I grew up in India. While in my late teens and studying to be a doctor, I met the girl whom I married some years later. A year or so into our relationship we started to have sex. We decided to use condoms. Getting them at a government-run clinic was out of question. They were known to provide free condoms called Nirodh, which were said to be as smelly and thick as bicycle inner tubes. Asking our family doctor was also out of question. He knew my mother and I had no doubt that he would tell.
So, I used to walk to pharmacies, wait until other customers had left, and then muster up the courage to ask the person behind the counter for upmarket Durex condoms. Sometimes I was successful and walked out feeling like a king. Other times, I was scolded and sent away. I still recall my ears burning with shame. That was 40 years ago, but I know from adolescents around the world with whom I work that they continue to face many barriers to obtaining contraceptives.
Different adolescents, different barriers
In many societies, unmarried adolescents are not supposed to have sex. Laws and policies forbid providing them with contraception. Even when there are no legal or policy restrictions, health workers refuse to provide unmarried adolescents with contraception.
Even when there are no legal or policy restrictions, health workers refuse to provide unmarried adolescents with contraception.
Married adolescents are under pressure to bear children. Many societies require girls to be nonsexual before marriage, fully sexual on their marriage night, and fertile within a year. In this context, there is no discussion of contraception until they have one or more children, especially male children.
Most societies do not acknowledge the sexuality of groups such as adolescents with disabilities or those living with HIV. Neither do they acknowledge the vulnerability of adolescent girls and boys in humanitarian crises situations.
Finally, no one wants to know or deal with non-consensual sex, resulting from either verbal coercion or physical force by adults or peers. Girls who are raped may need post-exposure prophylaxis for HIV, emergency contraception, or safe abortion—all of which are taboo subjects.
Overcoming these barriers
These powerful and widespread taboos have resulted in limited and inconsistent progress on improving adolescent contraception access. This has to change. We must acknowledge adolescents as the sexual beings they are. We must try to remember what a joy it was to discover sex when we were adolescents. We must give adolescents the information, skills, and tools they need to protect themselves from unwanted pregnancies and sexually transmitted infections.
With that in mind, I recommend the following:
- We need to provide adolescents with sexuality education that meets their needs.
- We need to change the way we provide adolescents with contraceptives by offering them a range of contraceptives and helping them choose what best meets their needs, and use a mix of communication channels—public, private, social marketing and social franchising to expand their availability. We must go beyond one-off training to use a package of evidence-based actions to ensure that health workers are competent and responsive to their adolescent clients.
- We need to address the social and economic context of girls’ lives. In many places, adolescent girls do not have the power to make contraception decisions. Even when they are able to obtain and use contraception, an early pregnancy in or out of union may be the best of a limited set of bad options – when they are limited education and employment prospects.
To reach the 1.2 billion adolescents in the world, we must move from small-scale short-lived projects to large-scale and sustained programs.
To reach the 1.2 billion adolescents in the world, we must move from small-scale short-lived projects to large-scale and sustained programs. For this, we need national policies and strategies, and work plans and budgets that are evidence-based and tailored to the realities on the ground. Most importantly, we need robust implementation so that programs are high quality and reach a significant scale while paying attention to equity.
We need government led programs that engage and involve a range of players including adolescents. For this to happen, coordination systems must be in place to engage key sectors such as education, draw upon the energy and expertise of civil society, recognize the complementary role that the public, the private sector and social marketing programs can play, and to meaningfully engage young people.
Some countries have shown us that this can be done. Over a 15-year period, employing a multi-component program including active contraceptive promotion, England has reduced teenage pregnancy by over 50%. This decline has occurred in every single district of the country.
Ethiopia is another outstanding example. Civil war and famine in the mid-1980s had catastrophic effects on the country. However, over a 12 year-period, with an ambitious basic health worker program, Ethiopia has increased contraceptive use in married adolescents from 5% to nearly 30% . It has also halved the rate of child marriage and female genital mutilation, although this decline is more marked in some provinces than in others. These countries have shown that with good leadership and strong management progress is possible.
There will be logistic and social challenges in moving forward. Understanding and overcoming them will require leadership and good management, which is why a strong and sustained focus on implementation must be combined with monitoring and program reviews to generate data that could be used in quick learning cycles to shape and reshape policies and programs.
There is likely to be backlash from those that oppose our efforts to provide adolescents with contraceptive information and services, and to empower them to take charge of their lives. We must do our best to bring these individuals and organizations on board. But we must not be silenced or stopped. We must stand our ground and we must prevail. We owe that to the world’s adolescents.