Policy Brief on the Case for Investing in Research to Increase Access to and use of Contraception Among Adolescents

Publication date: 2015

AlliAnce for reproductive, MAternAl, And newborn HeAltH Policy brief on the case for investing in research to increase access to and use of contraception among adolescents How research into the best approaches to prevent unintended pregnancy will generate economic and health benefits PA TH /E ric B ec ke r overview Worldwide, more than 46,000 adolescent girls give birth each day.1 Childbirth at such a young age is associated with many negative social and health outcomes, including elevated maternal and newborn death rates.1,2 The health and well-being of adolescents and their future children is critical to the economic fortunes of developing countries. Early and closely spaced pregnancies contribute to school dropout and limit the economic opportunities of young people. A key strategy to expand those opportunities is to improve access to contraceptives and address the social and economic conditions that lead to early and closely spaced childbearing. This document highlights why governments and donors should invest now in research to help determine and implement the most effective and efficient ways to enable adolescents to access and use contraception. Growing evidence suggests that the long-term economic and health benefits of increasing contraceptive access will far outweigh the costs, and the costs of inaction are high. cost And consequences of pregnAncy And cHildbirtH AMong Adolescents Worldwide, about 1 in 6 people is an adolescent.3 This equals 1.2 billion people between the ages of 10 and 19—comparable to the population of India. Adolescents have specific needs that set them apart from children and adults.4 Research on how best to meet those needs with age-appropriate interventions is key to helping them realize their full potential as adults and to maximizing their future contributions to their families and communities. Pregnancy and childbirth among adolescents are major global health concerns. Nearly 1 in 5 adolescent girls in developing countries becomes pregnant before age 18.5 Young women 15 to 19 years old give birth to 16 million children each year, and another million babies are born to tHe cAse for AdditionAl reseArcH Although we have evidence that helping adolescents delay and space pregnancy by increasing access to and use of contraception will lead to many health, social, and economic benefits, more research is needed to determine where, when, and how to intervene for the greatest impact at the lowest cost. Reasons for governments and donors to invest in research and evaluation concerning the use of contraception by adolescents include: • Making the money count. There are important gaps in the evidence on what works, what does not, and why. By knowing the most effective and efficient approaches to avoiding unintended pregnancy among adolescents, we can strategically direct limited resources and maximize the return on investment—choosing to girls under age 15.1 Childbirth at such an early age has many negative consequences for both mothers and their children:1 • Reduced earnings potential. Women who were mothers at a very young age have lower rates of participation in the labor force, difficulty finding employment, and lower earnings. Their children typically have reduced earning potential. This can perpetuate the cycle of poverty from generation to generation. • Poor educational performance. Both young mothers and their children tend to have fewer years of education and lower school performance. • Illness or death. Adolescent girls are at increased risk of illness and death from complications of pregnancy and childbirth, and mortality rates are four times as high in poor countries as in rich countries. In addition, their children have increased risk of neonatal mortality (the younger the mother, the higher the mortality rate), malnutrition, and impaired cognitive ability. As highlighted in a 2014 World Health Organization report on adolescent health,6 the world has made progress since 2000 in addressing adolescent pregnancy. For example, pregnancy rates have declined among adolescents in a number of countries. Also, deaths due to complications of pregnancy and childbirth among adolescents have dropped significantly during the past decade, particularly in regions where maternal mortality rates are highest, including Africa and Southeast Asia. Nevertheless, maternal mortality still ranks second among causes of death among older adolescent girls globally, and about 1 in 20 girls aged 15 to 19 currently gives birth each year—representing 11 percent of all births. previous reseArcH on contrAceptive use by Adolescents Most sexually active adolescent girls in developing countries do not use contraception. Recent data from several countries in sub-Saharan Africa show that only a third of unmarried, sexually active girls 15 to 19 years old are using contraception, with most of the others indicating an unmet need for methods to delay or space pregnancy.7 Among married adolescent girls 15 to 19 years old, unmet need for contraception has been estimated at 62 percent in Ghana, 57 percent in Haiti, and 42 percent in Nepal.7,8 The data clearly show a gap between the reproductive intentions of adolescent girls—whether married or unmarried—and their use of contraception. Enabling the use of contraception can reduce the number of adolescent girls who become pregnant. This will not only improve the health and well-being of these young women and the children they may eventually have but also contribute to potential economic benefits (see text box). Growing evidence on economic benefits To justify increased investment in improving access to contraception among adolescents, policymakers and donors would like to have firm research data showing that each dollar invested leads to a specific amount of cost savings and increased productivity in a country. Much stronger research is needed, however, to build a solid economic case for investing in interventions. The studies highlighted below illustrate ongoing efforts to build the research base and are based on modeling assumptions that require further validation. Several studies have estimated the economic benefits of increasing use of contraception among sexually active youth in developing countries. A World Bank study, for example, calculated that if all 200,000 adolescent mothers in Kenya had completed secondary school and were employed instead of having children so early, the cumulative effect would be to add US$3.4 billion to Kenya’s gross income every year—an amount equivalent to the entire Kenyan construction sector.9 The same study noted that the lifetime opportunity cost related to adolescent pregnancy—measured by the young mother’s forgone annual income over her lifetime—ranged from 1 percent of annual gross domestic product in China to 26 percent in Nigeria, 27 percent in Malawi, and 30 percent in Uganda. A modeling exercise using data from Uganda suggested that this country could potentially save $3 for every dollar it spends on family planning for adolescents, representing a combination of health costs saved and societal benefits, such as productivity increases.10 Also, the researchers estimated that would it cost only $3.47 million annually to meet the country’s unmet need for contraception among girls 15 to 19 years of age. and warrant more emphasis. Some abstinence-only programs have actually resulted in an increased risk of pregnancy. Research is needed to better understand the effectiveness of interventions, including how faithfully the implementation followed the original plans, the capacity of the staff, and the challenges in the particular setting.11 Flexible, sufficient funding for implementation research enables the use of data for ongoing monitoring and program adjustments. • Facilitating the translation of research into programs. Interventions that prove successful still need strong policies and systems to put them into action. Research is needed to understand the factors that promote or inhibit scale-up of successful pilot programs, to develop indicators assessing achievement of policy commitments, and to better calculate the costs and benefits of investing in programs to meet adolescents’ contraceptive needs. Knowing what does not work and avoiding wasted resources is also critical. For example, although a recent paper12 found multiple studies demonstrating that services delivered through multipurpose youth centers are neither effective nor cost-effective, this conclusion is not well known, and such centers continue to be funded. Existing research findings, both positive and negative, need to be used in decision-making while additional program research is carried out. tHe cAse for investing now Worldwide, nearly 2,000 adolescent girls give birth every hour, with adverse health consequences for both the young mothers and their children. The more we invest in research to increase access to and use of contraception, the better we can help to reduce maternal and neonatal deaths and other adverse health and social effects associated with early and closely spaced childbearing. monitor, scale up, and learn from proven approaches rather than repeating programs that do not work well. By enabling targeted investment, this research will contribute to health and economic benefits. • Supporting global health priorities and adolescents’ rights. Nations have committed to expanding access to contraceptives as part of their work to address global health priorities, such as those announced as part of Millennium Development Goal 5 in 2000 and at the 2012 London Summit on Family Planning and through the resulting FP2020 global partnership (see www.familyplanning2020.org). Greater attention to adolescents—a group that has long been ignored—will help the international community and individual nations meet goals for health and development. It will also address the long-standing neglect of adolescents’ rights, and help adolescents reach their full potential as adults. • Recognizing the unique, crucial role of governments and donors. The research and subsequent interventions will have broad benefits for adolescents, children, families, communities, and nations. Governments and donors (including private foundations) are the most capable and appropriate agents to invest in generating the evidence needed to contribute to these societal impacts. specific reseArcH needs Although existing data vividly demonstrate the consequences of lack of contraceptive use among adolescents, little is known about what makes program and policy interventions successful and, therefore, what recommendations will best serve governments and donors interested in helping adolescents meet their contraceptive needs. To develop the most informed approaches, research investments should consider the following: • Segmenting the market of adolescents. Adolescents are an extremely diverse group, and research must reflect this diversity to ensure interventions effectively address a variety of economic and social factors. Systematic data are needed on unmarried girls, including those under age 15; on young married couples who may feel pressured to have children; on adolescent mothers who want to delay subsequent births after the birth of their first child; on boys and their role in preventing unintended pregnancy; and on the link between poverty and contraceptive access. Research must also account for regional differences and for institutional contexts and requirements. • Delving more deeply into promising interventions. Previous research has provided evidence on which interventions are working well and which ones are not. For example, cash transfers and other financial incentives have proved effective in motivating positive reproductive health behaviors in a variety of settings Ph ot o co ur te sy o f t he D av id a nd L uc ile P ac ka rd F ou nd at io n March 2015 In addition, as fertility rates fall around the world, countries have the potential to experience rapid economic growth provided that their burgeoning youth populations are educated and employed. Early childbearing undermines countries’ investments in education and labor force expansion and reduces their potential to realize the promise of this “demographic dividend,” as recently highlighted in the United Nations Population Fund’s State of World Population 2014.13 By investing in research and in programs proven to be effective to facilitate informed choice and increase use of contraception, governments and donors can pave the way for a brighter future for young people, their children, and their communities. Growing evidence suggests that the benefits of investment outweigh the costs. The time to invest is now. References 1 World Health Organization (WHO). Adolescent Pregnancy [fact sheet 364]. Geneva: WHO; 2014. Available at: http://www.who.int/mediacentre/ factsheets/fs364/en/. 2 Nove A, Matthews Z, Neal S, Camacho AV. Maternal mortality in adolescents compared with women of other ages: evidence from 144 countries. Lancet Global Health. 2014;2:e155–164. Available at: http://www.thelancet.com/ journals/langlo/article/PIIS2214-109X(13)70179-7/abstract. 3 World Health Organization (WHO). Adolescents: Health Risks and Solutions [fact sheet 345]. Geneva: WHO; 2014. Available at: www.who.int/mediacentre/ factsheets/fs345/en/. 4 Singh S, Darroch JE, Ashford LS. Adding It Up: The Costs and Benefits of Investing in Sexual and Reproductive Health 2014. New York: Guttmacher Institute; 2014. Available at: https://www.guttmacher.org/pubs/AddingItUp2014.pdf. 5 United Nations Population Fund (UNFPA). Motherhood in Childhood: Facing the Challenge of Adolescent Pregnancy. State of World Population 2013. New York: UNFPA; 2013. Available at: http://www.unfpa.org/sites/default/files/pub-pdf/ EN-SWOP2013-final.pdf. 6 World Health Organization (WHO). Health for the World’s Adolescents: A Second Chance in the Second Decade. Geneva: WHO; 2014. 7 Chandra-Mouli V, McCarraher DR, Phillips SJ, et al. Contraception for adolescents in low and middle income countries: needs, barriers, and access. Reproductive Health. 2014;11:1. 8 MacQuarrie KLD. Unmet Need for Family Planning Among Young Women: Levels and Trends. DHS Comparative Report No. 34. Rockville, Maryland: ICF International; 2014. Available at: http://dhsprogram.com/publications/ publication-cr34-comparative-reports.cfm. 9 Chaaban J, Cunningham W. Measuring the Economic Gain of Investing in Girls: The Girl Effect Dividend. Policy Research Working Paper 5753. Washington, DC: The World Bank Poverty Reduction and Economic Management Network, Gender Unit; 2011. 10 Greene M, Merrick T. A Business Case for Investing in Research on Adolescent Access to and Use of Contraception. Alliance for Reproductive, Maternal, and Newborn Health website [in press]. To be available at: http://www.usaid.gov/ what-we-do/global-health/family-planning/alliance-reproductive-maternal- newborn-health. 11 Hindin MJ, Fatusi A. Exploration of Young People’s Sexual and Reproductive Health Assessment Practices. Baltimore: Bill & Melinda Gates Institute for Population and Reproductive Health, Johns Hopkins Bloomberg School of Public Health; 2014. Available at: http://gatesinstitute.org/content/exploration-young- peoples-sexual-and-reproductive-health-assessment-practices. 12 Denno DM, Hoopes AJ, Chandra-Mouli V. Effective strategies to provide adolescent sexual and reproductive health services and to increase demand and community support. Journal of Adolescent Health. 2015;56(1):S22–S41. 13 United Nations Population Fund (UNFPA). The Power of 1.8 Billion. State of World Population 2014. New York: UNFPA; 2014. Available at: www.unfpa.org/ swop. About the Alliance The Alliance for Reproductive, Maternal, and Newborn Health is a strategic partnership among four core international development organizations: the US Agency for International Development (USAID), the UK’s Department for International Development (DFID), the Australian Department of Foreign Affairs and Trade (DFAT), and the Bill & Melinda Gates Foundation. Together, these partners are working collectively at both the global and country levels to ensure the most effective and efficient use of existing resources to accelerate progress in averting unintended pregnancies and reducing maternal and neonatal mortality. In December 2012, the Alliance co-hosted a donor meeting on research gaps in family planning, and a subgroup formed at the meeting identified the need for this business case analysis. This brief was written by Judith Frye Helzner and Linda Sussman and is based on research by Dr. Margaret E. Greene and Dr. Tom Merrick. It was produced with editorial and graphic design support from the Creative Partners for Programs team at PATH. This policy brief is available online at www.path.org/ publications/detail.php?i=2518. For the full report and citations on which this policy brief is based, see www.path.org/publications/detail.php?i=2538. The material in this document may be freely used for educational or noncommercial purposes, provided that the material is accompanied by an acknowledgment line. PA TH /G le nn A us ti n

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