This article is published in honor of International Women’s Day, March 8th, 2010.
Approximately 99 percent of the 529,000 annual deaths related to pregnancy and childbirth occurs among women living in low and middle-income countries. Their lifetime risk of maternal death is 1 in 76 live births, compared to 1 maternal death in 8,000 live births in high-income countries. Describing the situation by the word “inequality” would seem indecently euphemistic. But there is another inequality, that of the brunt borne by young women and girls due to pregnancy- and childbirth-related mortality and morbidity, one that public health research, policies and programmes have failed to address.
The World Health Organization (WHO) affirms that while adolescent pregnancies represent approximately 10 percent of all births worldwide–the large majority occurring in low- and middle-income countries–they account for more than one-fourth of the overall burden of disease from pregnancy and childbirth. The 2004 State of the World Population report’s conclusion on that matter is categorical: pregnancy and childbirth are the leading cause of death among adolescent girls and young women in low- and middle- income countries. But the number of deaths alone does not reflect the full scale of this tragedy, another indecently euphemistic word to describe the situation. In fact, for every adolescent girl and young woman who dies from pregnancy or childbirth, 30 more face complications leading to severe morbidities, including injuries, infections, and lifelong disabilities.
So why adolescent girls and young women particularly?
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Physiology plays a major role. The birth canals and pelvic structures of adolescent girls are still developing, and their physical immaturity greatly increases the risk of obstructed and prolonged labour, major causes of childbirth-related death and chronic disabilities, including obstetric fistula. Difficult labors put girls at higher risk of post-partum infections and sepsis, other major causes of childbirth-related deaths in low- and middle-income countries. Poor nutritional status, anaemia, malaria and other conditions further contribute to poor pregnancy outcomes. Additionally, approximately 3 million adolescent girls and young women undergo unsafe abortions every year and face a much higher incidence of complications from unsafe abortion compared to older women.
All of the above causes of deaths and illness are preventable and avoidable. Dramatically reducing these deaths and illnesses would require concerted efforts to address the multiple, complex and intertwined social and economic factors that hamper access by adolescent girls and young women to information and comprehensive quality healthcare.
Among these factors are child marriage and social pressure to bear children immediately after marriage; lack of access to education and economic resources; lack of access to comprehensive sexual and reproductive health care services and supplies; laws and user-fees restricting access to these services, particularly contraceptives and safe abortion services and counselling; failure of the available services and healthcare providers to respond to the specific needs of adolescent girls and young women. These act in synergy, leading to disastrous pregnancy and childbirth outcomes for adolescent girls and young women.
So where should we start?
Operational research is an essential first step. Better documentation of these issues is critical to determining exactly who, where, when and why adolescent girls and young women are dying or facing severe pregnancy and childbirth-related complications. Maternal Deaths Reviews (MDR) are an effective tool to ensure accurate reporting on pregnancy and childbirth mortality and to provide effective guidance to policy makers for the implementation of cost-efficient interventions. MDRs need to be more youth-sensitive and need to include effective mechanisms to report on the major causes of adolescent girls and young women pregnancy and childbirth related mortality, particularly that related to unsafe abortion. Meaningful community participation – particularly that of adolescents and young people – in the review and development of such tools is crucial.
Legal Action also is strongly needed, particularly to eradicate child marriage, eliminate all the barriers that prevent unmarried adolescent girls and young women from accessing sexual and reproductive health information and services, and make abortion a legitimate right for all women, regardless of age.
Operational research and evidence-based programming need to consider adolescent girls and young women as a special group, outside the usual “15 to 49” age range into which they are placed. We need to consider the diversity of this group and take a focused but comprehensive approach to meeting the various and varying needs of adolescent girls and young women.
Last, but definitely not least, further funding specifically allocated to initiatives serving adolescent girls and young women’s sexual and reproductive health needs is needed, without creating further verticalisation of programs but with a clear distinction in terms of the populations targeted, the nature of the intervention(s), and management, monitoring and evaluation processes from broad maternal mortality programmes.
Adolescent girls and young women need to become a priority in public health research, legal reforms, development strategies and public health expenditure. Only that way, can our societies overcome these “indecently euphemistic inequalities.”