ADVOCATES FOR YOUTH

The Facts

Adolescent Sexual & Reproductive Health in Sub-Saharan Africa

Many governments in sub-Saharan Africa view with concern the region's continued rapid population growth, high birth rates, and escalating rates of HIV infection. Unprotected adolescent sexual activity significantly contributes to these numbers. Promoting contraceptive and condom use among youth can lead to decreases in morbidity and mortality due to unsafe pregnancy, abortion, and sexually transmitted diseases (STDs), including HIV/AIDS, and can slow population growth. Many non-governmental organizations and some governments are working to meet the reproductive health needs of adolescents by providing sexuality education and life skills development, but more needs to be accomplished.

African Adolescents Are Sexually Active.

• By age 20, at least 80 percent of sub-Saharan African youth are sexually experienced. Seventy-three percent of all Liberian women ages 15 to 19 have had intercourse, as have 53 percent of Nigerian, 49 percent of Ugandan, and 32 percent of Botswanan women.¹
• In many sub-Saharan countries, first sexual activity takes place before marriage.^{2, 3} Among Kenyan women, the median age at first marriage is 18.8 years, while the median age of first intercourse is 16.8 years. Data also show that four percent of Kenyan men are married by age 18, although 64 percent report sexual intercourse before that age.²
• Factors that influence the median age at first intercourse include residence and education. In Kenya, rural young women engage in intercourse earlier than urban women, and the median age at first intercourse for women with no education is three years earlier than women with at least a secondary school education.²

Early Sexual Activity Is Linked to Adolescent Morbidity and Mortality.

• In a study conducted in a rural community in Nigeria, 42.1 percent of the sexually active female adolescent participants had experienced either an abortion or a sexually transmitted disease.⁴
• Sub-Saharan Africa's adolescent fertility rate is generally higher than for other regions in the world.³ Adolescent childbearing poses health risks for both mother and child, including toxemia, hemorrhage, anemia, infection, malnutrition, cephalopelvic disproportion, obstructed labor, vesico- or recto-vaginal fistula, low birth weight, and perinatal and maternal mortality.^5,6
• The maternal mortality rate for Ethiopian women ages 15 to 19 is 1,270 per 100,000 live births, approximately three times higher than for women ages 20 to 34. ¹ In Niger, 80 percent of all cases of fistulae occur to women between the ages of 15 and 19.⁷
• In a Ugandan study, 17 percent of young women ages 15 to 18 have undergone an abortion.¹ A review of 13 studies in seven sub-Saharan African countries shows that adolescents between the ages of 11 and 19 years account for 39 to 72 percent of all abortion-related complications. ⁷ Complications include sepsis, hemorrhage, uterine perforation, and cervical trauma and may cause infertility and chronic illness.⁸
• STDs have a particularly large impact on young women who are more easily infected than older women and who, compared to men, are more frequently asymptomatic, more difficult to diagnose, and suffer more serious and long-term complications, such as pelvic inflammatory disease and ectopic pregnancy.⁹
• Few data on the incidence of HIV infection among African youth are available, but adolescent rates are often high. In Abidjan, 11 percent of females under the age of 20 attending a maternal-child health center were HIV positive. Over time, HIV infection has shifted to younger segments of the population.¹⁰
• Young women are particularly susceptible to HIV infection. In Uganda, HIV prevalence in teenage females is six times higher than in teen males.¹¹
• New data suggest over 7,000 new infections per day among those 15- to 24-years-old in sub-Saharan Africa. Nonetheless, in Malawi, nine out of 10 teenage boys, (50 percent of whom report at least one casual sex partner in the past year) feel invulnerable to HIV.¹²
• In Nairobi and Abidjan, up to 90% of female commercial sex workers are HIV positive, and adolescent African males are often clients of commercial sex workers. In Zimbabwe, nearly 16 percent of male high school students report having had sex with prostitutes.¹⁰

Adolescent Reproductive Health Is Affected by Cultural, Economic, and Social Factors.

• In a Senegalese study, four percent of adolescent women and seven percent of adolescent men surveyed have ever visited a family planning clinic. Reasons cited for non-use of services include unmarried status (among women), embarrassment, cost, poor reception by clinic staff, lack of knowledge about sexuality, concern about the efficacy and side effects of contraceptives, and contradictory social perceptions around premarital sex and contraceptive use.¹³
• Gender imbalance in sexual decision making influences teen women's contraceptive use. In a study in Malawi, over 57 percent of adolescent girls said that it is easier to risk pregnancy than to ask a partner to use a condom.¹⁴
• Young men often begin sexual activity earlier and have more sexual partners than young women. In Guinea, the mean age for first sexual intercourse among young men is 15.6 and among young women, 16.3. Further, Guinea's sexually active young men report a mean lifetime number of four sexual partners, compared to 2.1 partners among sexually active young women.¹⁵
• Female genital mutilation (FGM) is practiced in at least 28 countries in Africa and is performed anywhere from infancy up to age 16.¹⁶ Doctors estimate that 10 to 30 percent of girls in the Sudan die from FGM-related complications.¹⁷
• Early marriage is still relatively common. The average age of brides is 15.¹ years in Niger, 16.5 years in Cameroon, and 17.5 years in Burkina Faso.¹⁸ Marriage often occurs between young girls and considerably older men. In Cameroon, the average age difference between husband and wife is 15 years, while in Kenya, it is seven years.19 Young women married to much older men often have less power in decision making around sexual intercourse, childbearing, and birth control, and are less able to protect themselves from STDs, exploitation, or abuse.¹⁹
• Among 315 adolescent abortion clients surveyed in a hospital in Dar es Salaam, almost a third of the pregnancies were caused by a man 45 years or older.²⁰

Programs and Policies Can Change Adolescent Knowledge, Attitudes, and Practices.

• A comparison of two surveys in Uganda (1989 and 1995) on HIV/AIDS and sexual behavior found significant behavior changes in teenage respondents. Proportions of males and females reporting never having had sex increased from 31 percent and 26 percent, respectively, in 1989, to 56 percent and 46 percent, respectively, in 1995 Overall, condom use among sexually active teens has increased for males from 15.4 percent in 1989 to 55.2 percent in 1995 and, for females from 5.8 percent in 1989 to 38.7 percent in 1995. Uganda also reports declines in HIV seroprevalence rates in young people.²¹
• The Kenyan Youth Initiative Project (KYIP) has reached nearly 10,000 Kenyan leaders, urging the provision of education, counseling, and services to youth. KYIP also has developed an interactive educational radio program, the Youth Variety Show. Evaluation suggests that about 3.3 million youth nationwide listen to theshow. Within four months of the show's commencement, 56 percent of clients at youth clinics cite radio as their main source of referral, up from 23 percent.²²
• In Nigeria and Ghana, evaluation of peer education programs implemented in nine communities shows that peer educators significantly increase knowledge, self-efficacy, ever use of contraceptives, and willingness to purchase contraceptives among target populations. Evaluation also shows that peer education is most effective among secondary school students and that males are more receptive to peer education than are females.²³

References

1. Noble J, Cover J, Yanagishita M. The World's Youth, 1996. Washington, DC: Population Reference Bureau, 1996.
2. National Council for Population & Development. Kenya Demographic and Health Survey, 1993. Calverton, MD: Macro International, 1994.
3. McDevitt TM. Trends in Adolescent Fertility and Contraceptive Use in the Developing World. [IPC/95-1.] Washington, DC: U.S. Dept. of Commerce, 1996.
4. Brabin L, Kemp J, Obunge OK, et al. Reproductive tract infections and abortion among adolescent girls in rural Nigeria. Lancet 1995; 345:300-304.
5. Shane B. Family Planning Saves Lives. 3rd ed. Washington, DC: Population Reference Bureau, 1997.
6. Daly P, Azefor M, Nasah B. Safe Motherhood in Francophone Africa. [Working Papers, no. HROWP 21.] Washington, DC: World Bank, 1994.
7. Senderowitz J. Adolescent Health: Reassessing the Passage to Adulthood. [World Bank Discussion Papers, no. 272.] Washington, DC: World Bank, 1995.
8. Coeytaux FM, Leonard AH, Bloomer CM. Abortion. In: Koblinsky M, Timyan J, Gay J, ed. The Health of Women: A Global Perspective. Boulder, CO: Westview Press, 1993.
9. Cates W, Stone KM. Family planning, sexually transmitted diseases, and contraceptive choice: a literature update, part I. Fam Plann Perspect 1992; 24:75-84.
10. De Cock KM, Ekpini E, Gnaore E, et al. The public health implications of AIDS research in Africa. JAMA 1994; 272:481-486.
11. World Health Organization. Young People and Sexually Transmitted Diseases. [Fact Sheets, no. 186.] Geneva, Switzerland: WHO, 1997.
12. UNAIDS/WHO Working Group on Global HIV/AIDS and STD Surveillance. Report on the Global HIV/AIDS Epidemic, December 1997. New York, NY: UNAIDS, 1997.
13. Nare C, Katz K, Tolley E. Adolescents' access to reproductive health and family planning services in Dakar (Senegal). Afr J Reprod Health 1997; 1(2):15-25.
14. Helitzer-Allen D. An Investigation of Community-Based Communication Networks of Adolescent Girls in Rural Malawi for HIV/STD Prevention Messages. [Research Report Series, no. 4.] Washington, DC: International Center for Research on Women, 1994.
15. Gorgen R, Yansane ML, Marx M, et al. Sexual behavior and attitudes among unmarried urban youths in Guinea. International Family Planning Perspectives 1998; 24:65-71.
16. Toubia N. Female Genital Mutilation: A Call for Global Action. New York: Women, Ink, 1993.
17. Heise L. Violence against women: the missing agenda. In: Koblinsky M, Timyan J, Gay J, ed. The Health of Women: A Global Perspective. Boulder, CO: Westview Press, 1993.
18. Kishor S, Neitzel K. The Status of Women: Indicators for Twenty-Five Countries. [Demographic and Health Surveys Comparative Studies, no. 21] Calverton, MD: Macro International, 1996.
19. Alan Guttmacher Institute. Hopes and Realities: Closing the Gap Between Women's Aspirations and Their Reproductive Experiences. New York, NY: The Institute, 1995.
20. Sharif H. AIDS education efforts begin to address plight of Tanzanian youth. AIDS Captions 1993; 1(1):20-21.
21. Asiimwe-Okiror G, Opio AA, Musinguzi J, et al. Change in sexual behaviour and decline in HIV infection among young pregnant women in urban Uganda. AIDS 1997; 11:1757-1763.
22. Kiragu K, Van Hulzen C, Obwaka E, et al. Adolescent Reproductive Health Needs in Kenya: a Communication Response, Evaluation of the Kenya Youth Initiatives Project. Draft. Baltimore, MD: Johns Hopkins University, Population Communication Services, 1998.
23. Lane C [and] Association for Reproductive and Family Health, African Regional Health Education Centre. West African Youth Initiative Final Evaluation Report. Unpublished materials. Washington, DC: Advocates for Youth, 1997.

Compiled by Lauren Hersh, Cate Lane, and Ammie Feijoo
August 1998 © Advocates for Youth

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