report

132 Pages·2013·5.5 MB·English

Motherhood
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United Nations Population Fund
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©UNFPA 2013
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ISBN 978-0-89714-014-0
Sales No. E.13.III.H.1
E/12,000/2013
state of world population 2013
Printed on recycled paper.
The State of World Population 2013 EDITORIAL TEAM
Editor: Richard Kollodge
This report was produced by the Information
Editorial associate: Robert Puchalik
and External Relations Division of UNFPA, the
United Nations Population Fund. Editorial and administrative associate: Mirey Chaljub
Distribution manager: Jayesh Gulrajani
LEAD RESEARCHER AND AUTHOR
Design: Prographics, Inc.
Nancy Williamson, PhD, teaches at the Gillings School of
Global Public Health, University of North Carolina. Earlier, Cover photo: © Mark Tuschman/Planned Parenthood Global
she served as Director of USAID’s YouthNet Project and the
Botswana Basha Lesedi youth project funded by the U.S. ACKNOWLEDGMENTS
Centers for Disease Control and Prevention. She taught at The editorial team is grateful for additional insights, contribu-
Brown University, worked for the Population Council and for tions and feedback from UNFPA colleagues, including Alfonso
Family Health International. She lived in and worked on fam- Barragues, Abubakar Dungus, Nicole Foster, Luis Mora and
ily planning projects in India and the Philippines. Author of Dianne Stewart. Edilberto Loiaza produced the statistical analysis
numerous scholarly papers, Ms. Williamson is also the author that provided the foundation for this report.
of Sons or daughters: a cross-cultural survey of parental preferenc-
es, about preferences for sons or daughters around the world. Our thanks also go to UNFPA colleagues Aicha El Basri,
Jens-Hagen Eschenbaecher, Nicole Foster, Adebayo Fayoyin,
RESEARCH ADVISER Hugues Kone, William A. Ryan, Alvaro Serrano and numerous
Robert W. Blum, MD, MPH, PhD, is the William H. Gates, collegues from UNFPA offices around the world for developing
Sr. Professor and Chair of the Department of Population, feature stories and for making sure that adolescents’ own voices
Family and Reproductive Health and Director of the Hopkins were reflected in the report.
Urban Health Institute at the Johns Hopkins Bloomberg
School of Public Health. Dr Blum is internationally recog- A number of recommendations in the report are based on
nized for his expertise and advocacy related to adolescent research by Kwabena Osei-Danquah and Rachel Snow at
sexual and reproductive health research. He has edited two UNFPA on progress achieved since the Programme of Action
books and written more than 250 articles, book chapters was adopted at the 1994 International Conference on Population
and reports. He is the former president of the Society for and Development.
Adolescent Medicine, past board chair of the Guttmacher
Institute, a member of the United States National Academy of Shireen Jejeebhoy of the Population Council reviewed literature
Sciences and a consultant to the World Health Organization and provided text on sexual violence against adolescents. Nicola
and UNFPA. Jones of the Overseas Development Institute summarized
research on cash transfers. Monica Kothari of Macro International
UNFPA ADVISORY TEAM analysed Demographic and Health Survey data on adolescent
Bruce Campbell reproductive health. Christina Zampas led the research and
Kate Gilmore drafting of aspects of the report that address the human rights
Mona Kaidbey dimension of adolescent pregnancy.
Laura Laski
Edilberto Loaiza MAPS AND DESIGNATIONS
Sonia Martinelli-Heckadon The designations employed and the presentation of material in
Niyi Ojuolape maps in this report do not imply the expression of any opinion
Jagdish Upadhyay whatsoever on the part of UNFPA concerning the legal status
Sylvia Wong of any country, territory, city or area or its authorities, or con-
cerning the delimitation of its frontiers or boundaries. A dotted
line approximately represents the Line of Control in Jammu and
Kashmir agreed upon by India and Pakistan. The final status of
Jammu and Kashmir has not yet been agreed upon by the parties.
UNFPA
Delivering a world where
every pregnancy is wanted
every childbirth is safe and
every young person’s
potential is fulfilled
state of world population 2013
Motherhood
in Childhood
Facing the challenge of
adolescent pregnancy
Foreword page ii
Overview page iv
1
A global challenge page 1
2 The impact on girls' health,
page 17
education and productivity
3
Pressures from many directions page 31
4
Taking action
page 57
5
Charting a way forward page 83
Indicators page 99
Bibliography page 111
© Getty Images/Camilla Watson
Foreword
When a girl becomes pregnant, her present and future change radically,
and rarely for the better. Her education may end, her job prospects evaporate,
and her vulnerabilities to poverty, exclusion and dependency multiply.
Many countries have taken up the cause of of girls as the true pathway to fewer adoles-
preventing adolescent pregnancies, often through cent pregnancies.
actions aimed at changing a girl’s behaviour. Efforts—and resources—to prevent adoles-
Implicit in such interventions are a belief that cent pregnancy have typically focused on girls
the girl is responsible for preventing pregnancy ages 15 to 19. Yet, the girls with the greatest
and an assumption that if she does become vulnerabilities, and who face the greatest risk of
pregnant, she is at fault. complications and death from pregnancy and
Such approaches and thinking are misguided childbirth, are 14 or younger. This group of very
because they fail to account for the circum- young adolescents is typically overlooked by, or
stances and societal pressures that conspire against beyond the reach of, national health, education
adolescent girls and make motherhood a likely and development institutions, often because these
outcome of their transition from childhood to girls are in forced marriages and are prevented
adulthood. When a young girl is forced into mar- from attending school or accessing sexual and
riage, for example, she rarely has a say in whether, reproductive health services. Their needs are
when or how often she will become pregnant. A immense, and governments, civil society, commu-
pregnancy-prevention intervention, whether an nities and the international community must do
advertising campaign or a condom distribution much more to protect them and support their safe
programme, is irrelevant to a girl who has no and healthy transition from childhood and ado-
power to make any consequential decisions. lescence to adulthood. In addressing adolescent
What is needed is a new way of thinking pregnancy, the real measure of success—or fail-
about the challenge of adolescent pregnancy. ure—of governments, development agencies, civil
Instead of viewing the girl as the problem and society and communities is how well or poorly we
changing her behaviour as the solution, gov- respond to the needs of this neglected group.
ernments, communities, families and schools Adolescent pregnancy is intertwined with issues
should see poverty, gender inequality, discrimi- of human rights. A pregnant girl who is pressured
nation, lack of access to services, and negative or forced to leave school, for example, is denied
views about girls and women as the real her right to an education. A girl who is forbidden
challenges, and the pursuit of social justice, from accessing contraception or even information
equitable development and the empowerment about preventing a pregnancy is denied her right
ii ii FOREWORD
to health. Conversely, a girl who is able to enjoy The international community is develop- s Dr Osotimehin
with adolescent
her right to education and stays in school is less ing a new sustainable development agenda to
peer educators
likely to become pregnant than her counterpart succeed the Millennium Declaration and its in South Africa.
who drops out or is forced out. The enjoyment associated Millennium Development Goals after © UNFPA/Rayana
Rassool
of one right thus puts her in a better position to 2015. Governments committed to reducing the
enjoy others. number of adolescent pregnancies should also
From a human rights perspective, a girl be committed to ensuring that the needs, chal-
who becomes pregnant—regardless of the lenges, aspirations, vulnerabilities and rights of
circumstances or reasons—is one whose rights adolescents, especially girls, are fully considered
are undermined. in this new development agenda.
Investments in human capital are critical to There are 580 million adolescent girls in the
protecting these rights. Such investments not world. Four out of five of them live in developing
only help girls realize their full potential, but they countries. Investing in them today will unleash
are also part of a government’s responsibility for their full potential to shape humanity’s future.
protecting the rights of girls and complying with
human rights treaties and instruments, such as the Dr Babatunde Osotimehin
Convention on the Rights of the Child, and with United Nations Under-Secretary-General
international agreements, including the Programme and Executive Director
of Action of the 1994 International Conference on UNFPA, the United Nations Population Fund
Population and Development, which continues to
guide the work of UNFPA today.
THE STATE OF WORLD POPULATION 2013 iiiiii
Overview
Every day, 20,000 girls below age 18 give birth in developing countries.
Births to girls also occur in developed countries but on a much smaller scale.
In every region of the world, impoverished, 18. Girls under 15 account for 2 million
poorly educated and rural girls are more likely of the 7.3 million births that occur to
to become pregnant than their wealthier, urban, adolescent girls under 18 every year in
educated counterparts. Girls who are from an developing countries.
ethnic minority or marginalized group, who lack
choices and opportunities in life, or who have Impact on health, education and
limited or no access to sexual and reproductive productivity
health, including contraceptive information and A pregnancy can have immediate and lasting
services, are also more likely to become pregnant. consequences for a girl’s health, education and
Most of the world’s births to adolescents— income-earning potential. And it often alters the
95 per cent—occur in developing countries, and course of her entire life. How it alters her life
nine in 10 of these births occur within marriage depends in part on how old—or young—she is.
or a union. The risk of maternal death for mothers under 15
About 19 per cent of young women in devel- in low- and middle-income countries is double that
oping countries become pregnant before age of older females; and this younger group faces
FACING THE CHALLENGE OF ADOLESCENT PREGNANCY
• 20,000 girls giving birth every day
• Missed educational and other opportunities
• 70,000 adolescent deaths annually from
complications from pregnancy, childbirth
• 3.2 million unsafe abortions among
adolescents each year
• Perpetuation of poverty and exclusion
• Basic human rights denied
• Girls' potential going unfulfilled
iv
©Naresh Newar/ipsnews.net
“I was 14… My mom and her sisters began to
prepare food, and my dad asked my brothers,
sisters and me to wear our best clothes
because we were about to have a party.
Because I didn’t know what was going on, I
celebrated like everyone else. It was that day
I learned that it was my wedding and that I
significantly higher rates of obstetric fistulae
than their older peers as well. had to join my husband. I tried to escape but
About 70,000 adolescents in developing was caught. So I found myself with a husband
cporeugnntarinecsy d aien dan cnhuiladllbyi rothf .c aPuresegsn raenlcayte dan tdo three times older than me…. This marriage was
childbirth are a leading cause of death supposed to save me from debauchery. School
for older adolescent females in develop- was over, just like that. Ten months later, I
ipnrgeg cnoaunntt treiensd. Atod oblee sfcreonmts lwowheor -bienccoommee found myself with a baby in my arms. One day
households and be nutritionally depleted. I decided to run away, but I agreed to come
Health problems are more likely if a girl back to my husband if he would let me go
becomes pregnant too soon after reaching
puberty. back to school. I returned to school, have
Girls who remain in school longer are three children and am in seventh grade.”
less likely to become pregnant. Education
Clarisse, 17, Chad
FACING THE CHALLENGE OF ADOLESCENT PREGNANCY UNDERLYING CAUSES
• Child marriage PREGNANCY BEFORE AGE 18
• Gender inequality
• Obstacles to human rights
About 19 per cent
• Poverty
of young women in
19%
• Sexual violence and coercion
developing countries
• National policies restricting access to
become pregnant
contraception, age-appropriate sexuality education
before age 18
• Lack of access to education and reproductive
health services
• Underinvestment in adolescent girls’ human capital
v
prepares girls for jobs and livelihoods, raises their barriers to girls’ empowerment so that pregnancy
self-esteem and their status in their households is no longer the likely outcome.
and communities, and gives them more say in One such ecological model, developed by
decisions that affect their lives. Education also Robert Blum at the Johns Hopkins Bloomberg
reduces the likelihood of child marriage and School of Public Health, sheds light on the
delays childbearing, leading eventually to health- constellation of forces that conspire against the
ier birth outcomes. Leaving school—because of adolescent girl and increase the likelihood that
pregnancy or any other reason—can jeopardize a she will become pregnant. While these forces are
girl’s future economic prospects and exclude her numerous and multi-layered, they all, in one way
from other opportunities in life. or another, interfere with a girl’s ability to enjoy
or exercise rights and empower her to shape her
Many forces conspiring against own future. The model accounts for forces at
adolescent girls the national level—such as policies regarding
An “ecological” approach to adolescent pregnan- adolescents’ access to contraception or lack of
cy is one that takes into account the full range of enforcement of laws banning child marriage—
complex drivers of adolescent pregnancy and the all the way to the level of the individual, such
interplay of these forces. It can help governments, as a girl’s socialization and the way it shapes
policymakers and stakeholders understand the her beliefs about pregnancy.
challenges and craft more effective interventions Most of the determinants in this model
that will not only reduce the number of pregnan- operate at more than one level. For example,
cies but that will also help tear down the many national-level policies may restrict adolescents’
PRESSURES FROM MANY DIRECTIONS AND LEVELS
An “ecological” approach to adolescent pregnancy is one that takes into account the full
range of complex drivers of adolescent pregnancy and the interplay of these forces.
Pressures from all levels conspire against girls and lead to pregnancies, intended or otherwise. National laws may prevent a
girl from accessing contraception. Community norms and attitudes may block her access to sexual and reproductive health
services or condone violence against her if she manages to access services anyway. Family members may force her into
marriage where she has little or no power to say “no” to having children. Schools may not offer sexuality education, so she
must rely on information (often inaccurate) from peers about sexuality, pregnancy and contraception. Her partner may refuse
to use a condom or may forbid her from using contraception of any sort.
vi
INDIVIDUAL FAMILY SCHOOL/PEERS COMMUNITY NATIONAL
access to sexual and reproductive health services, little autonomy—particularly those in forced
including contraception, while the community or marriages—have little say about whether or
family may oppose girls’ accessing comprehensive when they become pregnant.
sexuality education or other information about Adolescent pregnancy is both a cause and
how to prevent a pregnancy. consequence of rights violations. Pregnancy
This model shows that adolescent pregnancies undermines a girl’s possibilities for exercising
do not occur in a vacuum but are the conse- the rights to education, health and autonomy,
quence of an interlocking set of factors such as as guaranteed in international treaties such as
widespread poverty, communities’ and families’ the Convention on the Rights of the Child.
acceptance of child marriage, and inadequate Conversely, when a girl is unable to enjoy basic
efforts to keep girls in school. rights, such as the right to education, she becomes
For most adolescents below age 18, and espe- more vulnerable to becoming pregnant. According
cially for those younger than 15, pregnancies to the Convention on the Rights of the Child,
are not the result of a deliberate choice. To the anyone under the age of 18 is considered a
contrary, pregnancies are generally the result child. For nearly 200 adolescent girls every day,
of an absence of choices and of circumstances early pregnancy results in the ultimate rights
beyond a girl’s control. Early pregnancies reflect violation—death.
powerlessness, poverty and pressures—from Girls’ rights are already protected—on paper—
partners, peers, families and communities. And by an international, normative framework that
in too many instances, they are the result of requires governments to take steps that will make
sexual violence or coercion. Girls who have it possible for girls to enjoy their rights to an
ADOLESCENT BIRTHS
95 per cent of the
world’s births to
95%
adolescents occur
in developing
countries
vii
INDIVIDUAL FAMILY SCHOOL/PEERS COMMUNITY NATIONAL
education, to health and to live free from information. Governments, however, cannot do
violence and coercion. Children have the same this alone. Other stakeholders and duty-bearers,
human rights as adults, but they are also granted such as teachers, parents, and community lead-
special protections to address the inequities that ers, also play an important role.
come with their age.
Upholding the rights that girls are entitled to Addressing underlying causes
can help eliminate many of the conditions that Because adolescent pregnancy is the result of
contribute to adolescent pregnancy and help diverse underlying societal, economic and other
mitigate many of the consequences to the girl, forces, preventing it requires multidimensional
her household and her community. strategies that are oriented towards girls’ empow-
Addressing these challenges through measures erment and tailored to particular populations of
that protect human rights is key to ending a girls, especially those who are marginalized and
vicious cycle of rights infringements, poverty, most vulnerable.
inequality, exclusion and adolescent pregnancy. Many of the actions by governments and civil
A human rights approach to adolescent society that have reduced adolescent fertility
pregnancy means working with governments were designed to achieve other objectives, such
to remove obstacles to girls’ enjoyment of rights. as keeping girls in school, preventing HIV infec-
This means addressing underlying causes, such tion, or ending child marriage. These actions can
as child marriage, sexual violence and coercion, also build human capital, impart information or
lack of access to education and sexual and skills to empower girls to make decisions in life
reproductive health, including contraception and and uphold or protect girls’ basic human rights.
FOUNDATIONS FOR PROGRESS
EMPOWER GIRLS RESPECT HUMAN
Building girls' agency, enabling RIGHTS FOR ALL
them to make decisions in life Upholding rights can eliminate
conditions that contribute to
adolescent pregnancy
RECTIFY GENDER REDUCE POVERTY
INEQUALITY
In developing and developed
Put girls and boys on equal footing countries, poverty drives adolescent
pregnancy
viii