Today’s cohort of adolescents is the largest in history; 1.2 billion young people aged between 10-19 years, of which 70% live in developing countries. The leading causes of adolescent mortality are often disaggregated by gender, as only two of the top five causes of death are shared by both males and females: lower respiratory infections and self-harm. However, when looking at the data for girls and young women aged 10-19 years, maternal related conditions are the fourth leading cause of mortality, and the primary cause for girls aged 15-19. Understanding the data behind these troubling statistics is crucial to reducing mortality, addressing the social determinants of adolescent pregnancy, and improving the availability and quality of care provided to adolescents.
Adolescent birth rates have remained in the public health spotlight as an indicator of both Millennium Development Goal 5 and Sustainable Development Goal 3, with the latter aiming to reduce maternal mortality to less than 70 per 100,000 live births, and to ensure universal access to contraception by 2030. Every year it is estimated that 17 million girls give birth, 16 million of which are aged between 15-19 years, highlighting the urgent need for interventions targeting this age group. In addition to age, there are also huge variations in adolescent pregnancy rates according to region. Whilst the global adolescent birth rate is 70 births per 1000 women, in West Africa there are 115 births per 1000 women, and just 7 births per 1000 women in East Asia.
As is often the case when working with data, drawing accurate conclusions, and fully understanding the bigger picture can be a challenge. Very often, reports consist of findings obtained from small studies and/or sub-groups which are used to model what is happening on a global scale. This can be misleading. For example, while it is widely reported that adolescent girls have a higher risk of systemic infections, eclampsia, complications from abortion, as well as preterm delivery and low birthweight compared to women in older age groups, a 2014 WHO funded multi-country study found that although adolescents had a higher risk compared to women aged 20-24 years, this was less than previously thought, and their risk of complications was in fact lower than the risk faced by women more than 30 years old.
Under-reporting is also a significant issue to consider when trying to understand the outcomes for adolescent pregnancy and childbirth. Although adolescent pregnancies in low- and middle- income countries (LMIC) are more likely to occur within a marriage compared to those in higher income countries (HIC), deaths related to concealed pregnancies and unsafe abortion are also more likely to occur but are less likely to be reported. In Africa, unsafe abortion disproportionately affects girls aged 15-19 years, with 25% of all unsafe abortions performed on this age group, and although the risk of maternal mortality is highest amongst girls under 15 years (compared to all other age groups), this risk estimate is based on a much smaller amount of data available due to the lower number of reported cases.
As well as the biological and social associations between adolescence and maternal mortality, 10 to 19-year olds have less contact with Health Care Workers and Skilled Birth Attendants, and there is evidence that the quality of care they receive as a part of Antenatal and Postnatal care services is not as good as that provided to older women. Adolescent mothers are less likely to receive standard tests compared to older women, which is problematic given that adolescent mothers are more likely to be first-time mothers, and therefore maybe at higher risk of unrecognised complications. What is interesting, although perhaps unsurprising, is that within the 15-19 age group there are further variations, with 15-17-year olds receiving a lower standard of care than their 18-19-year-old counterparts.
So, with potentially conflicting data as well as under-reporting, how can adolescent maternal mortality be effectively addressed? Primarily, by addressing all factors that lead to adolescent pregnancy, including child marriage, poverty, and access to education. By reducing the unmet need for contraception for 15-19-year olds - which currently stands at 23 million in the developing world - unplanned pregnancies could be significantly reduced. Additionally, by focusing on adolescents who are most at risk of pregnancy - e.g. those living in rural populations and those not in education - the number of adolescents requiring medical care and undergoing unsafe abortions would decrease. And if by the end of the SDG era, unmet need for contraception, poverty, and equality has been successfully addressed, then it still remains for healthcare workers, facilities and services to become more ‘adolescent-friendly’ and able to meet the needs of society’s youngest mothers.
About the author
Cristianne Connor is a Research Assistant at the Centre for Maternal and Newborn Health, Liverpool School of Tropical Medicine. She received her MSc from the London School of Hygiene and Tropical Medicine and has a special interest in adolescent reproductive and sexual health.
Photo Credit: Pierre Holtz for UNICEF, Courtesy of Flickr