BACKGROUND PAPER Adolescent Fertility: Socio-cultural Issues and Programme Implications*
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- Title
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BACKGROUND PAPER
Adolescent Fertility: Socio-cultural
Issues and Programme Implications*
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BACKGROUND PAPER
Adolescent Fertility: Socio-cultural
Issues and Programme Implications*
Marcela Villarreal
Senior Population Officer/TSS Specialist
Population Programme Service (SDWP)
Women & Population Division
FAO
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INFORMATION
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UNFRfl
South Asia Conference on the Adolescent
21-23 July, 1998
New Delhi - India
* This paper was discussed with colleagues of the UNFPA Support Teams of Central and South Asia; East and
South-East Asia; East and Central Africa; Southern Africa; and Arab States and Europe, whose comments and
suggestions greatly enriched it, in particular with regard to operational aspects. In addition, it has benefitted from
comments and suggestions made by the TSS WHO specialists and colleagues at FAO Headquarters.
>
ADOLESCENT FERTILITY: SOCIO-CULTURAL
ISSUES AND PROGRAMME IMPLICATIONS
Marcela Villarreal
Senior Population Officer
TSS Specialist
Population Programme Service, Food and Agriculture Organization of the
United Nations, Via delle Terme di Caracalla, 00100 Rome
February 1998
Adolescent Fertility:Socio-cultural Issues and Programme Implications
TABLE OF CONTENTS
Page
PART I - SOCIO-CULTURAL ASPECTS OF ADOLESCENT PREGNANCY
1
Introduction
1
The specificity of adolescence and adolescent pregnancy from a cultural
point of view
1
Adolescent pregnancy
Age at marriage
Impact of westernization and urbanization
Impact of education
The ethnic factor
3
3
6
7
7
2.
Trends in adolescent fertility: some interesting evidence
8
3.
Gender issues in adolescent pregnancy: unequal relations and
unequal consequences
9
1.
4.
Value of virginity and gender
Unequal expectations
Unequal consequences
Health consequences
Social consequences
Economic consequences
11
12
13z
13
15
16
IEC: The need for a culture-based approach
16
PART II - PROGRAMME IMPLICATIONS
19
Bibliography
25
ANNEXES
Latin America: Percent variation in age-specific fertility rates, between
1950-55 and 1985-90
•
Countries least advanced in their demographic transitions
•
Countries advanced in their demographic transitions
•
Countries most advanced in their demographic transitions
•
Proportion of births to mothers aged 15-19
North Africa (selected countries): Proportion of births to mothers
aged 15-19 and variation in the birth rate
Asia (selected countries): Proportion of births to mothers
aged 15-19 and variation in the birth rate
Adolescent demographics worldwide
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Adolescent Fertility:Socio-Cultural Issues and Programme Implications
PART I - SOCIO-CULTURAL ASPECTS OF ADOLESCENT PREGNANCY
“I was having stomach pain and my mother decided we should go to the hospital. It happened
not long before my 14th birthday. I didn’t know what the doctor meant when he told mama
I was expecting soon. And I certainly didn’t know that it was because of doing the thing with
that boy who’d been my friend. He said it would be fun and everyone had to do it. Rea, my
daughter, came soon after. It was like having a dream. I kept saying, “Madi, wake up, wake
up!” but it’s Rea who wakes me up with her crying for feeding.”
Madeleine, Senegal
WHO, Safe Motherhood, 1996: 22 (3)
INTRODUCTION
In the past few years the issue of adolescent pregnancy has been increasingly perceived as a
problem. The International Conference on Population and Development (ICPD) identified the
adolescents as a distinct target group in need of ad hoc reproductive health programmes and
services. In many developing countries, government officials working in the social sectors
readily identify it as one of the pressing social issues. However, this perception is rarely
translated into programmes intended for adolescents, or into programmes which, although
intended for them, effectively reach them. As a group, they have been overlooked due to a
lack of awareness of their needs and the cultural specificity of these needs. Moreover, there
are methodological issues that hinder the setting up of appropriate programmes, such as
obtaining appropriate data, given that the data available -usually grouped in five year age
groups- hides enormous heterogeneity and widely differing needs.
The purpose of this paper is to provide an insight in the cultural dimension of adolescence and
very early pregnancy and to propose ways in which it can be translated into operative
programmes. It intends to show that adolescents need specific strategies in order to be
effectively reached, for they have distinct social and psychological characteristics that vary
greatly across cultures, and that if the cultural dimension is overlooked, programmes will lose
effectiveness. The paper will look into how the concept of adolescence has been constructed
culturally, with its meanings and characteristics varying across cultures. The aspect of gender
and power relations between the genders will be dealt with in some detail, for it plays a crucial
role in adolescent fertility and its differential consequences for adolescent girls and boys.
1. The specificity of adolescence and adolescent pregnancy from a cultural point of view
The concept of adolescence is relatively new in historical terms (the word, for example, was
introduced in the French language in the 13th century and in English only in the 15th !). In
most of the evolution of humankind, adulthood started very early on for full economic, social
and familiar responsibilities, many times including marriage, started at puberty, after a rite of
passage that marked the end of childhood. Thus, there was no period of transition from
childhood to adulthood as experienced today 2. This period has been expanding in duration
I
2
The roots of the word adolescence indicate a transition by nourishing (alere: prefix ad) and growing
(alescere) into the adult stage (adultus, grown up).
This, however, does not refer to the physiological transition from puberty to the end of physical
maturation. Athough all human beings undergo this biological process, there is no recorded evidence of
its social meaning, i.e. it does not have a social reflection, such as in rites of passage.
1
Adolescent Fertility:Socio-Cultural Issues and Programme Implications
and is increasingly characterized by a culture of adolescence that is being developed with the
aid of the mass media.
In a number of contemporary societies it does not make sense to talk about adolescence. In
many rural areas of the developing world, for example, adult responsibilities including family
formation and labor force participation are taken on very early in life, without any significant
transition period. In many languages, neither the word nor the concept exist. In India, for
example, adolescence is a controversial notion. It is viewed as an artifact of the extended
formal education in the West, and language-wise females are “girl children” until they marry
(Greene, 1997). Adolescence itself is a cultural construct that varies across settings and
contexts.
The preparation time for entry into adulthood has greatly increased with the specialization of
tasks and the increasing education needed to perform them, which have been related to the
process of urbanization. At the same time that the attainment of economic independence has
been postponed due to the longer time devoted to education, the attainment of biological
adulthood has either not changed much (boys) or is starting earlier, through a significant
decrease in the age at menarche 3. In some societies, the duration of adolescence has been
increasing and can plausibly continue to increase. How long is the period of transition? In
rural societies with very early marriage and little or no education necessary for performing
adult roles the period is either inexistent or very short, while in an urban milieu the standard
definition comprises ages 10- 19 4, and in post-industrial societies suffering from acute
problems regarding entry into the labor force among the young it might be expanding into the
early twenties.
As the culture of adolescence being constructed in some societies -including norms of
conduct, dress code and language- becomes more visible, it is easy to assume its universality
and to infer its existence in every culture. However, the fact that adolescence itself is a cultural
construct that varies significantly from society to society and across time, has to be kept in
mind when designing policies and programmes directed to the adolescents, for needs vary with
the different contexts and so should approaches. The incorporation of a socio-cultural
component will aid in the identification of needs and in the determination of the most effective
approaches.
Definition
Although the references to adolescence have become widespread in the literature on
reproductive health and psychology, many times they allude to different phenomena, for the
definition of adolescence presents serious obstacles. Being culturally determined and
presenting large cross-cultural variations, it does not make much sense to talk about
adolescence as a world-wide phenomenon. Due to the difficulties to provide a meaningful
definition, the result is that for the most part, the adolescents are defined as all of those
belonging in a particular age group (whose limits vary). This is a definition that makes little
sense from a cultural point of view. Available data, however, is usually organized by five-year
age groups, restricting the possibilities of more profound analysis. The classical 15-19
3
Earlier menarche is attributed to a steady improvement in the levels of nutrition
WHO, Health needs of adolescents, Geneva, 1977 (WHO Technical Report Series No. 609).
2
Adolescent Fertility:Socio-Cultural Issues and Programme Implications
grouping that demographers tend to use hides enormous heterogeneity from the health, social
and psychological points of view. The meaning of a pregnancy for an unmarried 15 year old,
for example, is entirely different from that for a 19 year old married woman 5.
When setting up programmes or formulating policy, it is important to have an appropriate
definition of their target group, and in the case of adolescents this definition is contextdependent. A national adolescent policy should be sensitive to the specific needs of groups
such as rural adolescents (in those places where it makes sense to talk about rural adolescents
rather than young adults), urban school-going adolescents, urban school drop-outs, young
married mothers, unmarried mothers, refugees, displaced persons and the like.
AdolescenLpregnancyL
If adolescence is a cultural construct, adolescent pregnancy is one aspect of it that is especially
sensitive to cultural context. The meaning assigned to teenage pregnancy varies among
different cultures, as do its implications and consequences. In places where it is accepted
behavior - usually related to whether it occurs within marriage--, socially defined appropriate
age at marriage tends to be low and childbearing is frequently the single most important
element of women’s status, in particular to produce a male heir. In these contexts, teenage
pregnancy is socially accepted, founds identity, is a source of status, and reaffirms entry into
adulthood. More and more frequently, however, pregnancy among very young mothers is
viewed as a social problem, especially when in occurs out of wedlock and it interferes with
expectations regarding education, self-realization, prospects for mariage and economic
prosperity.
Age at marriage
In most contexts, acceptability of teenage pregnancy is associated with marriage. In several
countries of sub-Saharan Africa, for example, adolescent fertility is sanctioned and valued
within the adequate ritual framework (marriage), but strongly condemned when out of wedlock
(Bledsoe and Cohen, 1993). In a few countries, however, mostly those in the infertility belt
(Central African Republic, South-west Sudan, Congo, Gabon and Cameroun), a pregnancy
constitutes a prerequisite to marriage, and adolescent girls who cannot prove their ability to
conceive, find no partners. In some of the Andean cultures also, the custom of servinacu, used
to be (Balan, 1996) a sort of trial period before marriage (about one year) to prove fitness of
the couple, fertility being one core aspect.
Early marriage in fact is favoured in different contexts to prevent the undesired effects of
premarital sexual activity and pregnancy. In the Gambia, for example, age at marriage has
been reported to be as low as 10 years (Jeng and Taylor-Thomas, 1985). In rural Ghana early
marriage shortly after puberty rites is the norm to ensure chastity and genital mutilation,
performed at several ages, would provide proof of virginity and guarantee long time fidelity
(Bulley, 1984). In rural Niger, 47% of women aged 20-24 during the DHS survey, had
married before 15 and 87% before 18. In this context, where early pregnancy is welcome,
53% of the women had had children before age 18. In the Islamic areas of Africa, early
5
Both WFS and DHS use the 15-19 age group. Because of this, given that they are major sources of
demographic information, this paper also is restricted into using it for some of the analysis.
3
Adolescent Fertility:Socio-Cultural Issues and Programme Implications
marriage is favored in order to prevent extramarital pregnancies (Locoh, 1994).
Legal codes governing family law usually establish the minimum age at first marriage, but they
sometimes conflict with each other. For example, in Tanzania the Penal Code states that
anyone of African or Asian descent may marry or allow the marriage of a girl under age 12
as long as it is not intended that the marriage be consummated before she is 12. At the same
time, the Law of Marriage Act establishes 15 as the minimum age at first marriage for women
(CRLP, 1997). In spite of the existing legal minimum ages for marriage, more often than not
these are not enforced, especially in the rural areas. The cultural definitions of acceptability
usually have much more force in the resulting outcomes than those imposed by law and
removed from the realities of the people they are supposed to apply to.
Age at marriage is a significant factor in women’s lives, not only because of its association
with overall completed fertility and with the meaning and consequences of adolescent fertility,
but also due to its relation with the status of women. Early marriages are usually performed
without the informed consent of the girl and often involve important age differences with the
spouse, one element of unequal power relations between the spouses and of difficulty for
empowerment (see section on gender relations).
Cultures also define who is entitled to access reproductive health services, sometimes by social
control and sometimes by laws, policy restrictions or other measures. In many African
societies only married women have access to family planning and other health services, and
unmarried pregnant adolescents are particularly affected (Bledsoe and Cohen, 1993). In
Gambia, provision of contraceptives is legally restricted to married couples and unmarried
women with at least one child (Jeng and Taylor-Thomas, 1985).
Three current processes have had a particularly strong influence on teenage fertility outcomes:
globalization, urbanization and education, in particular girl s education. As an overall effect,
the three tend to postpone age at first marriage or union, without postponing initiation of
sexual relationships 6. During these processes the binding force of the traditional social
controls on women’s premarital sexuality is weakened, but no alternative control mechanisms
have been generated and the result is an increase in unplanned pregnancy (although not
necessarily in the absolute numbers of pregnancies) that is unwanted and socially not accepted,
a rise in illegitimacy rates and in abortion, mostly unsafe (cf. section on gender). Among the
same groups, the same event, a pregnancy, that would have generated status and respect, can
generate stigma for the woman and/or her family if it happens out of the traditional norms of
accepted behavior. It can also have dire health consequences, for access to health services is
in this case limited by cultural restrictions.
6
There is however some recent evidence that among more educated women the age at first intercourse
would be slightly postponed (MacCauley and Slater, 1995).
4
Adolescents who have begun childbearing by Rural/Urban residence
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2
Adolescent Fertility: Socio-Cultural Issues and Programme Implications
Impact of westernization and urbanization
The process of urbanization and the increasing influences of western cultural precepts on many
population groups, but especially the young, are seen to be responsible for thebreakdown of
traditional customs. In this sense, the increase in premarital sexuality and the increase in
unmarried teenage pregnancy is seen by many authors as a consequence of the introduction of
“western” values and ways of conduct, which expand more easily in the urban context and
through the media available in this context. In Botswana, for example, until about 30 years
ago, traditional teachings and social practices including strict gender segregation for certain
activities, taboos, and a universal social disapproval of teenage pregnancy, made it a very rare
phenomenon. Urbanization and detribalization have loosened those social practices, and in the
process sexual behavior among youths has become more extended and unmarried teenage
pregnancy more frequent (Linchwe, 1992). The disappearance of polygamy, too, has been
cited as a factor in the higher prevalence of premarital sexual activities in Botswanian society
(Letamo, 1993). Westernization has had an important influence in the disappearance of certain
taboos and certain practices like initiation ceremonies, and in the transformation of the family
structure, generalising the nuclear family.
In Senegal, where women traditionally acquire full status only through marriage and
childbearing, although unmarried motherhood is considered a disgrace, a survey among 764
urban working women aged 16-21, showed that a significant proportion (31 %) were unmarried
mothers. In this case, economic factors are seen as largely responsible for the rejection of
traditional customs, given that due to unemployment and economic hardship marriage is
postponed and premarital sexual relationships rise (Jean-Bart, 1985).
In the process of urbanization, two factors are especially relevant in the changes in sexual
practices and outcomes: education (see next section) and the changes in the traditional systems
of social controls. In Latin America, the enormous rural-urban migration flows of the 60s and
70s provided young women a physical way to escape the traditional controls on their sexuality,
for with the change of location, young women (who comprised most of the flows) were able
to flee the controlling eye of the father, the local priest and the community. While entering the
labor market as domestic servants, a large proportion became single mothers.
With urbanization the socialization processes shifts from being entirely the responsibility of
the direct or extended family to being partially dominated by social institutions like the school,
under the ever stronger influence of the media. The introduction of western systems of thought
-within the power relationship that is generated by a dominant culture- often destroys local
taboos, along with the elements that legitimize them within the local belief systems. In the
same manner, other forms of social control lose relevance, as the weight of western values,
attractive to the young, cannot be countered by local propositions.
Early marriage and childbearing continues to be mostly a rural phenomenon (Figure 1). In the
urban areas young women have their first child significantly later, although this does not
necessarily mean later first pregnancies, for abortion is much more widely practiced among
urban adolescents. Urbanization has meant later marriages and first births, but for those who
do become young mothers, higher proportions of children born out of wedlock.
Source: US Bureau of the Census 1996
6
Adolescent Fertility: Socio-Cultural Issues and Programme Implications
Impact of education
Although there is still much to be said regarding the reasons for it to happen, education has
been proven to have the undisputed effect of delaying the age at marriage and first union. With
the postponement of first union, and even if no significant change in sexual practice takes
place, the exposure to the risk of premarital pregnancy is greatly increased. On the other hand,
with higher levels of education, as data from the DHS for all surveyed countries shows, the
incidence of adolescent pregnancy decreases (see Figure 2). However, part of this reported
decrease may be just an effect of attrition, given that pregnancy usually leads to the end of the
educational process for the girls.
Locoh (1994), links the decline in the number of very early marriages and pregnancies present
in most of the African countries where survey data is available for more than one year to
urbanization and school attendance rather than to any specific policy measure.
The lower rates of pregnancy and births are due to the fact that educated women are more
likely to use contraceptives, and are also more likely to resort to abortion, rather than to a
significant difference in the exercise of sexuality. One of the determining factors in this
outcome is the way in which the woman projects herself into the future, and the extent to
which she feels she guides her own destiny, i.e. that she can have control over what happens
to her own life. Education provides alternate means of creation of status for women, as well
as a source of self-esteem and self-value. It thus provides the motivation to use contraception,
facilitates its putting into practice, as well as the motivation to terminate the pregnancy if
unwanted. The programme implications of this are clear: a) education should be made widely
available for teenage girls --not a new proposition, of course—, and b) programmes that are
specifically targeted to the reduction of adolescent pregnancy should build on the factors that
the educational system provides and that have been shown to be effective (for example, to
build on self esteem and self value), without going through the entire educational process when
this is not possible (see more on this in the programme implications section).
The ethnic factor
The importance of ethnicity has been largely overlooked in relation to adolescent fertility. Few
studies address it directly, most of them carried out in the United States, where it is sometimes
undifferentiated from the racial factor, and where recent events have made it a piercing
political issue. Ethnicity is of prime importance in defining age at marriage, acceptability of
sexual behavior, initiation of sexuality, use of contraception, and the resolution of pregnancies
when these occur.
A study of Nepal, singled out ethnicity as the single most important factor in the determination
of the timing of marriage and of the first birth, much more important than education, religion,
urban/rural childhood residence and ecological region. Women’s mean age at marriage varied
from 13.5 among the Brahmins to 17.8 among the Tamangs, while the difference among the
literates and illiterates was very small (15.4 and 15.2 respectively), as well as that for the
ecological region (14.8 for the terai to 15.7 for the mountains) (Thapa, 1989). Other studies
for other parts of Asia have reported similar findings (Hirschman, 1985; Rindfuss, Parnell and
Hirschman, 1983).
7
Adolescent Fertility: Socio-Cultural Issues and Programme Implications
In Kenya, where adolescent fertility is reported to be among the highest in Africa, sexual
custom varies greatly among ethnic groups, with differing values on virginity, consequences
of premarital pregnancy, practice of genital mutilation, level of knowledge and use of
contraception, among other characteristics. While among the Luhya and the Luo the woman
who remained virgin until her wedding was given gifts of goats and cash, among the Kamba,
women were ritually deflowered by elder men from whom they received sexual teachings.
Contraceptive knowledge varied from 56% among the Kalenjin to 94% among the Kikuyu, and
while contraceptive use also varied greatly along ethnic lines, it was much lower than
knowledge for all groups (Ocholla-Ayayo et al., 1993).
In the United States, African American teenagers are much likelier (about five times) to have
a child before the age of 19 than are whites (Furstenberg, 1987), even after controlling for
socio-economic background factors (Maxwell and Mott, 1987). A study on ethnic differences
between non-Hispanic whites and Mexican American female adolescents (Aneshensel et al.,
1990) concluded that the Mexican Americans who had been born in Mexico tended to initiate
sexual intercourse later than the non-Hispanic whites, but that they had the highest rate ot
early births because they were the most likely to become pregnant if sexually active and the
least likely to terminate the pregnancy. The non-Hispanic whites had the lowest rate of early
births and the US born Mexican Americans were in between. Other studies corroborate these
differences, adding the effects of family structure, age at first conception, family size,
education and the fact of having a working mother (Cooksey, 1990; 1988). The effect of social
controls in the initiation of sexual intercourse was found to be significant among whites but
not among African Americans (Udry and Billy, 1987). Indexes of acculturation (language
spoken at home, place of birth of individual and father and residence) were found to be more
important than socio-economic background for fertility expectations (Sorenson, 1985).
To sum up, this section has shown that culture determines the meaning of pregnancy among
young women, as well as its consequences such as those regarding social status, health and
gender relations. The defining principle is not so much the age at which it occurs, but the
cultural acceptability of the pregnancy, and this is often linked to marriage. Age at marriage
is thus a central variable for analysis, both the actual age at which it takes place in different
settings, as well as the prescribed legal age and the differences between the two. The norms
of behaviour and the way in which specific behaviour is interpreted are cultural constructs and
vary over time. Major sources of change have been education, urbanization and globalization,
for they have a direct impact on the values, beliefs and practices. These processes have had
a much stronger effect in the determination of age at marriage than on the initiation of
sexuality, creating a separation in which pregnancy becomes unacceptable.
2. Trends in adolescent fertility: some interesting evidence
In most of the countries for which historical trend data can be found, the evolution in the age
specific fertility rates of the 15-19 year group marks a clear difference with that of all other
age groups. While the analysis of these trends is beyond the scope of this paper, a few
examples will illustrate the way in which they are different in order to bring attention to the
fact that specific policy and programme interventions are needed.
In Latin America, the kind of difference between the evolution of the 15-19 fertility and that
of the other age groups seems to be linked with the country’s stage in the demographic
s
Adolescent Fertility: Socio-Cultural Issues anti Programme Implications
transition. Although all age groups have reduced their fertility significantly since 1950, the 1519 group has shown relatively much lower reductions than the others, especially in the
countries that are more advanced in their fertility transitions. To name one typical example,
in Costa Rica, while the 15-19 group reduced its age-specific fertility by 18%, the 20-24 group
reduced it by 46%, the 25-29 group by 50% and the 45-49 group by 80% (see Figure A2 in
the annex). In three countries, those that have finished their transitions and have very low
fertility (Cuba, Argentina, Uruguay) there have been increases in the fertility rate of the 15-19
year olds (Figure A3).
In the poorest countries, those least advanced in their demographic transitions, the fertility
rates of adolescents either decreased more than other young age groups (Haiti and Guatemala)- probably due to an initial postponement in age at marriage, or had almost not varied at all
(Nicaragua, El Salvador) in the four decades studied (see Figure Al).
Although adolescent pregnancy is currently considered a pressing and increasing social
problem in Latin America, neither age-specific fertility rates nor absolute numbers of births
have increased in the last decades. However, due to the lower fertility reduction in the 15-19
group compared to all the others, the proportion of births to very young mothers has been
increasing, quite sharply in some countries. Cuba, the country with the lowest fertility is at
the extreme. In 1985-90 almost one of every four children (23%) born in the country had a
mother in the 15-19 age group, while in 1950-55 only 8% of births occurred in those ages. At
the other extreme, in Haiti, least advanced in the demographic transition, the proportion of all
births to adolescents has remained constant during the past decades. In average, the proportion
of births to young mothers has increased 25% since the 1950s in all the region.
In other regions no consistent pattern is found. Fertility in the 15-19 year group has remained
remarkably constant throughout several decades in countries like Egypt, Thailand and Sri
Lanka, while it shows a clear downward trend in others like Tunisia and Malaysia. (See graphs
in the annex).
The only common characteristic to most countries seems to be that the pattern and evolution
of fertility among the 15-19 year olds is clearly different from that of other age groups. While
fertility has decreased in a more or less smooth way responding to social and economic
development in groups above 20, the fertility behavior of the 15-19 year olds is unique, seems
to respond more to cultural, social and psychological factors, and has shown resilience to
overall socio-economic development. Moreover, this indicates that reproductive health
programmes have failed to effectively reach this age group.
3. Gender issues in adolescent pregnancy: unequal relations and unequal consequences
Gender is culturally constructed7, and much of this construction is related to sexual definitions
and sexual behavior. During adolescence, expected and sanctioned behavior for young women
begins to be widely differentiated from what is expected and sanctioned for young men. The
conditions of initiation, timing, related expectations, values, and meanings of sexuality diverge
enormously between the genders. Moreover, the consequences of adolescent sexuality are
Unlike sex, which is determined biologically, gender and gender relations are defined by the culture
and are subject to change.
9
Adolescent Fertility: Socio-Cultural Issues and Programme Implications
clearly gendered, with the adolescent girls bearing most of the negative social consequences,
and most of the health and economic consequences when pregnancy results. This section looks
into the interactions between gender aspects and adolescent pregnancy.
In every country covered by the DHS,surveys, boys are reported to start sexual activity on
average before girls, and at every age, a higher proportion of adolescent boys than girls have
sexual relations. Boys are more likely to have multiple partners and to have sex with casual
acquaintances, while girls more often report having sexual relations only with a steady
boyfriend (Berganza et al, 1989; Stycos, 1990; Kiragu, 1991; Morris, 1988). Peer pressure
among adolescent boys has been reported to be an important factor in the initiation of
sexuality. A survey of 1269 youths aged 12-19 in the USA, for example, showed that the
strongest predictor of sexual activity was the person’s assumptions about his peer’s sexual
activity. Among adolescent girls, there is evidence that peer pressure may be increasingly a
factor in early initiation (Villarreal, 1989).
The extent to which the initiation and practice of sexuality is a matter of choice varies strongly
along gender lines. Among girls, the early initiation of sexual activity is more likely to be
associated with coercion, exploitation and violence than among boys (Mahler, 1997). In
Uganda, almost half of the girls (49%) who became sexually active while in primary school
reported to have been forced into sexual intercourse. In fact, the younger the woman when she
starts having sexual relations, the higher the chances that it was done in a coercive situation
(AGI, 1994). Sexual abuse of female children was also found to be an important factor in the
incidence of adolescent pregnancy. Adolescent women who had been abused during childhood
were found to start sexual relations on average a year earlier than their peers (Boyer and Fine,
1992).
In spite of recent rapid increases in male prostitution, prostitution has overwhelmingly affected
women, bearing lifelong consequences, especially when initiated during the adolescent years.
As with other factors related to sexuality, prostitution takes place within cultural norms and
values. Cultural attitudes that encourage sexual activity among men and virginity among
women create a demand for prostitutes. The greater the asymmetry, the greater the stigma on
adolescent girls having sex and the greater the demand for prostitutes. In the other hand,
cultural norms combined with socio-economic conditions may account for a supply of young
women for prostitution (Mahler, 1997). In Thailand, for example, where according to Thai
family norms, daughters are partly responsible for their family’s economic well-being, 44-55%
of prostitutes said that the main reason for their becoming prostitutes was their parents’
financial need (Boonchalaksi and Guest, 1994). The rural migrants to Thai cities employed
in the sex industry send sizeable remittances to their rural families, far above those that could
be earned in the formal sector (Archavanitkul and Guest, 1994).
Most societies develop sophisticated mechanisms to control sexuality (norms, values,
restrictions, dress codes, social controls) and these are particularly visible in the case of
women. Because adolescence is a time when the dangers of premarital sex or out-of-wedlock
pregnancy are greater, many social controls are practiced during adolescence. One of the most
extreme is female genital mutilation (FGM), widely practiced in 28 African countries, and in
some of the Arab peninsula, mostly during adolescent years although sometimes earlier, with
the objective of reducing or annulling the woman’s sexual desire and thus insure fidelity. Other
forms of controls on women’s sexuality derive from a system of values which places
10
A dolescent Fertility: Socio-Cultural Issues and Programme Implications
restrictions on the times they may go out, the places they may go to and the type of persons
they may go with.
Age difference between sexual partners may constitute an important factor in adolescent
pregnancy outcomes. With an older or much older man, an adolescent girl may not feel she
can demand the use of a condom to be protected against STDs or pregnancy. With greater age
differences between the partners, power relations tend to be more unequal and this may mean
lack of empowerment for the woman to put into practice her own desires regarding number
and spacing of children. Age difference is also an important factor in the spread of AIDS, for
men seek younger women who they think to be likelier to be free from the virus. As a
consequence, women are becoming HIV infected at significantly earlier ages than men, in
average five to ten years before them (du Guerny and Sjdberg, 1993).
In several parts of sub-Saharan Africa, the role of “Sugar Daddies” is important in the sexual
activity of adolescent girls. They are older men (usually of the father’s age) who give money,
gifts or other perks like education fees in exchange for sex. In Kenya, for example, a growing
expectation for gifts or money is reported to be found among sexually active adolescent girls.
Survey data showed that 54% of girls believed that sex is for money and gifts. “These days,
a girl would not feel humiliated if it was known that she had accepted money or some gift for
sex, but perhaps she would be if she had not been offered any (Ocholla-Ayayo ct gI., 1993,
p. 391). In Uganda, 22% of interviewed adolescent girls anticipated receiving gifts for sex.
In the predominantly rural Transkei subregion of South Africa, teenagers with poor economic
prospects, often resort to offering sex in return for financial assistance from older men
(Chimere-Dan, 1996). The phenomenon of Sugar Daddies is on the rise and has also been
associated with risk of HIV/AIDS (du Guerny and Sjoberg, 1993a).
The age difference with the partner is important in understanding pregnancy outcomes in
adolescent women. A large age difference indicates not only greater vulnerability of the
woman, but is frequently associated with more deprived households. Using data from the
National Maternal and Infant Health Survey, it was found that, although most children of
adolescent mothers are fathered by men of a similar age, the younger the mother, the higher
the likelihood of having an older partner (Duberstein et al., 1997) and that adolescent mothers
with older partners were likelier to come from poorer households (Lamb, 1986).
Another gender issue related to pregnancy outcomes among adolescents is the perception by
many males that contraception is a woman’s responsibility. In different parts of the world, it
has been found that young men are more likely than young women to indicate lack of
knowledge as a reason for not using contraceptives and to consider that it is their partner’s
responsibility (McCauley and Salter, 1995).
Value of virginity and gender
Many societies value very highly women’s virginity and at the same time construct masculinity
around sexual activity, generating an unequal situation in which adolescent girls have either
to counter their male peer’s pressure to initiate sexuality or to face the social consequences of
losing virginity. Out of all the defining traits of masculinity, sexual activity may be the most
consistent one cross-culturally, perceived by both adolescent boys and girls as well as older
people. In Thailand, for example, a study reported girls to say that a boy that does not visit
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Adolescent Fertility: Socio-Cultural Issues and Programme Implications
prostitutes must be homosexual (McCauley and Salter, 1995). In fact, a study found that 65%
of rural Thai men under 20 years of age had visited a prostitute at least once (Brown and
Xenos, 1994).
The value of female virginity is one cultural characteristic that shows a very intricate pattern
of gender relations. It is frequently related to the importance of ensuring the legitimacy of the
child, by knowing who the father is. Although it would seem that this value relates to women
alone, it may arise from the male’s fears and insecurities regarding sexuality. As the following
group of quotations from in-depth interviews of Costa Rican high school adolescents show,
The value of virginity in this case is related to the men’s fear of sexually underperforming other
men. Women’s virginity would insure that men cannot be sexually compared to others. This
is an instance in which, a social control on women has the function of protecting males.
However, if virginity is lost, it is the woman who suffers the consequences.
Men believe that they are everything, that they are the greatest, and it he knows that his wife
is comparing him sexually with another man who is better - or whom he believes to be better- he is going to feel inferior and won’t like it at all. That is why they want to marry virgins.
Male, 11th grade UM9
Us men, we fear to be compared, we fear that they will take our woman away ..., because we
believe that women can find other men that are better than us, that is what we fear. Male, 10th
grade UU
For a man, there is nothing worse than to be compared with other men by a woman. Female,
10th grade UU
More than anything else, machismo is a feeling of insecurity. Male, 11th grade. UM
The danger of contracting AIDS has increased the value (including the commercial value) of
virginity. In Thailand, sex workers were reported to have lost their virginity in exchange for
a substantial fee that they or their families had received (Boonchalaksi and Guest, 1994). In
different parts of Africa, there is a belief that havign sex with a virgin will actually cure the
disease. In Morocco, for example, after having demanded a virginity certificate to marry a
much younger woman, a man with AIDS left her the legacy of HIV after his death (Fraser and
Restrepo-Estrada, 1998). Gender inequality has been shown to be an important factor in the
spread of the HIV infection (du Guerny and Sjdberg, 1993a; Mason, 1994).
Unequal expectations
Expectations of sexuality vary along gender lines. The reasons why adolescents engage in
sexual relations are different for young men and women. The in-depth study in Costa Rica,
for example, showed that adolescent boys were more likely to be motivated by peer pressure,
while adolescent girls tended to give in to their boyfriend’s insistence by fear of losing him.
K
In-depth interviews were carried out among 180 adolescents in three different high schools: one rural
(R), one urban middle class (UM) and one urban upper class (UU). Both girls and boys were
interviewed. (Villarreal. 1989).
See previous footnote for explanation of signs.
12
Adolescent Fertility: Socio-Cultural Issues and Programme Implications
In many countries in Latin America, as well as in other regions, it is not uncommon for
young men to put pressure on their girlfriends, threatening to leave them if they do not “prove
their love” by engaging in sexual relationships. At the same time, as the following excerpts
show, the adolescent boys’ motivation was to get a proof of the girlfriend’s moral inflexibility
(and thus a guard against future infidelity).
My cousin says that if a woman does not accept to have sexual relations with him even if he
insists for six months, he will marry her because she is not of the easy type. Male, Sth grade
UU
If a woman gives herself to a man, she feels more committed, while the man only wants to
satiate his desire. The woman is tied to him because after that no other man is going to want
her. She is going to be humiliated by society because society punishes more what it sees than
what was really done. M 11th grade R
If she has had boyfriends and she gave in easily to one, then it is logical to think that she did
the same with the others and so one looks down on her. M 11th grade R
[He will think] that she is too easy and that after marrying her she will do it with anyone in
spite of being married. Female, 9th grade UU
If I really loved her, I wouldn’t do it to her. In the case that she gave in I wouldn’t like it
because I would end up despising her, I wouldn’t consider her my girlfriend, she would be like
a loose woman (una mujer cualquiera). M 11th grade R
If you have a girlfriend and you love her a lot and you ask her to do it and she says yes, I
would think, diay, if she says yes to me, she could say yes to any other. Male 10th grade UM
The “proof of love” combined with another cultural perception, one that links use of
contraceptives to the woman’s infidelity, may end up in adolescent pregnancy. In other regions
of the world, sexual initiation among girls due to the partners’ pressure is not uncommon.
Among black South African teenagers in KwaZulu/Natal, “girls find it hard to refuse boy
friends who take full intercourse for granted, and who soon threaten to abandon girls who
refuse to comply” (Preston-Whyte, 1994: 243). And the negative consequences of pregnancy
tend to be disproportionately borne by adolescent girls. These consequences are mainly related
to health, social, and economic aspects.
Unequal consequences
“I thought that getting together with a man would bring peace, quiet, happiness and some
freedom, but things are not that way, they change. For example, I married when I was 16 and
by 17 I was a mother, taking on a big responsibility, like that of older people: to bring up a
child, look after it when it is sick, cook, wash the husband’s clothes, duties, ... at 18 I
regretted it. Yes, I regretted it because at that age I wanted to work, to get an education and
I couldn’t because I had a child. I felt like trapped. Marriage was not for me. I wanted to
leave, but I couldn’t because it was my duty to be there, beside the husband, beside the child.
My son wiped out everything I ever wanted to be.”
Gabriela, Peru
Cardich, R, Visiones del Aborto, Nexos entre sexualidad, anticoncepcion y aborto,
Movimiento Manuela Ramosy The Population Council, Lima, 1993
13
Adolescent Fertility: Socio-Cultural Issues and Programme Implications
Health consequences
Adolescents tend to have a higher maternal mortality rate than older women, especially when
the pregnancy occurs before age 15 (see graph below). In fact, the risk of death during
childbirth is 2-4 times higher for mothers younger than seventeen than for those older than 20
(McCauley and Salter, 1995). This risk is much higher in the rural areas, where, as the graph
shows, it can be 4-6 times larger than for poor urban areas. Young women, especially when
they are pregnant, have a higher likelihood to be malnourished and to have anaemia, an
important risk factor. In rural Egypt, for example, cultural patterns that favor older males in
the distribution of food, result in a higher incidence of anaemia among girls and women (Lane,
1992). In Singapore, the transformation of the social standards of the population is reported
to have produced an escalation in the number of pregnancies to unmarried teenagers, which
tend to show poor intrauterine growth, low birth weight and a resulting five-fold increase in
perinatal mortality (Kurup et al., 1989). A younger start in sexual relations is also associated
with more partners, with a higher danger of sexually transmitted diseases (McCauley and
Salter, 1995).
Maternal mortality ratio by age of
mother
>
o
o
o
T“
o (/)
«*
£
•u
75E
O
nj
s
180
160 .
140 .
Pakistan
(Hazara, 199192)
120 .
Bangladesh
(rural) 1987
100 .
80 .
i —a— Egypt, 1992
60 .
40 .
20 .
Bolivia (La Paz)
1992
0 _
CD
uS
o
CD
CM
in
CM
3
o
co
Age group
CM
CD
CO
uS
CO
China (30
provinces) 1989 i
Source: WHO, Safe Motherhood, 22 (3) 1996
A large proportion of the negative health consequences for adolescent girls is related with
induced abortion. Given the social restrictions on adolescent sexuality and the cultural
unacceptability of premarital pregnancy, abortion is a likely outcome, and is responsible for
at least a part of the increased maternal mortality. Adolescents tend to search for abortion later
and to do it in clandestine, unsafe conditions, increasing the health risk. In addition, it is more
difficult for them to get the financial resources needed (Singh and Wulf, 1993). It is estimated
that 1-4.4 million abortions per year take place among adolescents in developing countries
(Center for Population Options, 1992). In Kenya, abortions among adolescents account for 2864% of hospital abortions, and strict abortion laws make many resort to illegal ones (Ojwang
and Maggwa, 1991). In one teaching hospital in Ilorin, Nigeria, adolescents accounted for 74%
of all induced abortions, which made up 60% of all gynaecological admissions. More than
14
Adolescent Fertility: Socio-Cultural Issues and Programme Implications
50% of the girls were subsequently expelled from school (Adetoro et al., 1991). In Zambia,
the number of abortions among adolescents are reported to have been increasing quickly. Most
patients (80%) with abortion-related complications were under 19. In this country,
contraceptives are made available only to married adolescents (Likwa, 1989). In India, 30%
of all hospital abortions were performed on women under 20 years of age. Although the great
majority of abortions are carried out in the first trimester, among teenagers most of them occur
in the second trimester, most of those among unmarried adolescents (Solapurkar and Sangam,
1985).
The health consequences of teenage pregnancy, as these cases show, are closely linked with
the social and cultural context that determines accessibility to information, to contraceptive
services (by legal restrictions), to adequate nourishment and to safe abortion.
The decision to terminate a pregnancy among adolescents has been associated with the
opportunity cost of the mother’s time and expectations. Women with career plans and higher
socio-economic status tend to resort more frequently to abortion (King et al., 1992).
Social consequences
Pregnancy can bring status for married adolescents in cultures where motherhood is a core
aspect of the definition of women’s identity. Moreover, as previously mentioned, in countries
where infertility is widespread, a pregnancy may constitute a prerequisite for marriage.
However, when social controls over unmarried adolescent girl’s sexuality fail, the social
consequences are unbending for her, and can be also strong for her family and can even affect
a larger group of reference, such as the clan. Among the Luhya and the Luo communities in
Kenya, for example, traditionally, a woman who got pregnant before marriage would be an
embarrassment for the whole clan and would be married off to an old man. Nowadays,
pregnant unwed adolescents are abandoned or chased from the home and have no guaranteed
means of support for the child (Ocholla-Ayayo et al., 1993). In Algeria, recent mass raping
of adolescent girls by one of the armed groups, were perpetrated to disgrace the girl’s family,
by dishonouring her father. In this case the woman’s body is a vehicle for an aggression by
one male to another. This is not an uncommon situation during armed conflicts, in which rape
is used to humiliate the male by putting in evidence his failure to perform his protective role,
and at the same time by using the woman’s body to “plant” the genes of the dominator.
Social consequences are many, but usually do not affect the male who made the woman
pregnant. In the words of Costa Rican adolescents:
Women lose everything and men don’t lose a thing. Male, 11th grade UU
(If she agrees to have sex upon insistence) I would think she is not a serious person, she
doesn’t make herself be respected. She has to think what would happen to her with a
pregnancy, and what would happen to the child too. She should ask him to marry her instead,
anything but that, because it would be very damaging for her. If she is somebody’s girlfriend
and gets pregnant, he would leave her, so she has to think about how she is going to maintain
the child. Male, 9th grade, R
15
Adolescent Fertility: Socio-Cultural Issues and Programme Implications
Economic consequences
Studies in Latin America have shown that an adolescent mothers are more likely to be poor and
to remain poor throughout their lifetime, and that their children also have a higher probability
of being and remaining poor than children from older mothers. Moreover, daughters of
adolescent mothers will be adolescent mothers themselves in a higher proportion than
daughters of mothers above 20 years of age (Buvinic et al., 1992).
Adolescent pregnancy is thus an important factor in the intergenerational transmission of
poverty. In this case, poverty is associated with low levels of education, given that most
teenage mothers do not finish secondary education either because the school does not allow
them, or because they feel awkward and different from others and do not want to continue.
Low educational levels are associated with precarious access to the labor force. Moreover,
both low education and early childbearing are associated with higher fertility and higher overall
parity.
A fair amount of evidence worldwide shows that pregnant adolescents, more often than not,
do not return to school. In some countries legal restrictions prevent it, but in most cases it is
due to social or religious constraints, and these vary along a number of lines such as area of
residence. A study in Botswana showed that rural adolescent women were about as likely as
the urban ones to leave school due to a pregnancy, but less likely to be readmitted afterwards
(20% and 27% respectively) (Letamo, 1993). In Kenya, it is estimated that 10,000 girls are
expelled from school every year due to pregnancy, but no action is taken with the students who
father the children (McCauley and Salter, 1995).
In rural areas of developing countries, where both educational and labor force opportunities
are low, an early pregnancy may not worsen adolescents’ economic prospects (McCauley and
Salter, 1995). In fact, a pregnancy may be something to look forward to where the value of
children is defined by their potential labor force contribution.
4. IEC: The need for a culture-based approach
Throughout the world, a significant proportion of the births to young mothers are either
mistimed or unwanted. DBS data for selected countries shows that among women less than age
20, in many countries of Africa and Latin America up to one half of current pregnancies were
unintended while in Asia and North Africa the figures were about one third and one fifth
respectively (see Annex ). In the United States, about 82% of the one million pregnancies
occurring to adolescents every year are unintended (MacCauley and Salter, 1995). This is in
spite of the fact that most of teenage pregnancies world-wide still take place within marriage.
Unmet need for contraceptives is high in this age group.
In spite of relatively high levels of knowledge about contraception, use tends to be low in a
number of different cultural contexts. In Uganda, for example, although the majority of a
sample of 15-24 olds from urban and rural areas had appropriate knowledge on contraception
and a favorable attitude towards its use, only a small proportion of the sexually active was
using it at the time of the survey. Similarly, in spite of the majority being knowledgeable about
STDs, only a few were using condoms (Agyei, Epema and Lubega, 1992). A high incidence
of abortion was reported among the Ugandan adolescents (Agyei and Epema, 1990). In
16
4 dolescent Fertility: Socio-Cultural Issues and Programme Implications
Nigeria, a survey found most young urban Nigerians to be sexually active, but only 15% of
them were practising contraception (Makinwa-Adebusoye, 1992). In Kenya, more than 50%
of a sample of 3000 unmarried adolescents were sexually active, most of them having initiated
intercourse between 13 and 14 years of age, and the vast majority (89% of the active) had
never used contraceptives (Ajayi, Marangu, Miller and Paxman, 1991). In a Botswana study,
88% of the teenagers said they had become pregnant by accident and 94% said they viewed
teenage pregnancy as a problem (Letamo, 1993).
These data show the existence of an important gap between knowledge and behaviour
regarding reproductive health. It constitutes a pressing obstacle to reproductive health
programs, for most IEC interventions are designed to target knowledge, assuming that an
increased amount of knowledge will lead to changes in reproductive behaviour. Grasping the
determinants of behaviour is a pivotal factor for the design of successful programmes.
The issue is why adolescents are getting pregnant if they do not want to in spite of knowing
how to avoid pregnancy. The reasons for this are grounded in cultural norms, attitudes, myths
and in power relations, as well as psychological particularities of adolescents. A full
understanding of these reasons should be the basis for programmes and for IEC interventions.
In a study of the Machakos district in Kenya, where only 3% of the sexually active young
people had used contraceptives, 79% of the girls and 69% of the boys felt that sex is not
enjoyable when planned for and 80% thought that family planning methods are dangerous and
that it is sinful to use them (Ocholla-Ayayo et al., 1993).
Among black teenagers in KwaZulu/Natal, in the process of the construction of masculinity,
based on traditional polygynous society, sexual conquests are important, but proof of the
ability to father children is a centerpiece. The adolescent girls face the pressure to engage in
sexual relations, and once they do, they feel the need to prove their fertility by having a baby.
At the same time, young women see the role models of older women who frequently head
households and who can ‘go it alone’ and get the message that having a child before marriage
is not the end of the world. The interplay of lack of disincentives with the positive dimensions
of childbirth is the basis of early sexuality in this region (Preston-Whyte, 1994).
Among adolescents, conflicting attitudes and ambivalent feelings are very frequent, and are
often related to pregnancy outcomes. High educational expectations may coexist with positive
attitudes toward early pregnancy. Very frequently adolescents who get pregnant have not
thought about the consequences for their lives and the long-term implications for their future.
Interviews in Costa Rica showed that many of the teenage girls expected to undertake a major
career such as law or medicine, wanted to work before marriage in order to gain work
experience, and to stop working after marriage to devote themselves to their children,
following a cultural norm that expects married women to be at home. At the same time, they
expected to be married by age 21 (Villarreal, 1989). More often than not, adolescents have not
created a consistent self-image projected into the future. When they have given any thought
to the future, they have ideal images of different aspects that do not fit when put together.
Building a strong, coherent self-image would help them take appropriate action (such as using
contraceptives) to avoid events that would interfere with their plans.
17
Adolescent Fertility: Socio-Cultural Issues and Programme Implications
Another very important issue to address in IEC programmes is where teenagers get their
information on sexuality and contraception. It is widely assumed that the most important
sources of information are parents, school and peers, but in certain societies this may be far
from reality. Among the Kaguru of Morogoro (Tanzania), the dgubi dance, to which women
are introduced at puberty serves as a means to educate and socialize them in issues of sexual
initiation, reproductive knowledge, as well as in notions of female dependence and expected
behaviour (van de Walle and Franklin, 1996). In Kenya, the traditional role of sex education
was performed in the “grandmother house” by grandparents or aunts, where the boys and girls
stayed while growing up. Parents seldom undertook this function. With increasing migration,
friends have become a prime source for knowledge and for the provision of contraceptives,
frequently with poor information on their use (Ocholla-Ayayo, 1993).
Traditional sources of information, together with traditional modes of conveying messages
(where they still operate) are invaluable resources to tap on to while setting up effective
programmes.
Gender differences are also important in the determination of the source of information. While
in Ecuador and Chile male adolescents were more likely to name friends as the most frequent
information source, young women tended to name their mothers (McCauley and Slater, 1995).
Increasingly, throughout the world, the media is becoming a prime source of information
regarding sexuality, as well as a source of influence regarding values and behaviour of
adolescents. As the television broadcasts of the United States reach the most remote corners
of the world, their influence cannot be disregarded. An average teenager in that country sees
around 9200 scenes of suggested sexual intercourse (Center for Population Options, 1984). The
prevailing images imply that sex is risk-free, widespread and that planning interferes with
romance (Strasburger, 1993). When these images are transplanted into a socio-cultural context
that does not provide the framework of significance, they cannot be interpreted and given the
appropriate weight. For example, while US adolescents know that not all in the society have
the lifestyle portrayed in “Dynasty” (although they may desire it), it will be much more
difficult for an adolescent in a small city of the developing world to see it in relative terms.
In order to tackle the gap between knowledge and behaviour, a culture-sensitive approach is
needed and frequently lacking in reproductive health piogrammes. It is important to know the
cultural meanings of adolescent pregnancy, their positive and negative connotations, the
reasons why they are getting pregnant if they do not intend to, and why they are not using
contraception. Power relations between the genders and the cultural connotations of sexuality
need to be more thoroughly understood.
A culture-specific strategy needs to be designed and different audiences identified. Next, it is
necessary to determine meanings from an emic point of view (from within the culture) in order
to develop messages that can be effectively grasped by the audience. An appropriate
methodology to transmit the contents also needs to be identified. Examples of communicative
initiatives that have failed to convey the message due to cultural insensitivity or to vertical topdown approaches are numerous. Adolescents have particular relationships with authority, and
information or communication systems that are perceived to be authoritarian usually fail to
reach them (see more on this in the Programme Implications section).
18
Adolescent Fertility: Socio-Cultural Issues and Prof’ramme Implications
PART II - PROGRAMME IMPLICATIONS
Improvement of programmes through a socio-cultural perspective
The previous sections attempted to show that adolescent’s needs regarding pregnancy-related
reproductive health services vary according to the cultural context. This section proposes ways
in which programmes can be improved through the incorporation of a socio-cultural dimension
in the approach of adolescent pregnancy. It also draws on the lessons learned derived by
several sources throughout years of putting in practice adolescent reproductive health
programmes in a variety of contexts (Koontz and Conly, 1994; Amana, 1997; McCauley and
Salter, 1995; Senderowitz, 1995 and 1996).
Identify the problem
The first step is to characterize the problem in the particular area of the programme
intervention, for which a knowledge of the cultural context is needed. Adolescent pregnancy,
for instance, is not in itself a problem. It may be a problem if, for example, it is not accepted
socially, or if appropriate health services cannot be accessed, or if it interferes with educational
possibilities. Or it may be that the socially prescribed age at marriage is too low. Thus, the
nature of the problem has to be clearly understood within its cultural context and this should
be used to define the objective and approach of the programme. A programme that seeks to
lower adolescent pregnancy because of its health risks among married rural women will
necessarily have a different approach than one that seeks to lower it because of its association
with the intergenerational transmission of poverty among unmarried urban women.
The identification of the problem presupposes the delimitation of the group of people to which
the programme is oriented. It does not make sense to design programmes for ‘the adolescents
of the country’, given the enormous heterogeneity among them and the wide variation of the
meaning of pregnancy according to context.
Assess the socio-cultural context
The assessment should aim to obtain a clear understanding of the cultural aspects that affect
adolescent sexuality and pregnancy. This includes ascertaining norms, myths, cultural
constraints on access to reproductive health services or information and behavioral traits
regarding practice of sexuality. Some factors that should be looked into are:
♦
Age at marriage: legal, ideal, practiced
♦
Conditions of initiation of sexuality for each gender
♦
Acceptability of teenage pregnancy
♦
Meaning of pregnancy among young women: source of identity, status, affirmation of
entry into adulthood or obstacle to self-realization
♦
Pregnancy as proof of fecundity as a prerequisite for marriage
19
Adolescent Fertility: Socio-Cultural Issues and Programme Implications
♦
Existence of unequal gender relations that favor early pregnancy: wide age differentials
between husband and wife, little communication between them, dis-empowerment of
women, sugar daddies, sugar mummies
♦
Differences regarding socially expected and accepted sexual behavior among men and
women (e.g. value of virginity vs. demonstration of sexual performance as defining
traits of femininity and masculinity)
♦
Extent to which men are seen as co-responsible for reproductive outcomes
♦
Myths and taboos regarding fertility, use of contraception and health care services
♦
Legal or social bans on access to health services for unmarried young women
♦
Consequences of adolescent pregnancy: health, social, economic, educational
♦
Variation of these factors along ethnic lines
Data gathering: CulturaLbiases _and_accuracy of information
Gathering data to build a culture-sensitive programme has limitations that arise from culture
itself. Cultural norms that favor early sexual activity among males but scorn it among females,
for example, will have the effect of overreporting sexual experience for the first and
underreporting it for the latter. One study found that boys were likely to report what they
perceived as being the sexual behavior of their peers instead of their own. So the real extent
of the practice of sexuality and risks is likely to be unknown (when the more frequent ways
of collecting data are used), hindering the setting up of effective programmes.
Regarding age at marriage, when laws of minimum age at marriage exceed the age that is
practiced within the culture, fear of legal sanctions will cause an overreporting of age at
marriage.
Another source of potential bias when using survey data or designing interview or focus group
questions, is the difference between the norm and the expectation for the self. A national
representative survey carried out among Costa Rican adolescents asked if it was alright for a
married woman to work. The answer was an overwhelming “totally agree” among both boys
and girls. When boys were asked if it was alright for their own wife to work after marriage,
the percentage of approval dropped to less than one third (Villarreal, 1989). Many times
questionnaires ask for the culturally accepted norm, and get the norm as an answer. The
distinction between norm and self is especially important among the adolescent age group,
where norms and values are being formed and are subject to change. It can be assumed that
the personal expectation will have an important influence on behavior, although the influence
of the norm cannot be overlooked.
Therefore, regarding the gathering of appropriate data for setting up a programme, possible
cultural biases should be taken into consideration in the design of the instruments. Usually, a
combination of qualitative and quantitative methodologies is best to avoid this type of bias and
participatory research techniques have been shown to give very reliable results. AIDS research
20
Adolescent Fertility: Socio-Cultural Issues and Programme Implications
has developed innovative methodologies to look at the spread of the epidemic that could also
be tapped into.
Identify the specific needs of adolescents
In order to identify adolescent’s sexual health needs, their problems have to be seen from their
own perspective. In this sense it is imperative to obtain the views of those to whom the
programmes are intended to serve. Some key issues are:
♦
♦
♦
♦
♦
Reasons for initiation and practice of sexual activity by gender
Reasons for not using contraceptives
Reasons for not using available health services
Extent of knowledge of pregnancy risks and consequences
Access to information on sexuality and contraception
Incorporate a true gender approach
“In dating, we are misled by trying to live up to what others expect of us. A girl plays at sex
for which she is not ready, because fundamentally what she wants is love, and the boy plays
at love, for which he is not ready because what he wants is sex.”
Plenise Semu, Female, 17, Tuvalu 10
Most of the programmes to prevent adolescent pregnancy and to serve adolescent reproductive
health needs have been directed exclusively to young women, ignoring the gender relations that
frequently are at the core of the problem. Effective programmes need to be built with a true
gender approach, starting with the understanding of the underlying gender relations and their'
relation to the occurrence of pregnancy and targeting them through intervention. Programmes
should make sure to involve adolescent boys and to devise mechanisms for each gender to
know about each other’s expectations and motivations regarding sexuality as well as the
differential consequences regarding pregnancy.
For example, using the Costa Rican example, if adolescent girls knew that the motivation of
a boyfriend to insist on having sexual relations was not to obtain a proof of love, but to test
her moral integrity and capacity to say no, it would probably be easier for her to refuse.
Regarding adolescent boys, if they are more aware of the possibly damaging consequences of
their insistence for someone they love, they would probably act differently.
Programmes should explicitly address power relations between the genders and their impact
on unequal outcomes such as unwanted or unplanned pregnancy, STDs, etc.
Reach out to young men
Purposeful action has to be taken to effectively incorporate young men in programmes. In the
io
Quotes in this section are from 1996 UNFPA International Youth Essay contest — Promoting
Responsible Reproductive Health Behaviour, The Youth Perspective.
•''’library
____ AND______ ) p*
INFORMATION J
,
.
CENTRE
J
Zrr
21
cajH ' '30
/\na
Adolescent Fertility: Socio-Cultural Issues and Programme Implications
same way as development programmes historically left women out without intending to, many
reproductive health programmes leave men out because they do not devise a strategy to reach
them. In the case of some young male adults, outreach may be the only effective way to do
this.
The promotion of a responsible role in reproduction is an essential component of many
reproductive health programmes. The best way to attain this will be determined by the
assessment of the socio-cultural context, but it usually helps to show that behavior considered
irresponsible is the reflection of a cultural norm, not due to males being inherently mean or
irresponsible.
Involve adolescents in all stages of the programme
The assumption that experts or professionals know what is best for the adolescents is at the
heart of many programmes. However, experience in different contexts has shown that when
adolescents are not involved, these rarely have positive and lasting effects, so they should play
an active role in the phases of planning, implementation and evaluation of RH programmes.
Their involvement as peer educators, advocates, role models and advisers has been shown to
be beneficial.
Effectively communicate
In order to convey information in a way that is meaningful to adolescents, it should address
the relevant issues for them from their own perspective. This can only be done with an
understanding of the way in which they view the problems and the way these relate to their
own lives. This implies a clear differentiation of audiences and clear targets for the different
messages, as well as participation of the young in generating the messages and expresing them
(i.e. in their own language).
Given the gap between knowledge and behavior, effective strategies have to be developed to
provide information that will change behavior, and not only increase knowledge. This can be
achieved by a thorough understanding of the motivation of behavior and a method to generate
changes in it. One avenue is to detect identification symbols and to use them to convey
messages. For example, to target young men, a national football hero --or other widely
recognised symbol of virility—, can be interviewed on the importance of developing good
communication with his wife, or on the importance of not beating her. In this way, signs and
symbols from within the culture can be used to generate a change in culturally accepted
behavior.
Develop skills to avoid risks
“Although young people say they know about contraceptives, the use of contraceptives is not
widespread, since sexual relations between teenagers are unplanned, they just happen
depending on the situation. ... Another cause is a kind of thoughtlessness: It won’t happen to
me....” Maria Soledad Silva Cabrera, female 15, Paraguay
An unwanted pregnancy is many times the outcome of circumstances in which the adolescent
girl cannot effectively manage the situation as she would like, due to lack of empowerment.
22
Adolescent Fertility: Socio-Cultural Issues and Programme implications
insecurity, feelings of ambiguity or the like. Programmes thus should emphasize self-esteem
and self-value, provide elements to handle social and peer pressure, to control a situation, to
negotiate with the partner and to communicate more effectively.
In addition, programmes should help the adolescents work out a life plan and to develop skills
that will aid to put it into practice, including awareness of the consequences of events that
might interfere with it, such as an unplanned pregnancy. They should be given skills to make
them protagonists of their own destiny.
Generate capacity to make informed decisions
“If the youth is given access to correct details and facts, in all probability he/she will choose
the correct option”
H.M.A.H Warakaulle, Male, 17, Colombo Sri Lanka
In order to promote responsible behavior, adolescents should be given the elements (skills,
awareness and appropriate information) to make decisions, and these should be then fully
respected. Programmes should avoid the normative/impositive authority positions which
adolescents frequently react against.
Develop services that are accessible for adolescents
Services that are separate from adult services and that insure privacy and confidentiality have
had much higher success rates. If economic constraints avoid providing installations that are
entirely separate from those intended for adults, schedules can be set in the adult services so
that only adolescents attend during certain days (for example, during weekends) or certain
hours. In addition, services should avoid the requirement of setting up appointments (so that
no name has to be made public). Economic accessibility should also be taken into account, for
adolescents seldom have enough money to pay the full cost of the services.
Sensitize health personnel
Health personnel should be sensitized about the specificity of adolescents’ health needs, and
should be taught appropriate techniques to deal with them according to the cultural context,
with an emphasis on interpersonal communication skills. In many contexts, the authoritarian
top-down teaching approach should be avoided. It should also be noted that not all service
providers have the ability or the interest to deal with adolescents and this should be taken into
account. In addition, the need to link with other sectors should be emphasized, in order to
avoid a medicalized approach in dealing with problems that are rooted in social and cultural
factors.
Develop a multidisciplinary approach
Adolescent’s health problems should not be left to the health sector alone to deal with.
Programmes will be more effective inasmuch as they promote a holistic approach by
integrating education programmes, sports, entertainment and employment, inter alia. Sex
education programmes should be promoted from a culturally sensitive and meaningful
perspective, and teachers should be sensitized and trained taking into account their own
cultural constraints to addressing sexual issues. The methodological aspect is a key one, for
23
Adolescent Fertility: Socio-Cultural Issues and Programme Implications
the way in which sex education is taught is as important as the contents.
Create an appropriate environment for the programme
For a programme to work, it is important to take into consideration both the enabling and the
impeding factors from the environment. Both of these are determined to a large extent by
cultural factors, and should be studied when assessing the cultural context. A strategy to
involve the local community members and leaders including parents, teachers, religious leaders '
and local authorities should be devised so that they are supportive of the programme.
Financial, political and technical support networks are crucial elements of sustainability of the
programme, as well as the ability to remain flexible and to adapt to changing needs.
Conclusion
The incorporation of a socio-cultural approach to reproductive health programmes for
adolescents contributes largely to their appropriateness and to their ability to meet the needs
of adolescents within their cultural specificity and context. This approach may seem to require
a large amount of human and financial resources. However, this is not necessarily the case,
for a socio-cultural assessment need not be lengthy (a variety of rapid assessment techniques
are available) or expensive, and may, instead, insure effectiveness of the resources invested.
Socio-cultural research provides a means to change behavior, for it is based on the
understanding of the determinants of this behavior, while traditional approaches frequently
succeed in changing attitudes or increasing knowledge but much less frequently have an impact
on actual behavior.
The socio-cultural approach increases cost-effectiveness of programmes by avoiding spending
resources on areas that do not respond to felt needs or are not culturally relevant, or on
approaches that do not adequately reach the intended audiences. In addition, it allows better
monitoring and evaluation by providing a sound baseline. In the case of adolescent fertility it
is particularly germane given that adolescence itself is culturally defined and that the health,
social and economic consequences of very early fertility are culturally determined.
24
Adolescent Fertility: Socio-Cultural Issues and Programme Implications
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27
Background Paper on Adolescent Fertility: Socio-cultural Issues
ANNEXES
Figure A4
Latin America: Proportion of births to mothers
aged 15-19,1950-55 to 1985-90
25
■
20 .L
/
/
<0
15
iiw
5O
___
------ - -------------- ----------------------_______________ —4— Colombia
10
_
Costa Rica
-----------
o
—A— Cuba
0>
Q.
-■
5
0
19
5055
19
5560
19
eoes
19
6570
19
7075
19
7580
19
SO85
19
8590
Haiti
Figure A5
North Africa (selected countries): Proportion of births to mothers aged 15-19
and variation in the birth rate
Egypt
Egypt
200
0.15
■
0.1
150
‘y;.’
■
■ 'r!j
’
100
7
0.05
______ A...
~i~.............
1940
1970
1960
B
■■
1990
1980
1975
2000
1980
1985
Tunisia
1990
1995
Tunisia
0.15
300
'7- '■
0.1
0.05
____
250
w
1970
1975
1980
S<_
—
_
_____
200
—
150
100
1985
0 —
1965
1990
k
1970
1975
.— Total’]
15-19'1
50
!
0 _
1965
-
■
0
___________________ 1___________
1950
15-19
50
-—►
0
—•— Total-1
■
1980
1985
1990
Figure A6
Asia (selected countries): Proportion of births to mothers aged 15-19 and
variation in the birth rate
Malaysia
Malaysia
0.15
150
0.1
100
--___ ...
—
Total
0.05
0
1960
—
50
0 _
1965
1975
1970
1980
1985
1990
1995
1970
-B— 15-19
—i----------
1975
1980
Philippines
1985
1990
Philippines
0.15
140
120
0.1
0.05
0
1950
1960
1970
1980
1990
2000
100
80
60
40
20
0
1950
Total
15-19
1960
Singapore
1990
1980
1970
2000
Singapore
100
80
0.1
60
_ Total
40
i— 15-19
20
0 __
1960
1980
1970
0
1960
1990
1970
Sri Lanka
0.1
0.05
1965
1970
1975
1980
1985
1990
140
120
100
80
60
40
20
0
1960
»
1970
0.1
0.05
1960
1970
1980
1990
Thailand
0.15
1950
Total
15-19
Thailand
0
1940
2000
Sri Lanka
0.15
0
1960
1990
1980
1980
1990
2000
140
120
100
80
60
40
20
0
1950
— Total
15-19
1960
1970
1980
1990
2000
Country and
survey year
Sub-Saharan Africa
Botswana 1988
Burkina Faso 1992/93
Burundi 1987
Cameroon 1991
Central African Rep. 1994/95
Ghana 1993
Kenya 1993
Liberia 1986
Madagascar 1992
Malawi 1992
Mali 1987
~
Namibia 1992
Niger 1992______________
Nigeria 1990
Rwanda 1992
Senegal 1992/93
Tanzania 1991/92
Togo 1988
Uganda 1988/89
Zambia 1992
Zimbabwe 1988/89
Zimbabwe 1994
North Africa & Middle East
Egypt 1992______________
Jordan 1990
Morocco 1992
Sudan 1989/90
Tunisia 1988
Yemen 1991/92
Asia
Bangladesh 1993/94
India 1992/93
Indonesia 1991
Indonesia 1994
Pakistan 1990/91
%
population
10-19,
1996
% women
15-19 in
rural areas
24
22
23
23
22
23
25
u.
"23
23
23
23
23
23
25
23
23
23
23
24
u.
24
69
74
96
58
52
54
84
u.
’79
88
70
70
89
71
93
54
73
59
86
46
u.
73
62
27
67
61
48
52
u.
53
63
67
42
75
54
25
52
57
56
68
61
u.
50
22
u.
56
u.
29
u.
K
% women
20-24
who gave
birth by
20
K
23
22
23
59
40
77
26
13
41
24
21
u.
87
73
u.
62
64
66
49
u.
33
31
TT
22
ADOLESCENT DEMOGRAPHICS WORLDWIDE
% women
%vbirths
% births
Median
Median
40-44
to women
to women
age at first age at first
who gave
15-19,
15-19
sex 20-24
sex 45-49
birth by
1996
unplanned
20
50
57
39
64
59
50
59
u.
60
56
62
38
63
49
36
54
65
59
69
68
u.
55
14
18
6
19
20
15
18
u.
71
23
36
24
23
58
52
u.
T
n
18
20
15
21
17
7
19
16
15
22
39
18
50
11
10
40
26
20
44
35
33
u.
47
T7
u.
14
40
u.
39
61
36
35
13
u.
~6
12
iT
16
u.
22
15
23
u.
85
58
u.
18
9
u.
23
16
u.
5?
14
72
38
7
9
17.3
17.2
19.2*
16.1
u.
18.1
17.5
18.8
15.7
u.
To
TtJ
17.3
15.5
17.0
u.
15.9
18.7
15.0
16.6
20.2*
17.5
17.3
16.5
15.9
16.6
18.3
16.8
15.4
16.0
u.
T57
20.1
14.9
16.5
18.4
15.8
16.4
17.1
15.3
16.0
16.9
u.
u.
u.
u.
u.
u.
11.
u.
u.
u.
u.
u.
u.
u.
u.
u.
19J
Tzo
u.
u.
u.
u.
u.
u.
% women
who have
had sex
15-19
________
% women
who have
had sex
20-24
___________________________________________________________________ ’
Median
age at first
marriage
20-24
Median
age at first
marriage
45-49
% ever
used
modern
contracept
ion 15-19
24.9a
17.3
19.5a
17.3
u.
19.0
19.5a
18.2
19.5
17.7
15.9
24.9b
15.1
17.8
20.9a
18.3
19.0
18.6
17.8
18.6
19.7
u.
25.1
17.7
19.7
16.0
u.
34
8
4
12
u.
Ko
27
32
51
36
44
16
u.
98
60
8
87
u.
83
71
98
67
u.
42
73
27
66
17
34
67
84
72
80
48
u.
18.1
16.6
17.1
18.4
15.8
23.3
15.1
17.3
18.7
15.8
17.2
18.7
16.7
16.6
18.6
u.
14
6
3
12
4
33
1
2
9
1
4
9
5
15
42
u.
u.
u.
u.
u.
u.
u.
u.
u.
u.
u.
u.
u.
19.9a
21.2a
22.3a
20.5a
22.9a
18.1
18.3
18.9
17.6
16.3
19.9
15.7
19
9
40
u.
u.
u.
u.
u.
u.
u.
u.
15.3
17.4
19.8
u.
18.9a
13.6
15.5c
16.9
u.
64
18
2
44
u.
47
36
72
36
u.
“4
37
6
26
“9
u.
u.
TsT
TT
3
35
12
38
2
_______ .
Country and
survey year
___________ ■________ ____ ; -______ ADOLESCENT DEMOGRAPHICS WORLDWIDE
% w'omen
Median
% women % women
% births
% births
Median
%
20-24
40-44
to women
to women age at first age at first
population 15-19 in
15-19,
15-19
sex 20-24
rural areas who gave who gave
10-19,
sex 45-49
birth by
birth by
1996
unplanned
1996
39
31
39
31
13
17
42
50
19.3
18.9
8
30
20.6a
21.2
17
u.
u.
u.
u.
u.
3?
33
35
u.
50
35
u.
37
27
30
u.
36
52
39
u.
48
41
u.
34
36
40
u.
19?7
19.0
u.
u.
u.
20?0
20.0
u.
19.9*
19.9
u.
202
20.0
u.
u.
u.
20.6a
21.5a
u.
19.8a
19.8a
19.1
18.9
20.2a
18.6
20.8a
21.8a
19.7
u.
58
58
u.
45
24
32
7
38
14
39
23
58
7
2
15
u
4"
u
19
u
23
22
20
36
26
u.
u.
u.
25
32
40
u
u.
u.
T?
47
18
15
36
27
u.
20
33
u.
22
52
39
u.
~n
15
u.
14
12
13
2
”4
1
7
14
35*
u
u
u
73
u.
21.0*
19
9
TtJ
28
u.
“9
19.1
"4
u.
18.4
19.8*
18.2
18.9
19.7*
19.3
u.
18.4**
18.9
17.8
19.5
19.2
18.2
3
u.
u.
u.
u.
u.
u.
u.
u.
u.
u.
u. = unavailable
* Median is for women ages 25-29; median for 20-24 was not calculated since less than 50% had sex or had a birth.
** Women ages 40-44
a = Median is for women ages 25-29; median for 20-24 was not calculated since less than 50% had married
b = Median is for women ages 30-34 because median for younger groups was not calculated since less than 50% had married.
c = Women ages 40-49
d = Women ages 40-44
Source: DHS Surveys
21.1
20.0
19.5
18.3
u.
24
25
20
13
17
10
24
21.8a
23.2a
21.0a
20.0a
28
42
31
13
11
13
12
14
2
u.
u.
u.
21.1
u.
T9J
u.
26
16
u.
63
27
u.
50
21
59
under 1%
u.
u.
u.
% ever
used
modern
contracept
ion 15-19
16
16
62
17
21.9*
21
21
22
u.
24
22
u.
22
22
21
Median
age at first
marriage
45-49
41
28
31
22
41
86
74
42
u.
Median
age at first
marriage
20-24
4
8
14
6
22
21
20
20
2?
% women
who have
had sex
20-24
20
20
Philippines 1993
Sri Lanka 1987
Thailand 1987_______________
Turkey 1993________________
Latin America & the Caribbean
Bolivia 1993/94
Brazil 1986_________________
Brazil (Northeast) 1991________
Colombia 1990______________
Colombia 1995____________ t
Dominican Rep. 1991_________
Ecuador 1987________________
El Salvador 1985_____________
Guatemala 1987______________
Mexico 1987________________
Nicaragua 1992/93____________
Paraguay 1990_______________
Peru 1991/92________________
Trinidad & Tobago 1987_______
Developed Countries
France 1994
Germany 1992_______________
Japan 1992__________________
United Kingdom 1993_________
United States 1988
■ ,
____________
% women
who have
had sex
15-19
4
3
u.
17
9
2
u.
u.
u.
u.
u.
16
3
10
8
u.
48
23
6
u.
u.
u.
u.
u.
u.
u.
u.
u.
u.
u.
17.7
20.5
19.1
19.1d
19.1
18.2
21.0
20.7
18.8
u.
u.
u.
u.
u.
u.
u.
u.
u.
u.
- Media
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