Written by Dr. Stephen Bell, Kirby Institute, UNSW Sydney, Australia*

Associate Professor Angela Kelly-Hanku, Kirby Institute, UNSW Sydney, Australia; and PNG Institute of Medical Research (PNGIMR), Goroka, PNG

 This blog is presented on behalf of the authorship team of this recently published article.

*Corresponding author: [email protected]

Despite persistent international attention, adolescent pregnancy remains a major public health concern in low- and middle-income countries (LMICs). Given ongoing international concern about adolescent pregnancy and increasing attention to actively engaging young people in decisions about their health, we propose the need for novel youth-centred research to inform the development of policies, health services and outreach programs that pay honest, respectful attention to young people’s lived experiences of pregnancy. Here, and in our recently published article, we focus on Papua New Guinea (PNG), but our commentary is relevant to diverse international settings where the harmful impacts of pregnancy among young people persist.

Adolescent pregnancy as a global and regional concern

Adolescent pregnancy is a global priority [1, 2]. Young women aged 15-19 years account for 11% of all births worldwide, of which 95% occur in LMICs [3]. In Asia-Pacific countries, one in seven girls give birth by the age of 18, often within contexts of high unmet need for modern contraceptive methods, inadequate provision of youth sexual and reproductive health services and lack of skilled care during delivery [4]. In the Pacific, up to 43% of pregnancies among 15-19 year olds are unwanted [4]. Globally, complications during pregnancy and childbirth remain among the leading causes of death of young women aged 15-19 years, with risks most heightened for those aged under 16 years [4]. Socio-economic outcomes for girls and young women include school dropout and limited livelihood opportunities, which in turn contribute to gender inequality and women’s disempowerment in decision-making related to health service access for themselves and their children.

Adolescent pregnancy in PNG

Adolescent pregnancy is a national priority in PNG [5, 6] but there is a lack of strategic information to guide implementation of effective services and community programs. PNG has one of the highest adolescent fertility rates among Asia-Pacific countries [4]. Contraceptive prevalence rates are exceptionally low, and like other LMICs, this is a key reason for high unintended pregnancy amongst young people [4]. When contraception is used, short-term acting, user-dependent methods are more common [7], increasing risk of contraceptive failure and unintended pregnancy. PNG also has one of the highest maternal mortality ratios in the world, and the highest in the Pacific region [8]. Sepsis due to unsafe abortion is one of the leading causes of maternal mortality in PNG [9], but the legal environment inhibits the provision of safe abortion services to women [10], meaning that most abortions that do occur are performed unsafely outside the health service. Whilst there are no national level abortion data [4], studies indicate that women needing post-abortion care due to complications arising from induced abortion are likely to be younger, unmarried and experiencing unplanned pregnancy [10].

Pregnancy is a sexual, reproductive and maternal health issue

Pregnancy is a sexual health issue, a reproductive health issue and a maternal health issue. We specify each as a deliberate reminder to inform appropriate, holistic responses to pregnancy among young women and men. ‘Adolescent sexual and reproductive health’ programs and services tend to focus narrowly on sexual (i.e. STI prevention) and reproductive (i.e. family planning and contraception) health issues. The maternal health dimension is often forgotten, with insufficient recognition that young women (pregnant or not) and young men require information about, and access to, appropriate maternal health services for when they experience pregnancy, and whatever happens consequently.

Learn from young people’s lived experience

In any setting, research exploring lived experiences of pregnancy should move beyond the individual in order to examine the influence of social contexts on young people’s vulnerability to sexual, reproductive and maternal health risks. An understanding of social context enables a move from individual behaviour change-focussed adolescent pregnancy programs to structural interventions that aim to modify societal influences that affect the ability of young people to protect themselves from pregnancy-related risks. Such influences include cultural beliefs, gender norms, and laws and legislation, as well as interpersonal relationships and access to health services.

Yet in PNG, there is a paucity of research about these issues. While there is international guidance on what constitutes ‘youth-friendly’ health services [11, 12], we lack context-specific evidence in PNG about what constitutes ‘youth-friendly’ to inform effective approaches for the delivery of youth-friendly sexual, reproductive and maternal health services and outreach programs, particularly at scale. There is also little understanding about young people’s experiences within existing health services, their access to and experiences with contraception and family planning methods, or the influence of schools. We know little about the influence of gender relations, nor the discussions and negotiations that occur within young people’s intimate sexual and social relationships, even though over half of young people in PNG are estimated to be sexually active, and 19% of 20-24 year old married females were married by the age of 19 [4]. Crucially, there is limited understanding of the everyday strategies that young people use to prevent, reduce the risk of, avoid, cope with, or mitigate the impact of pregnancy.

Youth-centred research to learn from young people’s unique expertise

There are increasing international calls to involve young people as partners in the design of youth-friendly sexual, reproductive and maternal health programs and services. Yet as with other LMICs, young women and young men in PNG who experience pregnancy – as two people who have conceived a child, lost or aborted a child, as parents, or as mother and father who are not together – are rarely consulted for their thoughts and personal expertise about strategies to prevent or mitigate the harmful impacts of pregnancy at a young age.

These gaps are the target of our new qualitative youth-centred study in PNG, funded by the Australian National Health and Medical Research Council (Project Grant APP1144424). Our youth-centred research approach – which draws on expert knowledge from young Papua New Guineans about their sexual, reproductive and maternal health strategies – is outlined in more detail in our recently published paper. We hope this youth-centred research approach will enhance understanding of how to strengthen existing health services and community programs, and identify new youth-led responses to reduce their sexual, reproductive and health risks in PNG. But beyond PNG, almost one billion young people aged 10-24 years live in Asia and the Pacific, comprising 27% of the total regional population [13]. Given the magnitude of this young population, working with and learning from young women and young men who have experienced pregnancy offers unprecedented opportunity to improve their sexual, reproductive and maternal health, and population health more generally.

References

1. United Nations, Resolution adopted by the General Assembly on 25 September 2015. 70/1. 2015, United Nations: New York.
2. Starrs, A.M., et al., Accelerate progress-sexual and reproductive health and rights for all: report of the Guttmacher-Lancet Commission. Lancet, 2018.
3. WHO, WHO guidelines on preventing early pregnancy and poor reproductive outcomes among adolescents in developing countries. 2011, WHO: Geneva.
4. UNFPA, UNESCO, and WHO, Sexual and reproductive health of young people in Asia and the Pacific: a review of issues, policies and programmes. 2015, UNFPA: Bangkok.
5. PNG Government, National Population Policy 2015-2024. 2015: Port Moresby.
6. NDoH, PNG Youth and Adolescent Health Policy. 2014, NHoD: Port Moresby.
7. Sanga, K., et al., Unintended pregnancy amongst women attending antenatal clinics at the Port Moresby General Hospital. Aust N Z J Obstet Gynaecol, 2014. 54(4): p. 360-5.
8. PNG-DHS, DHS of Papua New Guinea 2006. 2009, National Statistics Office: Port Moresby.
9. Sanga, K., C. de Costa, and G. Mola, A review of maternal deaths at Goroka General Hospital, Papua New Guinea 2005-2008. Aust N Z J Obstet Gynaecol, 2010. 50(1): p. 21-4.
10. Asa, I., C. de Costa, and G. Mola, A prospective survey of cases of complications of induced abortion presenting to Goroka Hosp., PNG, 2011. Aust.NZJObst.Gyn., 2012. 52(5): p. 491-3.
11. WHO, Developing Sexual Health Programmes – A Framework for Action. 2010, World Health Organization.: Geneva.
12. WHO, Adolescent friendly health services: an agenda for change. 2002, WHO: Geneva.
13. UNICEF, The state of the world’s children 2015. 2015, UNICEF: New York.

Please note that blog posts are not peer-reviewed and do not necessarily reflect the views of RHM as an organisation.