Our study set out to answer two questions:
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(1)
What is the age distribution of first births to adolescents, and have the percentages of younger and older adolescent girls (10–14 and 15–19 years respectively) changed since 1990?
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(2)
How do the socio-economic characteristics (wealth and urban / rural residence) of young women having a first adolescent birth differ between younger and older adolescents and how have these characteristics changed over time?
Regarding the first question, our study finds very little evidence of marked progress in reducing adolescent first births in any of the countries. Indeed, in two countries (Colombia and Peru) there has been an increase and in a further two countries (Dominican Republic and Bolivia) the percentage has stagnated. It is particularly concerning to note the persistence, and in the case of Colombia increase, in births to young women under the age of 16 years. The implications of this are underlined by evidence that the risks of ill health and mortality to the mother and child associated with adolescent births are most concentrated within this age-group [4, 8].
Regarding the second question, our study clearly shows that adolescent first births remain concentrated among poorer and rural women, and in some countries these differentials have increased over time. Inequities between both wealth and place of residence have only decreased in Peru (although because wealth is measured at the time of survey, it is impossible to state categorically whether poverty is a cause or a result of adolescent motherhood). Younger adolescent mothers are also more likely to be poor and live rurally when compared to their older counterparts [4, 8], which further adds to their vulnerability [23].
Our finding of the limited reduction in adolescent first births in the five countries studied are consistent with those from other studies in the LAC regions, which describe stagnation or increases in the levels of teenage motherhood. For instance, a study by Rodriguez-Vignoli [17] found stagnation or increases in the proportion of women aged 15–19 years who were pregnant or had had a first child in a number of countries within the region during a similar period. It is interesting to note that stagnation in Dominican Republic and Bolivia occurs within the context of overall decline in ASFR 15–19 years . This gives further support to Rodriguez-Vignoli’s argument that such declines in LAC are driven by a reduction in the number of births to each adolescent, not the proportion of young women who become adolescent mothers in the first place [13]. Batyra’s study in Colombia [24] also demonstrates how successive cohorts of women are increasing the timing of subsequent births.
This lack of progress is clearly concerning: not only does this negatively impact the health and wellbeing of young women and their children [4, 7], it will have wider repercussions for families and communities and will also hinder progress towards the Sustainable Development Goals (SDGs). The adolescent fertility rate is an indicator for the third SDG: Ensure healthy lives and promote well-being at all ages. However, reducing adolescent pregnancies will also potentially contribute more widely to the SDGs through reducing the cycle of deprivation, as well as positively impacting on the goals focussing on poverty, hunger, quality education, gender equality and decent work and economic growth [5, 25,26,27,28].
The concentration of adolescent births to poorer mothers identified in this study is also in line with other work from the region [29, 30] that finds socio-economic inequalities persist in adolescent pregnancies. Bozon et al. [29] reflects that the traditional feature of marked inequality within Latin American societies translates into gross inequities in sexual experiences and outcomes. Further, our finding that younger adolescent mothers are also more likely to be poor and rural residents compared to their older counterparts are in line with similar findings in the East African context [23].
Our study clearly indicates the need for increased efforts to address adolescent births within these countries. As adolescent pregnancy is often underpinned by social, economic and cultural factors, it is increasingly understood that individual-level focused interventions are likely to have limited impact, and that it is vital to involve families, communities, and wider society [31]. As Caffe et al. have noted, addressing the issue of adolescent first births in LAC is likely to require a broad and multisectoral approach, and strategies that address both the proximal and the distal determinants of adolescent fertility within the LAC context have been widely supported [32].
Education is seen as a key component of multisectoral approaches to reducing adolescent births, and attempts to increase school enrolment through conditional cash transfers have had some success in both Colombia and Peru: both have improved school enrolment and there is some indication of reduced adolescent pregnancy [14]. However, there are no simple solutions. The relationship between education and adolescent pregnancy in LAC is complex, and advances in education coverage in some LAC countries have failed to reduce teenage pregnancies. Rogriguez-Vignoli and Cavenaghi’s study [33] found that the impact of education on adolescent pregnancy was not linear, and the threshold for impact increased from 5 years in the 1990s to 7 years in more recent periods. They highlight problems in the educational system whereby inequalities in quality persist, and where educational thresholds for employment have increased as much as, or more than, increases in average education, meaning many more disadvantaged young people are still excluded from the job market. In addition, complex social and cultural factors mitigate the relationship between education and adolescent pregnancy in LAC, including gender relationships and low aspirations.
In addition, adolescents need sexuality education that provides information and skills to protect themselves and avoid adverse health and social outcomes. The social and cultural aspects of adolescent pregnancy underline the importance of a holistic approach to sexuality education that addresses social and cultural norms including gender inequality and relationship dynamics [31]. Within the five countries there is wide variation in approaches to adolescent sexuality education: while Colombia has adopted many of the principles of comprehensive sexuality education (CSE), Peru and the Dominican Republic continue to focus on a much narrower curriculum [34].
Thirdly, adolescents need to be able to obtain contraceptive information and services, including emergency contraception. Rodriguez-Vignoli [13] highlights that lower rates of adolescent pregnancies in other countries with high rates of adolescent sexuality are driven by increased access to contraception and abortion. The First Latin American and Caribbean Regional Conference on Population and Development, held in Montevideo in August 2013 provided a forward-looking consensus, which agreed to the implementation of:
“…comprehensive, timely, good-quality sexual health and reproductive health programmes for adolescents and young people, including youth-friendly sexual health and reproductive health services with a gender, human rights, intergenerational and intercultural perspective, which guarantee access to safe and effective modern contraceptive methods, respecting the principles of confidentiality and privacy, to enable adolescents and young people to exercise their sexual rights and reproductive rights, to have a responsible, pleasurable and healthy sex life, avoid early and unwanted pregnancies, the transmission of HIV and other sexually transmitted infections, and to take free, informed and responsible decisions regarding their sexual and reproductive life and the exercise of their sexual orientation”) [35].
However, despite promising moves towards improving sexual and reproductive rights and services in the region, barriers remain for marginalized populations, including adolescents. Socio-economic inequalities in access remain problematic [36], and our findings relating to persisting socio-economic differences highlight the importance of improving access for the poorest and rural residents.
Finally, gender based violence (GBV) needs to be addressed effectively. GBV is a significant problem in much of LAC, and many of the adolescent births may result from coerced sexual contact or abuse from an adult male [28]. It is estimated that between 18% (Dominican Republic) and 43% (Bolivia) of women aged 15–19 years have experienced intimate partner violence (IPV) in the five countries within our study [37]. In all five countries, adolescent respondents aged 15–19 years had an increased risk of experiencing IPV in the previous 12 months than women aged 30–39 years [37]. Additionally, in some countries, reports of forced sexual debut are common. The link between IPV and adolescent pregnancy is clearly recognised in a number of strategies within the region, including the Mexican Adolescent Pregnancy Strategy [38], and most countries in the region now have national commissions to address violence against women. Some countries face particular challenges: in Haiti, where 21% of women aged 15–24 described their first experience of intercourse as “forced” or “rape” [37], a number of reports and studies point to increased SGBV, transactional sex and adolescent pregnancies among displaced communities and populations most affected by the earthquake in 2010 [39, 40]. Additionally, in Colombia many women are still suffering the effects of conflict and displacement, which creates specific problems and hinders progress [41].
Latin American countries have made strides in strengthening legislation around this issue, and there have been promising initiatives to promote change among law enforcement agencies, as well as developing interventions to support victims. A number of community- and school-based programmes have demonstrated success in changing violence-related attitudes and behaviours, and the gender norms that underpin this problem [42], which must be viewed as a vital component of strategies to reduce adolescent births.
Our study has a number of limitations, which reflect constraints in the data on which the analysis is based. Our study only relates to live births, and does not cover spontaneous or induced abortion. An estimated four million induced abortions take place in Latin America each year, despite the fact that it is highly restricted in all countries [43]. The vast majority of these abortions are likely to be unsafe. There is limited understanding on adolescents’ use of abortion in this region, and while data are collected in DHS (albeit without distinguishing induced abortion from other pregnancy loss) it is of very poor quality [44] so has not been included in this study.
As mentioned in the methodology section, there are a number of limitations associated with cross-sectional data that influence the interpretation of the findings. In particular, the characteristics of place of residence and wealth are measured at the time of the survey rather than at the time of the birth. This creates problems in interpretation: poverty could be either a driver or a result of adolescent motherhood. Furthermore, young women may migrate following a birth (either to live in a different household or to find employment) which also means the analysis of urban / rural residence should be interpreted with some caution.
It must also be noted that our data is somewhat dated, and may not reflect recent improvements resulting from efforts to address this issue or from wider social and economic changes. The adolescent births identified in the 20–24 year age group could have occurred up to about 10 years before the date of the survey, and some of the surveys themselves are already somewhat dated. At the time of writing the data had not been released for the Colombia 2015 DHS, but the preliminary report suggests that the proportions of women aged 15–19 at the time of survey who have either begun childbearing or are pregnant have fallen [45]. It is vital that new survey data is comprehensively analysed as it is published and additional sources are explored to ensure a contemporaneous picture of ongoing trends in the region.
