93933 Knowledge Brief Health, Nutrition and Population Global Practice SOCIOECONOMIC DIFFERENCES IN ADOLESCENT SEXUAL AND REPRODUCTIVE HEALTH: FAMILY PLANNING Jennifer Yarger, Mara Decker, Claire Brindis, Rafael Cortez and Meaghen Quinlan-Davidson January 2015 KEY MESSAGES:  Safe and effective modern contraceptive methods prevent unplanned pregnancies and barrier methods can reduce sexually transmitted infections, including HIV.  We found that the level of modern contraceptive use among adolescent women is low (below 10 percent) in all six countries studied, except for among ever-married adolescent women living in Bangladesh, Ethiopia, and Nepal.  Contraceptive use is higher among married adolescents in urban areas in Bangladesh, Ethiopia, and Nepal, ranging from 26 percent among married, urban adolescent women in Nepal to 52 percent among their counterparts in Bangladesh. Introduction Weidert, and Sreenivas, 2013). Adolescents face many barriers to obtaining contraceptives, including legal Adolescent Sexual and Reproductive Health (ASRH) is restrictions and social stigma against providing one of five areas of focus of the World Bank’s contraceptives to adolescents (Chandra-Mouli, et al., Reproductive Health Action Plan 2010–2015 (RHAP), 2014; Williamson, Parkes, Wight, Petticrew, and Hart, which recognizes the importance of addressing ASRH as 2009). Even when contraceptives are available to a development issue with important implications for unmarried adolescents, social norms and lack of poverty reduction. Delaying childbearing and preventing knowledge act as barriers to their use (Chandra-Mouli, et unintended pregnancies during adolescence has been shown to improve health outcomes and increase al., 2014. Marston and King, 2006; Williamson, et al., opportunities for schooling, future employment, and 2009). Relatively little is known about barriers to earnings (Greene and Merrick, 2005). contraceptive use among married adolescents. Safe and effective modern contraceptive methods prevent Regional data on the contraceptive prevalence rate unintended pregnancies and barrier methods can reduce between 2000 and 2011 indicates that among 15–19 year sexually transmitted infections, including HIV, yet past old girls who are married or in a union, 15 percent use research has found a high unmet need for contraception contraception in South Asia; 16 percent in Sub-Saharan among adolescents in developing countries (Blanc, Tsui, Africa; 41 percent in East Asia and the Pacific; and 53 Croft, and Trevitt, 2009; Chandra-Mouli, McCarraher, percent in Latin America and the Caribbean (UNFPA, Phillips, Williamson, and Hainsworth, 2014; Prata, 2012). Page 1 HNPGP Knowledge Brief  This brief is part of a larger study whose overall purpose Figure 1. Percentage of women aged 15–19 who is to: (i) highlight the multi-sectorial determinants of ASRH currently use a modern contraceptive method, by outcomes; (ii) explore further the multisectoral supply- and country and marital history demand-side determinants of access, utilization, and provision of services relevant to identified ASRH Ever-married Never-married outcomes; and (iii) identify multisectoral programmatic 41% and policy options to address critical constraints to improving ASRH outcomes. The goal is to incorporate the main findings and recommendations from these studies into existing and new World Bank lending operations 20% while simultaneously informing ASRH policies, policy 14% dialogue and interventions for inclusion in country strategies. 6% 6% 6% 6% 1% 3% <1% <1% Using data from the most recent Demographic and Health Surveys (DHS) on female respondents aged 15–19, this brief examines the current status of adolescent use of family planning, and compares adolescent family planning use by socioeconomic status (SES) in 6 countries: Bangladesh, Burkina Faso, Ethiopia, Nepal, Niger, and *Only ever-married women were surveyed in Bangladesh. Nigeria. Source: Bangladesh DHS 2011; Burkina Faso DHS 2010, Ethiopia DHS 2011, Nepal DHS 2011, Niger DHS 2012, Nigeria DHS 2008. Cross tabulations between socioeconomic characteristics and family planning outcomes for never-married and ever- Among never-married women, almost none (1 percent or married adolescent women within each country were less) are using a modern contraceptive method in completed if at least 10 percent of the subpopulation (for Ethiopia, Nepal, and Niger. About 6 percent of never- example, never-married women in Nepal) reported family married women are using a modern contraceptive method planning outcomes. Pearson’s chi-squared tests were in Burkina Faso and Nigeria. used to assess the statistical significance of differences in Socioeconomic differences were found in the use of family planning outcomes by rural/urban residence, modern contraceptive methods for ever-married women in education level, employment status, and household Bangladesh, Ethiopia, and Nepal. In all three countries, wealth quintile. Only differences significant at the 0.05 the percentage of ever-married adolescent women who level (two-tailed tests) are discussed in this brief and all currently use a modern contraceptive method is higher in data are weighted. urban than rural areas (Figure 2). Figure 2. Percentage of women aged 15–19 who Study Findings currently use a modern contraceptive method, by country and residence Figure 1 presents the percentage of ever-married and 60 never-married adolescent women who are currently using a modern contraceptive method, including oral 50 contraceptives, intrauterine devices (IUD), injections, 40 Percent diaphragms, condoms, female sterilization, male sterilization, implants, lactational amenorrhea, female 30 condom and foam/jelly. Use of a modern contraceptive 20 method is most common among ever-married women in Bangladesh (41 percent), followed by Ethiopia (20 10 percent) and Nepal (14 percent). Less than 10 percent of ever-married women use a modern contraceptive method 0 in Burkina Faso, Niger, and Nigeria. Urban Rural Bangladesh* Ethiopia* Nepal* *Statistically significant difference (p<.05) Source: Bangladesh DHS 2011; Ethiopia DHS 2011, Nepal DHS 2011. Page 2 HNPGP Knowledge Brief  Figure 4. Percentage of women aged 15–19 who In Bangladesh, Ethiopia, and Nepal the percentage of ever-married adolescent women who currently use a currently use a modern contraceptive method, by modern contraceptive method varies little across the country and education level poorest, poorer, and middle-income households (Figure 60 3). However, the use of modern contraceptive methods increases for ever-married adolescent women in the top 50 two wealth quintiles. The wealth differential is particularly dramatic in Ethiopia where 45 percent of ever-married 40 Percent adolescent women from the richest households use a modern contraceptive method, compared with 22 percent 30 of those from richer households and 15 percent of those from the poorest households. 20 Figure 3. Percentage of women aged 15–19 who 10 currently use a modern contraceptive method, by country and wealth quintile 0 None Incomplete Complete More than 60 primary primary primary 50 Bangladesh* Ethiopia* Nepal* 40 *Statistically significant difference (p<.05) Percent Source: Bangladesh DHS 2011; Ethiopia DHS 2011, Nepal DHS 2011. 30 20 Policy Challenges 10 Most young people become sexually active during 0 adolescence, however contraceptive use is generally low, Poorest Poorer Middle Richer Richest particularly among adolescents from rural and poor areas, and with low levels of education. The barriers that young Bangladesh* Ethiopia* Nepal* people face with contraception include, among others, a lack of access to and information about affordable family planning services, social and cultural norms, and *Statistically significant difference (p<.05) Source: Bangladesh DHS 2011; Ethiopia DHS 2011, Nepal DHS 2011. restrictive legislation for adolescents. These barriers contribute to high rates of unplanned pregnancies, sexually transmitted infections, abortions, and maternal In Bangladesh, Ethiopia, and Nepal, the percentage of and neonatal morbidity and mortality. Promoting ever-married adolescent females who currently use a contraceptive access and use has health and economic modern contraceptive method increases with higher benefits, including maternal health and child survival, education levels (Figure 4). The education disparity is poverty alleviation, and female empowerment. The WBG greatest in Ethiopia where 13 percent of ever-married is working to improve ASRH through its RHAP by adolescent women with no education use a modern supporting better access to, and provision of, affordable contraceptive method, compared with 50 percent of those ASRH services and strengthening monitoring and who have obtained education beyond primary school. The evaluation of these services and interventions. Post-2015, education gap in modern contraceptive use (and the the WBG is working to ensure Universal Health Coverage overall rate) is substantially smaller in Nepal; 12 percent (UHC) of SRH by helping countries to build healthier, of ever-married women with no education in Nepal use a more equitable societies. To do this requires the following, modern contraceptive method, compared with 27 percent adapted to each country’s unique needs: of those with more than primary education. In Ethiopia, ever-married adolescent women who are  Scaling up the most effective ways to incentivize working are more likely to use modern contraceptive demand for ASRH, including family planning at the methods than their unemployed counterparts (29 percent country level versus 18 percent).  Delivering on the continued need to strengthen country capacity Page 3 HNPGP Knowledge Brief   Leveraging the WBG’s multisectoral advantage to References improve ASRH outcomes, including SRH as a tool for women’s empowerment Blanc, A. K., A.O. Tsui, T.N. Croft, and J.L. Trevitt. 2009. Patterns and Trends in Adolescents' Contraceptive Use and Discontinuation in Developing Countries and  Reaching the poorest, marginalized, and vulnerable Comparisons with Adult Women. International populations to facilitate access to health services and Perspectives on Sexual and Reproductive Health, 35(2), promote UHC and equity 63-71. Chandra-Mouli, V., D.R. McCarraher, S.J. Phillips, N.E. Williamson, and G. Hainsworth. 2014. Contraception Conclusion for Adolescents in Low and Middle Income Countries: Needs, Barriers, and Access. Reproductive Health, 11(1), 1-8. This brief highlights the limited contraceptive use among adolescent women and the socioeconomic disparities in Greene, M.E., and T. Merrick. 2005. Poverty family planning among this population. The results Reduction: indicate the importance of investing in programs aimed at Does Reproductive Health Matter? HNP Discussion increasing access to safe and effective contraceptive Paper. Washington, DC: The World Bank. methods and expanding adolescents’ knowledge of Marston, C., and E. King. 2006. Factors that Shape modern contraception, particularly among adolescent Young People's Sexual Behaviour: A Systematic Review. women in rural and poor areas and/or those with limited The Lancet, 368(9547), 1581-1586. or no education, regardless of marital status. Prata, N., Weidert, K., and Sreenivas, A. 2013. Meeting the Need: Youth and Family Planning in Sub- Saharan Africa. Contraception, 88(1), 83-90. Further research is needed to understand the extent to United Nations Population Fund. 2012. Marrying Too which socioeconomic disparities in adolescent Young. New York: UNFPA. contraceptive use are driven by barriers to accessing Williamson, L.M., Parkes, A., Wight, D., Petticrew, M., contraceptives, social norms, and/or limited desire to use and Hart, G.J. 2009. Limits to Modern Contraceptive Use contraception among some segments of the population. Among Young Women in Developing Countries: A Clearly, intentions to become pregnant may be strongest Systemic Review of Qualitative Research. Reproductive among adolescent women who are recently married and Health, 6(3), 1-12. socially disadvantaged, given the relative lack of competing opportunities available to them. In addition, as the socioeconomic characteristics examined in this brief are interrelated, further research is needed to understand This HNP Knowledge Brief was prepared by a team of the relative influence of each one on adolescent family World Bank staff and consultants including Rafael Cortez planning behavior. Continued investment should be made (World Bank’s Team Lead), Jennifer Yarger Mara Decker, in female education and empowerment as a means to Claire Brindis, Diana Lara (University of California, San reach economic development goals, as well as related Francisco), and Meaghen Quinlan – Davidson (World goals, such as an increase in adolescent contraceptive Bank Consultant) as part of the World Bank’s Economic use to reduce the incidence of unplanned pregnancies. Sector Work on Adolescent Sexual and Reproductive Health (P130031) funded by the World Bank-Netherlands Partnership Program (BNPP).. The Health, Nutrition and Population Knowledge Briefs of the World Bank are a quick reference on the essentials of specific HNP-related topics summarizing new findings and information. These may highlight an issue and key interventions proven to be effective in improving health, or disseminate new findings and lessons learned from the regions. For more information on this topic, go to: www.worldbank.org/health. Page 4