nearly 50 percent of the teenage mothers reported not seeking
any assistance for maternal complications.
_____________________________________________________________________________________
Prepared by Gisela Garcia, Trine Lunde and Nishta Sinha
For more information, please contact Gisela Garcia at ggarcia3@worldbank.org
PREM Gender & Development Unit
DHS data show that quality of care provided through health checkups is also a problem. First
pregnancies are at a higher risk of neonatal mortality and giving information on potential complications
is an important component of antenatal care for young mothers. However, DHS data show that in some
countries, young mothers who access antenatal care are more likely to get checkups but are less likely to
be told about pregnancy complications.
Evidence on the consequences of adolescent motherhood is limited in developing countries and,
sometimes contradictory in developed countries (World Development Report 2007). In the United
States, for example, a number of studies find significant negative impact of teenage childbearing on
schooling and earnings while others find that a good part of the consequences can be attributed to prior
social and economic disadvantages and not to teenage childbearing (Klepinger, Lundberg, and Plotnick
(1997), Geronimus and Bound (1990), Geronimus and Korenman (1992)). Indeed, the key empirical
challenge in assessing the impact of early childbearing is to isolate the causal impact of becoming a
young mother from the mother’s socioeconomic background. Hoffman (1998) argues that instead of
being contradictory, these results reflect different periods of time in the United States. It is possible that
when social conditions made it difficult for girls to cope with teenage pregnancy, young mothers were
hurt by this event in their lives. Over time, better access to second chances programs ensuring school
continuation for teen mothers may have lead studies to find no causal impact of teen pregnancy on girls’
outcomes.
In developing countries, empirical evidence suggests that there is a negative correlation between
schooling, adolescent sexual initiation and childbearing in developing countries (Buvinic 1998; Lloyd
2005, Lloyd and Mensch 2008). Kaufman, de Wet and Stadler (2001) find that while young girls are likely
to leave school after a birth, many return o complete their schooling, at least in part due to the
availability of informal child care. The physical or health consequences for the mother and her child are
better recognized. Teen mothers are twice as likely as older women to die of pregnancy-related causes
(World Bank, 1998), and conditions such as malnutrition place teen mothers’ children at higher risk of
illness and death (AGI, 1998). The age below which the physical risks of childbearing are considered
significant varies depending on general conditions and on access to good prenatal care. In societies with
good nutritional levels and widespread access to high quality prenatal care, the physical risk of having a
child may not be significant when the mother is 15 or 16 (Makinson (1985); Zabin and Kiragu (1998)).
However, in countries where anemia and malnutrition are common and where access to health care is
poor, childbearing among 18 or 19 year olds may bring disproportionate health risks.
What interventions can be used to prevent and address the impact of early childbearing?
A series of policies and programs have the potential to affect the risks, the opportunities, and ultimately
the outcomes in terms of the reproductive health of youth. Using the same “youth lens” as employed by
the 2007 World Development Report, interventions to address adolescent reproductive health can be
divided into those providing: (i) Opportunities; (ii) Capabilities/Agency; and/or (iii) Second Chances (see
table 1).
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PREM Gender & Development Unit
Expanding access to and improving the quality of education and health services, facilitating the start to a
working life; giving young people a voice to articulate the kind of assistance they want and a chance to
participate in delivering it are all examples of interventions providing Opportunities for developing
human capital. Developing young people’s capabilities to choose well among these opportunities, by
recognizing them as decision-making agents and helping ensure that their decisions are well informed,
adequately resourced, and judicious, are examples of interventions providing Capabilities. Second
chances interventions are targeted programs that give young people the hope and the incentive to catch
up from bad luck—or bad choices.
Broadly, we can divide these interventions also by whether they address fertility and reproductive
health directly or indirectly. Examples of direct interventions would be mostly associated with the
provision of ‘youth friendly’ reproductive health and family planning services and information/
education/communication campaigns while the traditional example of indirect interventions is the
increase in schooling among young girls.
Why consider interventions with indirect effects, such as human capital building and income
generation? Since many of the adverse consequences of teenage motherhood appear hand-in-hand
with low levels of schooling, intervening by getting girls into school can be one way to prevent an early
transition to motherhood. Indeed a strong body of evidence shows that schooling – in particular
secondary schooling – strongly affects the reproductive outcomes for women, and is positively linked to
higher age at marriage and later child bearing (Mathur et al. 2003, Martin 1995, Choe et al. 2001, Welti
2002), and negatively linked to fertility (Schultz 1997). For instance, in six countries from Sub-Saharan
Africa, median age at marriage for women with 10 or more years of schooling and women with no
formal schooling differs by 4 to 6 years on average (Martin 1995). In 13 countries from Sub-Saharan
Africa, women with 7-10 years of schooling have 0.2 to 0.7 fewer children ever born, while primary
education alone does not reduce fertility (Ainsworth et al. 1996).
Extracted from: Women & Health: Today’s Evidence and Tomorrow Agenda, WHO 2009
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PREM Gender & Development Unit
Providing income earning opportunities, another indirect intervention, potentially improves young
women’s future opportunities and thus gives them an incentive to delay motherhood and invest in their
future. Earning an income can also improve young women’s ability to negotiate with partners and/or
with their families. An interesting illustration of these effects comes from a program that provides
conditional cash transfers to young women (and their families) in Mexico called Oportunidades. The
transfers are aimed at encouraging young people from poor households to stay in school. A recent
analysis shows that for girls in urban areas, program participation significantly delayed the onset of
premarital sex, marriage and the timing of first births (Gulametowa-Swan (2009)).
Interventions to address the age at which young girls and women are married might also have the
potential to delay early childbearing. Recent DHS data shows that the percentage of young women
married by the age of 18 goes from 43% to an alarming 75% in many African countries as well as in India
and Bangladesh. Broadly half of these young women (20 to 24 years old) are married by the age of 15.
References
Ainsworth, M., Beegle, K.,and Nyamete, A. 1996. “The impact of women’s schooling on fertility and contraceptive
use: A study of fourteen Sub-Saharan African countries.” World Bank Economic Review. 10(1): 85-122.
Amin, S., Diamond I., Naved, R.T., and Newby, M. 1998. “Transition to adulthood of female garment-factory
workers in Bangladesh.” Studies in Family Planning, 29(2): 185-200.
Buvinic, Mayra. 1998. The Costs of Adolescent Childbearing: Evidence from Chile, Barbados, Guatemala and
Mexico. Studies in Family Planning Vol. 29, No. 2. The Population Council.
Choe, M.K., Thapa, S., and Achmad, S.I. 2001. “Surveys show persistence of teenage marriage and childbearing in
Indonesia and Nepal.” Asia-Pacific Population and Policy. 58:1-4.
Dupas, Pascaline. 2006. “Relative Risks and the Market for Sex: Teenagers, Sugar Daddies and HIV in Kenya.”
EHESS-PSE. Paris. Processed
Gertler, P. J., S. F. Bertozzi, J. P. Gutierrez, and J. Sturdy. 2006. “Preliminary Results from Analysis of Poverty and
Adolescent Risk Behavior in Mexico.” World Bank. Washington, DC. Processed
Gulametova-Swann, M. 2009. "Evaluating the Impact of Conditional Cash Transfer Programs on Adolescent
Decisions about Marriage and Fertility: the Case of Oportunidades," Ph.D. Dissertation, University of
Pennsylvania.
Huffman, W. E., and Peter F. Orazem. 2004. “Agriculture and Human Capital in Economic Growth: Farmers,
Schooling and Health.” Ames, Iowa: Iowa State University, Economics Working Papers 04016.
Kalwij, A.S. 2000. “The effects of female employment status on the presence and number of children.” Population
Economics 13: 221-239.
Lloyd, Cynthia B., ed. 2005. Growing up Global: The Changing Transitions to Adulthood in Developing Countries.
Panel on Transitions to Adulthood in Developing Countries, National Research Council. Washington, D.C.:
National Academies Press.
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Lloyd, C. B. and B. S. Mensch. 2008. "Marriage and Childbirth as Factors in Dropping Out from School: An Analysis of DHS
Data from Sub-Saharan Africa." Population Studies 62(1): 1-13.
Mammen, K., and C. Paxson. 2000. “Women’s Work and Economic Development.” Journal of Economic Perspectives
14(4):141–64.
Martin, T.S. 1995. “Women’s education and fertility: Results from 26 Demographic and Health Surveys.” Studies in
Family Planning. Vol 36, no. 4, pp 187-202,
Mathur, S., Greene, M., and Malhorta, A. 2003. Too young to wed: The lives, rights, and health of young married
girls. Washington DC: International Center for Research on Women.
Schultz, T. P. 1997. "Demand for children in low income countries," in M.R. Rosenzweig and O. Stark (eds.),
Handbook of Population and Family Economics. Amsterdam: Elsevier.
Speizer, I., Magnani, R. and Colvin, C.2003. The effectiveness of adolescent reproductive health interventions in
developing countries: a review of the evidence. Journal of Adolescent Health, Volume 33 Issue 5, pp 324-348.
The World Bank, 2007. World Development Report 2007: Development and the Next Generation. Washington, D.C.
World Bank/IMF, 2009. Global Monitoring Report 2009: A Development Emergency. Washington, D.C.
Welti, C. 2002. “Adolescents in Latin America: Facing the future with skepticism,”. in B.B. Brown et al. (eds.), The
world’s youth: Adolescence in eight regions of the globe. Cambridge, England: Cambridge University Press.
World Health Organization, 2009. Women & Health: Today’s Evidence and Tomorrow Agenda. Geneva, Switzerland, WHO
Press.
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PREM Gender & Development Unit
Table 1. Youth Interventions with direct or indirect effects on adolescent reproductive health
DIRECT
Health
interventions
Conditional
and
unconditional
cash transfer
programs to
affect
behaviors
6
Opportunities
Capabilities
Second Chances
Expand opportunities for building
human capital and help youth acquire,
improve and deploy skills.
Improve capability to make good decisions, by providing the right
information or incentives.
Remedy undesirable outcomes, offer second
chances, put youth back on the path of human
capital building.
Supply-side incentives to facilities:
facilities receive payments against
results (Results Based Financing);
“delay first pregnancy” is one of the
indicators used in Rwanda against
which results will be measured
Youth-friendly health and pharmaceutical services: outreach
programs, mobile clinics, health centers geared to respond to the
needs of young people. Information, Education and Communication
(IEC) Campaigns. Examples include:
Reproductive health education program in Namibia delayed girls’
first sexual encounter (Stanton et al. 1998, Fitzgerald et al 1999).
Provision of youth-friendly services in Zambia was associated with
increases in contraceptive use by youth (Nelson and Magnani 2000).
A an integrated school- and facility-based RH intervention program
had an effect in delaying first sex, in increasing contraceptive use,
and in reducing unwanted pregnancies in Chile, but only had a small
impact on visits to linked clinics. Apparently, youth obtained their
services elsewhere (Murray, Toledo et al. 2000).
Lack of info available on the effect of mass media programs in
averting teen pregnancies. A reproductive health mass media pilot
directed to youth in Zimbabwe, showed an apparent effect in
promoting abstinence and in the use of contraceptives (Kim et al.
2001).
Scarce information on the impacts of social marketing, or peer
counseling programs
Cash transfer to reduce risky sexual behavior (e.g. Tanzania, Malawi
and Lesotho). Early impacts of Malawi CCT include: reduce dropout
rates, delayed onset sexual activity and early marriage.
Cash transfer to educate girls and increase the age at marriage of
girls (e.g. Apni Beti Apna Dhan in Haryana, India) Parents increased
their investment in daughters’ human capital as a result of the
program. No info on effect on marriage.
Family planning services, emergency
contraception and post-abortion care
Maternal Care services targeted to youth
as in Pathfinder’s Newlyweds Program in
Bangladesh
Some cash transfer programs target
recent drop out of school girls (Malawi)
PREM Gender & Development Unit
INDIRECT
Conditional
and
unconditional
cash transfer
programs to
build human
capital
Formal
schooling
Opportunities
Capabilities
Second Chances
Expand opportunities for building
human capital and help youth acquire,
improve and deploy skills.
Improve capability to make good decisions, by providing the right
information or incentives.
Remedy undesirable outcomes, offer second
chances, put youth back on the path of human
capital building.
Stipend and scholarship programs
in general.
Free uniforms given to primary
school students reduced dropout
rates, childbearing and marriage in
Kenya (Duflo, Kremer and
Sinai/Dupas)
Recent suggestive evidence on the
Oportunidades CCT shows delays in
pre-marital sex, marriage and
timing of first birth as a result of the
program.
Linked to higher age at marriage
and later child bearing, and
negatively linked to fertility.
Scholarship and stipend programs targeted to girls only, aiming at
increasing their bargaining power (Bangladesh, Cambodia). The
Bangladesh Female Secondary School Assistance Project is an
example where girls enrollment increased after receiving stipends
and despite the low graduation rates, the program contributed to
delays in age at marriage.
Conditional or unconditional cash
transfers can be targeted to vulnerable
groups such as young parents, out of
school young boys and girls, etc.
Oportunidades includes incentives for youth (post-secondary) to
save and invest, and to continue onto high school and higher
education
Curriculum-based sex-education programs are often provided in the
formal education system (Namibia My Future My Choice). The
‘abstinence campaign’ version of these has shown ineffective.
Educational system that allows for the
participation of pregnant teenagers and
young mothers, and ideally facilitates
their participation and reintegration.
Livelihoods
programs
Includes modules aimed at
facilitating girls’ income generation
(Katz)
Safe spaces for information sharing, formation of supportive social
networks, learning
Safe spaces can also be a way of
‘catching’ particularly vulnerable girls.
Vocational
training
To facilitate employment and
increased earnings - both are
negatively correlated with fertility
(e.g. Projoven, AGI)
More and more vocational training programs now incorporate life
skills training (Katz)
Other
interventions
for economic
opportunity
Access to economic assets have
also been found to reduce fertility
(e.g. urban land-titling in Peru)
Often used as a way to reach out to
youth who dropped out of school early.
Programs like the Jamaica Foundation
Program provided vocational training and
child care for young mothers
participating in the program (WDR 07).
Child care services for teenage mothers
to continue education and/or to facilitate
their entering the labor force.
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PREM Gender & Development
_____________________________________________________________________________________
Prepared by Gisela Garcia, Trine Lunde and Nishta Sinha
For more information, please contact Gisela Garcia at ggarcia3@worldbank.org