1. Guttmacher Institute New evidence on adolescent sexual and reproductive health in Sub-Saharan Africa

2. Guttmacher Mission Mission: Advance sexual and reproductive health worldwide through social science research, policy analysis and public education Program: A unique combination of policy-relevant research and evidence-based advocacy Approach: Partnership with national institutions to build capacity and ensure local ownership of findings

3. About the Guttmacher Institute Founded in 1968 Based in NY and DC $12 million budget Domestic and international programs Wide range of issues –Abortion; contraception; adolescents; HIV

4. Scientific and Policy Publications Perspectives on Sexual and Reproductive Health International Family Planning Perspectives Guttmacher Policy Review Occasional Reports and Monographs www.guttmacher.org

5. New and Forthcoming Research Findings Adolescent sexual & reproductive health –With partners in Kenya, Ghana, Burkina Faso, Malawi, Uganda, Nicaragua, Honduras, Guatemala, Costa Rica –Forthcoming: With partners in India, Nigeria & Mexico

6. New and Forthcoming Research Findings Global & regional estimates of abortion –With WHO

7. New and Forthcoming Research Findings Incidence, causes & costs of unsafe abortion –With partners in Nigeria, Uganda, Guatemala & the Philippines & with Population Council in Pakistan –Forthcoming: with Population Council, incidence estimates for Mexico and with Ipas in Ethiopia and Burkina Faso; with UNFPA new cost studies in Pakistan, Mexico and Ethiopia

8. New and Forthcoming Research Findings Understanding unmet need for contraception –Analysis of DHS surveys in 55 developing countries Trends in maternal mortality –Forthcoming: Analysis of existing data in India, Mexico & Nigeria

9. Learning from Young People about HIV and Pregnancy Prevention in Sub-Saharan Africa

10. Project Objectives Provide new evidence on the unmet sexual and reproductive health needs of adolescents Use the new evidence to mobilize political support for policy and program change Increase the capacity of African partners to do policy-relevant research and evidence- based advocacy

11. African Research Partners Institut Supérieur des Sciences de la Population, Burkina Faso University of Cape Coast, Ghana Centre for Social Research, Malawi Makerere Institute of Social Research, Uganda African Population and Health Research Center, Kenya

12. About the African Population and Health Research Center (APHRC) An international organization committed to conducting high quality and policy-relevant research on population and health issues facing sub-Saharan Africa APHRC’s mission is to promote the wellbeing of Africans through policy relevant research on population and health issues

13. APHRC Core Programs POLICY ENGAGEMENT Engage policymakers in research Inform policy & programs Promote positive change Stimulate new thinking STRENGTHENING RESEARCH CAPACITY Fellowships Training workshops Support to universities UrbanizationPopulation Dynamics HealthEducation Generation and Synthesis of Scientific Knowledge RESEARCH

14. African Communications Partners Initiative Privée et Communautaire de Lutte Contre le VIH/SIDA, Burkina Faso Planned Parenthood Association of Ghana Youth Net and Counseling, Malawi Panos Eastern Africa, Uganda African Population and Health Research Center, Kenya

16. Key Findings Very young teens are sexually aware and most older teens are sexually active, usually before marriage Less than half get any kind of sex education Contraceptive education that begins in secondary school comes too late Adolescents are concerned, but have too little information about pregnancy or HIV prevention to protect themselves

17. Key Findings (cont.) Abstinence-until-marriage is not a message that resonates with adolescents Adolescents want information and services from professional sources Both cost and embarrassment are barriers to services Condom use is fairly widespred Unintended pregnancy is a more immediate concern than HIV

18. The reality is that young people are or will soon be sexually active

19. Few girls under 15 report having had sex, but many are sexually aware % of 12-14 year old females

20. The same is true for young boys % of 12-14 year old males

21. Adolescence is a time when changes in sexual activity happen fast % of 20-24 year olds who had sex by certain ages

22. Most young women become sexually active by choice

23. Early mandatory sex education is critical

24. At most half of 15-19 year olds received any sex education at school

25. Young people support sex education % of 12-14 year olds * Ever attended school †Know of AIDS

26. Detailed knowledge of HIV prevention is low % of 15-19 year old males and females

27. Cost and embarrassment are major barriers to services

28. Young people prefer clinics and hospitals for contraception % distribution of 15- 19 year olds who ever had sex

29. Fear or embarrassment is the main barrier to getting contraception (Uganda) % reporting barrier among 12-19 year olds who had sex in last 12 months Male Female

30. Lack of confidentiality and cost are main barriers AT CLINICS: “When you stay for a while like this, [the] consult medical officer saying ‘Eh! Those having gonorrhea whatever, there!’ The way you know, so you stand amongst many people, so you feel embarrassed.” [Malawi, urban, female] WITH FAMILY AND OTHER PEOPLE: “The only problem here is money. If you have the money you can go to the hospital without the knowledge of your house people.” [Ghana, rural, male]

31. Pregnancy is at least as important a concern as HIV

32. Young women use the male condom to prevent pregnancy more so than HIV % of females 15-19 who had sex in the last 12 months and used a condom

33. Unwanted and mistimed pregnancies are a major problem 7.9 million pregnancies Pregnancy outcomes for adolescents aged 15-19 in Sub-Saharan Africa

34. Many adolescents report that they have close friends who tried to end a pregnancy % of 15-19 year olds

35. Less than half of young men use condoms consistently % of 15-19 year old males

36. Research to Action

37. Recommendations

38. Because African adolescents are or soon will be sexually active: Fund comprehensive programs that accept the reality of adolescent sexuality, promote abstinence for younger teens and work to de-stigmatize sexual activity among older unmarried adolescents. Provide a counterweight to pressures from the United States to emphasize only abstinence-until-marriage and restrict condom availability.

39. Because early sex education is critical: Start in primary school and make it universal Mobilize community and moderate faith- based groups Include more detailed information on pregnancy and STI/HIV prevention, including condom demonstrations Encourage delayed sexual debut for younger adolescents

40. Because cost and embarrassment are barriers to services: Make services for adolescents very low cost or free Ensure confidential and non- judgmental services Expand existing health facilities to meet the needs of the most vulnerable youth

41. Because pregnancy prevention is at least as important a concern as HIV: Promote condoms for pregnancy prevention, not just HIV prevention Integrate family planning and HIV prevention efforts so that both are addressed in any setting Build on current levels of adolescent condom use by improving correct and consistent use

42. Because Washington is an “evidence-free zone” Progressive governments must continue to: –Shore up support for sexual health within multilateral organizations –Use donor coordination mechanisms within countries to support good policies –Move quickly to address contraceptive shortfalls

43. Hope on the Horizon Waning influence of religious conservatives Return of evidence-based U.S. policies 2008 U.S. national elections Importance of European governments

45. This presentation was supported in part by the Gates Foundation, the Rockefeller Foundation and U.S. National Institute of Child Health and Human Development For more information, visit www.guttmacher.org

46. Early Childbearing and Sexual Risk Behaviors among Young in El Salvador, Guatemala, Honduras and Nicaragua

47. Why study youth in Central America? Substantial and growing segment of the population Highest adolescent fertility of all Latin America High unmet need for contraceptives High levels of risks for STIs/HIV

48. Adolescent childbearing in focus countries is the highest in all of Latin America

49. Significant proportions of adolescents have had sex % men/women aged 15-19 who had sexual intercourse

50. Rural adolescent women are more likely to have had sex than their urban counterparts… % women aged 15-19 who had sexual intercourse

51. … but among adolescent men the situation is reversed % men aged 15-19 who had sexual intercourse

52. Young women who have had sex are usually in a union % men/women aged 15-24 sexually active

53. Young men are more likely to identify condom use as a means of avoiding HIV/AIDS % aged 15-24 who spontaneously identify specific means of avoiding HIV/AIDS Condom Monogamy/be faithful and limit partners Abstain from sex MenWomenMenWomenMenWomen Nicaragua68191719813 Honduras66525440722 El Salvador643019241415 Guatemala49325437422

54. Rural women are more likely than urban women to enter into union as adolescents… % aged 20-24 in union before age 20

55. ..and to be adolescent mothers % women 20-24 who have had a child before age 20

56. Many young women do not want a child soon but are not using modern contraceptives Country% women 15-19 who do not want a child soon % women 15-19 in need of modern contraceptives Nicaragua8636 Guatemala8452 El Salvador7946 Honduras7048

57. One-third or more of adolescents’ births are unplanned % of live births to women aged 15-19 that were unplanned

58. Rural young women are less likely than urban women to receive prenatal and delivery care % aged 15-24 who receive care

59. High proportions of young men are at risk of STI/HIV % of sexually active 15-24 with 2+ partners in the past 12 months

60. This presentation was developed with support from the Swedish International Development Cooperation Agency For more information, visit www.guttmacher.org

61. Research Partners Costa Rica: Regional Partner – Centro Centroamericano de Población Guatemala –Dr. Werner Figueroa, –Dr. Felipe López Honduras –Lic. Kenia Sabonge Nicaragua –Dr. Luis Blandón –Dr. Luis Carballo