The Public Health Perspective of "ER"
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Source: Center for Reproductive rights
http://www.crlp.org/pub_fac_atkadol.html
Who are adolescents?
The term "adolescents" refers to people between the ages of 10 and 19. In a 1998 joint statement, the World Health Organization, the United Nations Children's Fund, and the United Nations Population Fund agreed on the following categorizations of young men and women:
Adolescent: 10 to 19 years
Youth: 15 to 24 years1
Young people: 10 to 24 years
As defined above, adolescents comprise 20% of the world's population.2
Lack of safe, legal abortion services for adolescents jeopardizes their health and lives and undermines their right to make decisions concerning childbearing. Unsafe abortion has particularly serious health implications for adolescents and young women, especially where abortion is illegal, severely restricted, or difficult for adolescents to access. Governments should take steps to ensure that adolescents can terminate pregnancies safely, both by liberalizing restrictive abortion laws and addressing the particular reproductive health needs of adolescents.
Adolescents face social, cultural, and legal barriers to family planning. As demonstrated in Table I, in countries worldwide, a high percentage of adolescent pregnancies are unplanned.
Governments should acknowledge adolescents' heightened risk of unwanted pregnancy.
· Because many societies continue to regard adolescent sex as a social taboo, adolescents generally do not have the information they need to avoid pregnancy.3
· Even where adolescents are aware of contraception, they often cannot easily obtain it. Not only may they lack the financial means to purchase contraception, but also many adolescents live in countries that require parental or spousal consent or set a minimum age for obtaining contraception.4
Unsafe abortion and early childbirth pose enormous risks to adolescents' lives and health.
Governments should ensure access to legal and safe abortion services for adolescents.
· Non-married pregnant girls face shame, social isolation, interruption of education, increased economic hardship, and diminished opportunity to marry. For these reasons, abortion is the most common solution to an unwanted pregnancy for a non-married girl in most parts of the world.5
· Carrying a pregnancy to term is more dangerous for young girls than for mature women. Adolescents' physical immaturity contributes to difficulties they face during labor. Mothers aged 17 or younger face a risk of death during childbirth that is two to four times greater than that faced by mothers aged 20 or older.6 Infant mortality and morbidity is also higher among infants born to adolescents: the risk of dying in the first year of life is approximately 30% greater among babies whose mothers are aged 15 to 19 than among babies born to mothers aged 20 to 29.7
· Adolescents' shame, guilt, and fear of discovery often lead them to a state of psychological denial about the reality of their pregnancies. Paralyzed by their emotions and unaware of the consequences of delay, many adolescents wait longer than adult women to terminate their pregnancies. Adolescents are thus more likely to undergo late abortions and, consequently, to experience complications.8
· Even where abortion is legal, the procedure may be too expensive or too difficult for an adolescent to obtain without the involvement of family or neighbors. As a result, regardless of abortion's legal status, non-married adolescent girls most often seek unsafe abortion services from non-medical providers. 9
· Because adolescents who have babies often cannot pursue education and develop marketable skills, they often have difficulty supporting themselves financially.10 The effects of poverty on their nutrition, health care, and environment could contribute to future health problems.
Adolescents face special barriers to abortion services. Among these barriers are laws that require adolescents to notify their parents or obtain their parents' consent prior to undergoing an abortion.
These parental involvement requirements interfere in adolescents' decision-making about abortion by forcing them to engage their parents in their private deliberations. Adolescents may well wish to involve their parents in their decision, but governments should not mandate that they do so.
· The Convention on the Rights of the Child, which defines a "child" as anyone under the age of 18, recognizes "the evolving capacities of the child" when considering the role of parents in guiding a child's exercise of her rights.17 Governments should thus acknowledge that a parent's role is limited by the child's own capacity for independent decision-making.
· Rather than mandating parental involvement, governments should ensure that health care providers are trained to assess the capability of adolescents to make reasonable, independent, and confidential decisions regarding their reproductive health.18
· Parental involvement requirements may cause serious rifts in girls' relationships with their parents or give rise to violent reprisals. They may also cause adolescents to delay seeking an abortion, increasing the physical risks of the procedure with each week of delay.
· Governments should ensure that adolescents have access to appropriate, high- quality abortion services. Women's health care services should be equipped to meet the health needs of adolescents. In addition, health personnel should be trained to provide information to adolescents about preventing and terminating pregnancy.
Special tabulations of fertility surveys for each country. Reproduced with the permission of The Alan Guttmacher Institute from: The Alan Guttmacher Institute, Into a New World, New York, NY: The Alan Guttmacher Institute, 1998, p. 52, Appendix Table 6.
Country and survey year % of adolescent births that are unplanned
Bangladesh, 1993-94 21
Bolivia, 1994 35
Botswana, 1988 77
Brazil, 1996 49
Côte d'Ivoire, 1994 42
Egypt, 1992 16
Guatemala, 1987 23
India, 1992-93 16
Madagascar, 1992 24
Morocco, 1992 24
Pakistan, 1990-91 11
Peru, 1991-92 52
Philippines, 1993 44
United States, 1995 66
· Studies from several low- and middle-income nations reveal that pregnant, unmarried adolescents decide to terminate their pregnancies more frequently than other groups.11 Between one million and four million adolescent women in low- and middle-income nations obtain clandestine, usually unsafe, abortions.12
· Each year, at least five million induced abortions are performed on adolescents between the ages of 15 and 19, which means that girls in this age group account for at least 10 % of all induced abortions worldwide each year. Many of these abortions are performed under unsafe conditions.13
· Adolescents tend to delay obtaining an abortion until after the first trimester and often seek help from a non-medical provider, leading to higher rates of complications. Self-induced abortion is also common among adolescents in many countries.14
· The World Health Organization has estimated that in many African countries, up to 70% of all women who receive treatment for complications of abortion are under age 20.15
· Among industrialized countries, the United States has one of the higher adolescent abortion rates. The abortion rates per 1,000 for 15 to 19-year-olds vary from three in Germany, six in Japan, 19 in England and Wales, to 36 in the United States.16
1 United Nations Population Fund, Technical and Policy Division Draft Report, The Sexual and Reproductive Health of Adolescents 2 (April 1998) [hereinafter Sexual and Reproductive Health of Adolescents].
2 Id. at 4, citing United Nations, The Sex and Age Distribution of the World Population (1996).
3 See, e.g., G.S. Mpangile, M.T. Leshabari, and D.J. Kihwele, Induced Abortion in Dar es Salaam, Tanzania: The Plight of Adolescents, in Abortion in the Developing World, 387, 392 (Cynthia Indriso & Axel I. Mundigo eds., 1999).
4 Alan Guttmacher Institute, Into a New World 31 (1998).
5 Cynthia Indriso & Axel I. Mundigo, Introduction, in Abortion in the Developing World 23, 47 (Cynthia Indriso & Axel I. Mundigo eds., 1999).
6 Alan Guttmacher Institute, Issues in Brief: Risks and Realities of Early Childbearing Worldwide (viewed on May 12, 2000) < http://www.agi-usa.org/pubs/ib10.html> [hereinafter AGI Early Childbearing], citing A.P. McCauley & C. Salter, Meeting the Needs of Young Adults, Series J, No. 41 POP. REPORTS (1995).
7 AGI Early Childbearing, supra note 6, citing J.M. Sullivan et al., Infant and Child Mortality, (Macro Int'l, Demographic and Health Surveys Comparative Studies No. 15, 1994).
8 Indriso & Mundigo, supra note 5, at 48.
9 Indriso & Mundigo, supra note 5, at 47-48.
10 AGI Early Childbearing, supra note 6.
11 Sexual and Reproductive Health of Adolescents, supra note 1, at 5.
12 Judith Senderowitz, World Bank Discussion Papers, Adolescent Health: Reassessing the Passage to Adulthood 16 (1995) [hereinafter Reassessing the Passage to Adulthood].
13 Indriso & Mundigo supra note 5. at 47 citing P. Senanayake and M. Ladjali. Adolescent Health: Changing Needs, 46(2) International Journal of Gynecology and Obstetrics, 137-43 (1994).
14 The Center for Population Options, International Center on Adolescent Fertility, Adolescents and Unsafe Abortion in Developing Countries: A Preventable Tragedy 3 (1992).
15 Safe Motherhood Inter-Agency Group, Unsafe Abortion (last visited February 17, 2000) citing World Health Organization, The Health of Young People: A Challenge and a Promise (1993).
16 Alan Guttmacher Institute, Into a New World 35, tbl. 6b (1998).
17 Convention on the Rights of the Child, opened for signature Nov. 20, 1989, arts. 1, 5, G.A. Res. 44/25, 44 U.N.GAOR Supp. (No. 49), U.N. Doc. A/44/49, 28 I.L.M. 1448 (1989) (entered into force Sept. 2, 1990).
18 Rebecca Cook & Bernard M. Dickens, Recognizing Adolescents' "Evolving Capacities" to Exercise Choice in Reproductive Health Care, Int'l J. of Gynecology and Obstetrics, Word Report on Women's Health Year 2000 (forthcoming 2000) (manuscript at 15, on file with the Center for Reproductive Rights).