Some indicators were only reported for currently married women despite 'all women' being sampled. Five of the 40 indicators were disaggregated by both age and marital status to demonstrate outcomes for unmarried adolescents. However, only four countries Marshall Islands, Samoa, Solomon Islands and Tuvalu reported data for unmarried adolescents for one or more of these indicators.
A significant proportion of women commence sexual activity during adolescence Table 2. The median age of sexual debut for women aged ranges from The proportion of women who commence sexual activity before the age of 15 varies considerably, from 0. The proportion of adolescents who are currently sexually active within the last four weeks or have ever had sexual intercourse also varies considerably among countries that report data for 'all women'. Around half of adolescents in Marshall Islands, Nauru and Solomon Islands have ever had sex, and a considerable proportion commence sexual activity before the age of 15 years.
The median age of first birth ranges from Between 3. By 19 years of age between Adolescent fertility rates are high in most of the eleven countries, ranging from 25 to births per women aged years, and while they have declined in most countries compared with the 10 to 14 years preceding the survey, rates have remained relatively unchanged in Philippines, Samoa, Tuvalu and Vietnam, and have increased in Marshall Islands.
Proportion of women aged who have commenced childbearing at age x for A. A significant proportion of births to adolescents are spaced less than 18 months apart. For the four countries that include data on women aged for this indicator, Proportion of births to women aged spaced less than 18 months for A. Between A significant proportion of adolescent pregnancies are mistimed or unwanted. In Marshall Islands, Nauru and Solomon Islands more than half of women aged report that their last pregnancy was unintended.
These countries also report the highest proportion of adolescents who have ever had sex relative to the proportion who are currently married. Current contraceptive prevalence, any method, among married adolescents varies greatly, ranging from 5. The majority of adolescents currently using contraception are using a modern method. However, a relatively large proportion of adolescents in Cambodia, Nauru, Papua New Guinea, Philippines, Solomon Islands and Vietnam are relying on traditional and presumably less effective methods.
Current use of contraception is considerably lower among 'all women' combining both married and unmarried adolescent women compared with married women for those countries that report data for both groups. Marshall Islands, Nauru, Solomon Islands and Tuvalu also report contraceptive use for unmarried sexually active women, but only Marshall Islands and Solomon Islands report these data for adolescents: current use of any method for sexually active unmarried adolescents is Ninety and In all countries with data, the contraceptive prevalence any, modern and traditional methods is lowest for married adolescents compared with adults, except for women aged Figure 4.
This age-related trend is also observable for data reported for 'all women' or unmarried sexually active women. Low contraceptive prevalence may reflect a desire to become pregnant or an inability to access family planning, resulting in an unmet need for contraception. A woman is considered to have an unmet need if she is of reproductive age and able to become pregnant, is married or in a consensual union, wants to limit or delay pregnancy, and is not using a traditional or modern method of contraception.
This includes women who are pregnant or have given birth in the last six months if the pregnancy was unintended [ 22 ]. Between 1. One to Married women aged have the highest unmet need of any age group in Indonesia, Marshall Islands, Philippines and Vietnam and among the highest unmet need in Cambodia, Samoa and Solomon Islands. Proportion of currently married women aged with A. Some DHS also report source and cost of contraception, informed choice, problems with current method, reasons for and rate of discontinuation, intention for future use, reasons for non-use, and preferred methods.
However, none of these indicators report data for women aged The percentage of women aged currently or 'ever-married' with knowledge of a modern method of contraception ranges from In countries with overall high knowledge of modern contraception, the difference between adolescents and older women appears to be minimal.
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However, in settings where overall knowledge is lower, a greater proportion of adolescents than older women cannot recognise or name a modern method. Papua New Guinea and Timor-Leste also report knowledge of a source of family planning: Knowledge, exposure and access to information and services.
In most countries, a larger proportion of adolescents than women aged have not discussed or been exposed to family planning information. In addition, between Problems accessing care include financial barriers, poor geographical access, lack of knowledge of services and concerns about availability of health workers and commodities. Problems related to needing permission, not wanting to go alone and concern that there would be no female provider are particularly noted by adolescents compared with older women. DHS reports provide a large amount of useful information about adolescent fertility and family planning that is relevant to policymakers and programmers.
All countries report data for adolescent fertility, contraceptive use and unmet need, and the majority also report data for adolescent sexual activity, knowledge and access to family planning information and services.
However, DHS reports have been demonstrated to have some limitations [ 36 ]. These include the omission of young adolescents years , the omission of unmarried adolescents or failure to report data for unmarried sexually active adolescents, and the failure to report age-disaggregated data for some important indicators, particularly contraceptive preferences and discontinuation.
Data reporting broader sexual and reproductive health outcomes for adolescents, including sexually transmitted infections, HIV, and gender-based violence, are also required to inform comprehensive reproductive policy and programs. While beyond the scope of this review, the availability of these data in DHS reports has also been demonstrated to be limited [ 36 ]. The inability to determine outcomes for unmarried sexually active adolescents from the reported data is significant, particularly as some countries report a high prevalence of currently or ever sexually active adolescents in the context of a low prevalence of adolescent marriage.
In general, the countries that include data for 'all women' married and unmarried report different outcomes to those that only include 'ever-married women', suggesting that unmarried adolescents' health outcomes and access to information and services differ to married adolescent women. Other studies have indicated that unmarried adolescents experience unique barriers to accessing reproductive health services and have different outcomes in relation to contraceptive use, unintended pregnancy and abortion [ 3 — 7 ], therefore their inclusion in reports of national-level surveys is vital.
A significant proportion of women commence sexual activity during adolescence.
Many adolescents, married and unmarried, are exposed to the risk of early pregnancy, highlighting the need for access to family planning information and services. Available data suggest this need is not being met, with a considerable proportion of adolescents commencing childbearing by the age of 19, a substantial number of adolescent births spaced less than 18 months apart, and a significant proportion of pregnancies unintended or unwanted. A greater proportion of adolescent pregnancies are reportedly unwanted in countries that collect data for unmarried and married women compared with those that only include married women, particularly in those countries that report low adolescent marriage but high adolescent sexual activity.
This could suggest that more unintended pregnancies occur among unmarried adolescents, although this was not able to be determined from the DHS reports due to the lack of data disaggregated by both age and marital status. An earlier review of adolescent childbearing in low income countries demonstrated that pregnancies to unmarried adolescents are much more likely to be unintended than married women [ 3 ], highlighting the need to report data for unmarried adolescents to inform policy and programs that aim to increase access to family planning.
Early pregnancy, intended or unintended, carries an increased risk of adverse health and socio-economic outcomes for women and their families and may result from poor access to information about family planning and the benefits of delaying first birth, poor access to reproductive health services, and socio-cultural expectations of early marriage and childbearing. Further research is required to better understand the factors that influence early childbearing and contraceptive use among married and unmarried adolescents in East Asia and the Pacific and identify potential targets for intervention.
The prevalence of modern methods of contraception among married adolescents is low in most countries. Low contraceptive use among young women is often considered to reflect a desire to become pregnant, particularly in settings where there is socio-cultural pressure to prove fertility [ 7 , 12 , 37 ].
However, the findings of this review suggest that a significant proportion of married adolescents want to delay or space their pregnancies but are unable to do so. This includes women who have already proven their fertility, but still report a high unmet need for contraception to space their next birth.
The reasons for this are likely to be complex, and may include socio-cultural factors or limited choice of appropriate and acceptable methods for birth-spacing [ 5 ], and require further investigation. There is very little data on contraceptive use and unmet need among unmarried sexually active women. Contraceptive prevalence is considerably lower when all adolescents regardless of marital status are included. This suggests that a large proportion of unmarried adolescents are not using contraception, although it can't be determined what proportion of these are sexually active from the DHS reports.
Only Marshall Islands and Solomon Islands report data for this group, and contraceptive prevalence is low among unmarried sexually active adolescents in both countries. Use of any method is lower than for married adolescents in Marshall Islands, but higher in Solomon Islands. Other studies have demonstrated that unmarried adolescents have different patterns of contraceptive use compared to married women, often reporting higher contraceptive prevalence but also higher unmet need and higher rates of discontinuation [ 4 , 16 , 17 , 38 ]. Further research is warranted to explore the context-specific reasons for low contraceptive use and discontinuation among both married and unmarried adolescents, and to identify preferred contraceptive methods.
Inadequate knowledge is one of the factors that contributes to low contraceptive use [ 4 , 39 , 40 ]. Married adolescents' knowledge of modern methods of contraception varies considerably between countries, and is limited in some settings. Countries that report the lowest levels of knowledge, Timor-Leste, Samoa, Solomon Islands and Papua New Guinea, also report the lowest contraceptive prevalence among married adolescents. As many women commence sexual activity during adolescence, reproductive health information needs to be provided from an early age, with evidence suggesting that this can have life-long protective health effects [ 39 , 41 ].
The proportion of adolescents who have been exposed to family planning messages in the media also varies substantially, and is low in some countries. Delivering family planning information through mass media, in addition to other promotion efforts including referral to services, has been associated with an increase in contraception uptake [ 42 ], so appropriate channels to better reach adolescents need to be explored.
The majority of adolescents not using contraception have not discussed family planning with a health worker and a considerable proportion report at least one barrier to accessing health care. Adolescents face unique barriers to accessing reproductive health information and services, contributing to low contraceptive use in this age group [ 12 ]. These include lack of decision-making power and access to or control over resources, socio-cultural norms regarding adolescent sexual behaviour and childbearing, and policy and legal restrictions [ 39 , 40 , 43 , 44 ].
The real and perceived skills, beliefs and attitudes of health workers can also affect the quality of information given to adolescents and their access to reproductive health services, including family planning [ 45 , 46 ].
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Many of these factors are context-specific, highlighting the need for DHS data to be complemented by qualitative research. In addition, the information and service delivery preferences of adolescents require further investigation to identify how these barriers may be overcome. In all eleven countries adolescents are less protected against unintended pregnancy than older women, with contraceptive use considerably lower in this age group than all others, except women over the age of This is consistent with previous studies of contraceptive use in other low income countries [ 5 , 6 ]. In most countries adolescents also have higher unmet need for contraception, less knowledge, and poorer access to information and services than older women.
These findings suggest that efforts to scale up reproductive health interventions, including increasing the uptake of family planning, do not necessarily reach adolescents and that targeted responses are required. While there is a growing body of evidence regarding youth-targeted programs to deliver reproductive health information and services [ 12 , 47 — 49 ] there is a need to support more rigorous evaluations to identify effective approaches.
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This review has a number of limitations. Some surveys were conducted more than five to ten years ago and it is likely that adolescent fertility and contraceptive use have changed in that time. Only data available in DHS reports were included to reflect data readily accessible to policymakers and programmers. Analysis of primary data was beyond the scope of this review, however, further analysis is likely to yield useful information. This would be particularly relevant to those indicators not disaggregated by age, such as contraceptive preferences and discontinuation, as well as exploring outcomes for unmarried sexually active adolescents.
In addition, sampling populations, survey questions and reporting of age-disaggregated data and marital status vary between countries for some indicators, limiting the ability to make country comparisons. DHS reports provide much useful data accessible to policymakers and programmers; however they are limited by the failure to report data for unmarried sexually active adolescents or report age-disaggregated data for some indicators. Available data indicate that adolescent sexual activity and pregnancy are common in East Asia and the Pacific in the context of low contraceptive prevalence.
Adolescents also appear to have lower use and higher unmet need for contraception, poorer knowledge of family planning and less access to information and services than older women. The prevention of adolescent pregnancy is an integral component of efforts to improve maternal health and ensure universal access to reproductive health, but it cannot be assumed that adolescents will automatically benefit from policies and programs that are aimed at the general population. Further research is required to better understand the barriers that both married and unmarried adolescents face accessing reproductive health information and services, and their information and service delivery preferences, so that interventions can be effectively targeted to meet their needs.
Adolescent fertility and family planning in East Asia and the Pacific: a review of DHS reports
In addition, greater investment is needed to support rigorous evaluation of strategies that target adolescents so that effective approaches can be identified. Guttmacher Institute: Facts on sexual and reproductive health of adolescent women in the developing world. In Brief. Singh S: Adolescent childbearing in developing countries: a global review.
Studies in Family Planning. New York. United Nations: World Population Monitoring - Reproductive rights and reproductive health: selected aspects. Stud Fam Plan. WHO: Adolescent pregnancy: unmet needs and undone deeds. The Lancet. Have one to sell? Sell now - Have one to sell? Get an immediate offer. Get the item you ordered or get your money back. Learn more - opens in new window or tab.
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