93543 Knowledge Brief Health, Nutrition and Population Global Practice SOCIOECONOMIC DIFFERENCES IN ADOLESCENT SEXUAL AND REPRODUCTIVE HEALTH: SEXUAL ACTIVITY Jennifer Yarger, Diana Lara, Mara Decker and Claire Brindis January 2015 KEY MESSAGES:  Early age at sexual debut puts young people – particularly females – at an increased risk for unplanned pregnancies, sexually transmitted infections, maternal mortality and morbidity.  An analysis of data from six countries shows that adolescent sexual activity is closely tied to marital status. In all six countries studied, nearly all ever-married adolescent women have had sexual intercourse, but almost all those never-married have abstained, except in Burkina Faso and Nigeria where less than one quarter of never-married women have had sexual intercourse.  The age at sexual debut is also closely linked to age at marriage. Over one third of ever-married women had sexual intercourse before age 15 in Nigeria (38 percent), Bangladesh (37 percent), and Niger (37 percent).  In Burkina Faso and Nigeria, sexual activity is lowest among never-married adolescent women with no education (15 percent and 7 percent, respectively). Introduction Miller, and Ford, 2005), and in most countries, sexual activity among adolescents typically occurs within Adolescent Sexual and Reproductive Health (ASRH) is marriage. one of five areas of focus of the World Bank’s Reproductive Health Action Plan 2010–2015 (RHAP), Available regional data indicate that sexual debut and which recognizes the importance of addressing ASRH as activity ranges between 13 and 19 years of age in Latin a development issue with important implications for America and the Caribbean (LAC) (PAHO, 2013); and 17 poverty reduction. Delaying childbearing and preventing and 22 years in East Asia and the Pacific (Kennedy, Gray, unintended pregnancies during adolescence has been Azzopardi, and Creati, 2011). shown to improve health outcomes and increase opportunities for schooling, future employment, and This brief is part of a larger study whose purpose is to: (i) earnings (Greene and Merrick, 2005). highlight the multisectoral determinants of ASRH outcomes; (ii) explore further the multisectoral supply- and Sexual activity is a key factor contributing to adolescents’ demand-side determinants of access, utilization, and reproductive health. Premarital sex and early sexual provision of services relevant to identified ASRH debut are associated with higher risk of unintended outcomes; and (iii) identify multisectoral programmatic pregnancies and sexually transmitted infections (STIs) and policy options to address critical constraints to during adolescence (Bearinger, Sieving, Ferguson, and improving ASRH outcomes. The goal is to incorporate the Sharma, 2007; Hindin and Fatusi, 2009; Kaestle, Halpern, main findings and recommendations from these studies into existing and new World Bank lending operations Page 1 HNPGP Knowledge Brief  while simultaneously informing ASRH policies, policy Figure 1. Percentage of women aged 15–19 who have dialogue and interventions for inclusion in country ever had sexual intercourse, by country and marital strategies. history Ever-married women Never-married women Using data from the most recent Demographic and Health Surveys (DHS) on female respondents ages 15 –19, this brief examines the current status of adolescent sexual 99% 100% 96% 99% 99% 100% activity and compares indicators of sexual activity by socioeconomic status (SES) in 6 countries: Bangladesh, Burkina Faso, Ethiopia, Nepal, Niger, and Nigeria. Cross tabulations between socioeconomic characteristics 24% and sexual activity outcomes for never-married and ever- 18% married adolescent women within each country were 3% 1% 2% completed if at least 10 percent of the subpopulation (for example, never-married women in Nepal) reported an outcome. Pearson’s chi-squared tests were used to assess the statistical significance of differences in sexual activity outcomes by rural/urban residence, education level, employment status, and household wealth quintile. *Only ever-married women were surveyed in Bangladesh. Throughout the report, only differences significant at the Source: Bangladesh DHS 2011; Burkina Faso DHS 2010, Ethiopia DHS 0.05 level (two-tailed tests) are discussed. All data in this 2011, Nepal DHS 2011, Niger DHS 2012, Nigeria DHS 2008. report are weighted. Among never-married adolescent women in Nigeria, more Study Findings working women have had sexual intercourse (35 percent) than their non-working counterparts (21 percent). Further, EVER HAD SEXUAL INTERCOURSE there is no clear pattern of adolescent sexual activity by rural/urban residence. Among never-married adolescent Figure 1 presents the percentage of ever-married and women in Nigeria, having had sexual intercourse is more never-married adolescent women who have had sexual common in rural (27 percent) than urban areas (20 intercourse. As expected, there is an exceptionally strong percent). The opposite is true in Burkina Faso: having had association between marriage and adolescent sexual sexual intercourse is more common in urban (24 percent) activity. In all countries nearly all ever-married adolescent than rural areas (13 percent). women have had sexual intercourse. In comparison, less than three percent of those who have never married have had sexual intercourse in Ethiopia, Nepal, and Niger. SEXUAL INTERCOURSE BEFORE AGE 15 Sexual activity is more common among never-married adolescent women in Burkina Faso (18 percent) and Initiating sexual activity at an early age increases Nigeria (24 percent). women’s years of exposure to unplanned pregnancy and STIs. Figure 2 shows the percentage of ever-married and Significant socioeconomic differences in sexual activity never-married adolescent women who had sexual among never-married adolescent women in Burkina Faso intercourse before age 15. Among ever-married and Nigeria were found. In both countries, sexual activity adolescent women, over one third had sexual intercourse is lowest among never married adolescent women who before age 15 in Bangladesh (37 percent), Niger (37 have not had any education (15 percent in Burkina Faso; percent), and Nigeria (38 percent). In comparison, less 7 percent in Nigeria) and highest among those with than one percent of never-married adolescent women had primary education (25 percent in Burkina Faso; 28 sexual intercourse before age 15 in Ethiopia, Nepal, and percent Niger. Early sexual debut among never-married adolescent women is most common, although still Sexual activity among never-married adolescent women relatively rare, in Nigeria (6 percent) and Burkina Faso (2 tends to increase with wealth in both Burkina Faso and percent). Nigeria. However, in Nigeria, the wealthiest never-married women have the lowest incidence of sexual intercourse (18 percent), as compared to 27 percent in the second wealthiest group and 23 percent in the poorest group. Page 2 HNPGP Knowledge Brief  Figure 2. Percentage of women aged 15–19 who had Household wealth is negatively associated with sexual sexual intercourse before age 15, by country and intercourse before age 15 in Bangladesh, Burkina Faso, marital history Ethiopia, and Nigeria (Figure 4). Ever-married women Never-married women Figure 4. Percent of ever-married women aged 15–19 37% 37% 38% who had sexual intercourse before age 15, by country and wealth quintile 31% 50 45 19% 16% 40 35 6% 30 Percent 2% <1% <1% <1% 25 20 15 10 5 *Only ever-married women were surveyed in Bangladesh. 0 Source: Bangladesh DHS 2011; Burkina Faso DHS 2010, Ethiopia DHS Poorest Poorer Middle Richer Richest 2011, Nepal DHS 2011, Niger DHS 2012, Nigeria DHS 2008. Bangladesh* Burkina Faso* Ethiopia* Early sexual debut among adolescent women (regardless Nepal Niger Nigeria* of marital status) is associated with rural residence, less *Statistically significant difference (p<.05) wealth, and less education in some of the countries Source: Bangladesh DHS 2011; Burkina Faso DHS 2010, Ethiopia DHS studied. Education tends to be negatively associated with 2011, Nepal DHS 2011, Niger DHS 2012, Nigeria DHS 2008. sexual intercourse before age 15 in all countries except Burkina Faso, but the relationship is not always linear. In In Burkina Faso and Ethiopia, significantly fewer ever- Bangladesh and Nepal, ever-married adolescent women married adolescent working women had sexual with incomplete primary education had the highest intercourse before age 15 than their non-working incidence of sexual intercourse before age 15 (47 percent counterparts. The opposite is true in Bangladesh (Figure and 27 percent, respectively) (Figure 3). 5). Figure 3. Percentage of ever-married women aged 15– Figure 5. Percent of ever-married women aged 15–19 19 who had sexual intercourse before age 15, by who had sexual intercourse before age 15, by country country and education level and employment status 50 60 40 50 40 30 Percent Percent 30 20 20 10 10 0 0 None Incomplete Complete More than Not working Working primary primary primary Bangladesh* Burkina Faso Ethiopia* Bangladesh* Burkina Faso* Ethiopia* Nepal* Niger* Nigeria* Nepal Niger Nigeria *Statistically significant difference (p<.05) *Statistically significant difference (p<.05) Source: Bangladesh DHS 2011; Burkina Faso DHS 2010, Ethiopia DHS Source: Bangladesh DHS 2011; Burkina Faso DHS 2010, Ethiopia DHS 2011, Nepal DHS 2011, Niger DHS 2012, Nigeria DHS 2008. 2011, Nepal DHS 2011, Niger DHS 2012, Nigeria DHS 2008. Page 3 HNPGP Knowledge Brief  More ever-married adolescent women had sexual agencies and donors to continue to improve SRH in intercourse before age 15 in rural areas than urban areas developing countries. in Niger (38 percent versus 19 percent) and Nigeria (40 percent versus 28 percent). References Policy Challenges Bearinger, L.H., R.E. Sieving, J. Ferguson, and V. Sharma. 2007. Global Perspectives on the Sexual and Reproductive Early age at sexual debut puts young people, particularly Health of Adolescents: Patterns, Prevention, and Potential. The females, at an increased risk for negative SRH outcomes Lancet, 369(9568), 1220-1231. including, STIs and unintended pregnancies (Bearinger et al., 2007; Hindin and Fatusi, 2009; Kaestle et al., 2005). Fewer, S., J. Ramos, and D. Dunning. 2013. Economic Empowerment Strategies for Adolescent Girls: A Research The World Bank is working to improve ASRH through its Study Conducted for the Adolescent Girls’ Advocacy and RHAP by supporting better access to, and provision of, Leadership Initiative. Oakland, CA: Public Health Institute. affordable ASRH services and strengthening monitoring and evaluation of these services and interventions. Post- Greene, M.E., and T. Merrick. 2005. Poverty Reduction: Does 2015, the World Bank is working to ensure Universal Reproductive Health Matter? HNP Discussion Paper. Washington, DC: The World Bank. Health Coverage (UHC) of SRH by helping countries build healthier, more equitable societies. To do this requires the Hindin, M.J., and A.O. Fatusi. 2009. Adolescent Sexual and following, adapted to each country’s unique needs: Reproductive Health in Developing Countries: An Overview of Trends and Interventions. International Perspectives on Sexual and Reproductive Health, 35(2), 58-62.  Scaling up the most effective ways to incentivize demand for ASRH, including family planning at the Kaestle, C.E., C.T. Halpern, W.C. Miller, and C.A. Ford. 2005. country level Young Age at First Sexual Intercourse and Sexually Transmitted Infections in Adolescents and Young Adults. American Journal  Delivering on the continued need to strengthen of Epidemiology, 161(8), 774-780. country capacity Kennedy, E, N. Gray, P. Azzopardi, and M. Creati. 2011.  Leveraging the World Bank’s multisectoral advantage Adolescent Fertility and Family Planning in East Asia and the to improve ASRH outcomes, including SRH as a tool Pacific: A Review of DHS Reports. Reproductive Health, 8(11). for women’s empowerment Pan American Health Organization (PAHO). 2013. 2012  Reaching the poorest, marginalized, and vulnerable Progress Report: Elimination of Mother-to-Child Transmission of populations to facilitate access to health services and HIV and Congenital Syphilis in the Americas. Washington, DC: PAHO. promote UHC and equity Conclusion This brief highlights the socioeconomic disparities that exist in adolescent sexual activity. The results indicate the importance of investing in interventions aimed at delaying This Knowledge Brief was prepared by a World Bank team marriage which, in turn, delays sexual activity and including: Rafael Cortez (Task Team Leader), Mara Decker, Claire childbearing. Disparities in early sexual debut by wealth Brindis, Jennifer Yarger and Diana Lara (University of California, and education suggest the need to continue to invest in San Francisco); and Meaghen Quinlan-Davidson (Consultant, World Bank). This note was prepared as part of a series of products of the female education and economic empowerment. Programs World Bank’s Economic Sector Work on Adolescent Sexual and need to go beyond placing women into jobs and ensure Reproductive Health (P130031) funded by the World Bank- that they are receiving the skills, training, and access to Netherlands Partnership Program (BNPP). financial services and support that are needed for long- term economic advancement, which in turn impacts gender roles and power dynamics (Fewer, Ramos, and Dunning, 2013). These findings reinforce the importance of efforts by countries, the World Bank, and other The Health, Nutrition and Population Knowledge Briefs of the World Bank are a quick reference on the essentials of specific HNP-related topics summarizing new findings and information. These may highlight an issue and key interventions proven to be effective in improving health, or disseminate new findings and lessons learned from the regions. 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