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“The only thing necessary for these diseases to the triumph is for good people and governments to do nothing.”

 

  
 

Adolescent Women Face Triple Jeopardy: Unwanted Pregnancy, HIV/AIDS
and Unsafe, Abortion
 
by Aruna Radhakrishna, M.A., Robert Gringle, M.Ed.,
Forrest Greensiade, Ph.D.
 
http://www.hsph.harvard.edu/ 
 
Taken from the Women's Health Journal (2/97) Latin American and Caribbean 
Women's Health Network
 
The authors are researchers at IPAS, a non-profit, non-governmental institution 
based in Carrboro, North Carolina, USA. IPAS seeks to improve women's 
health through a focus in reproductive health care, and they emphasize the 
right of all women to safe reproductive options and high quality care. IPAS 
works to prevent unsafe abortion, treat its complications and reduce its 
consequences, and to improve women's access to a wide range of reproductive 
services.
 
Introduction
 
New HIV infections and AIDS cases continue to increase in most developing 
countries, while the AIDS epidemic has most recently reached a plateau or 
shown signs of a slight overall decline in much of the developed world.  Where 
AIDS is increasing, new HIV infection is disproportionately high among young 
women who contract the virus through sexual intercourse.  Data presented at 
the XI International Conference on AIDS (Vancouver, Canada 1996) indicates 
that among these women, adolescents 15-19 years old form the highest risk 
group for newly acquired HIV infections.  This same group has the highest rate 
worldwide of unwanted pregnancy, pointing to a potentially significant 
epidemiological overlap of reproductive health risk.  M. Baldo, writing for the 
World Health Organization (WHO), estimates that 70% of the 3,000 women 
who become infected with HIV every day are between 15-24 years old, an age 
group that will account for over 50% of new HIV infections in the next decade.  
Most of these infections will occur in the developing world.  In addition, the 
International Center for Research on Women (ICRW) estimates that 60% of 
adolescent pregnancies and births in the developing world are unintended and 
by definition result from "unprotected" sexual intercourse.  When faced with an 
unwanted pregnancy, adolescent women have always found it difficult to obtain 
appropriate services to meet their needs, including safe abortion care.  The 
AIDS epidemic exacerbates these difficulties and adds new medical, legal and 
ethical dimensions to the practice of unsafe and illegal abortion procedures that 
put young women's health and lives in danger.
 
While HIV infection, unwanted pregnancy and unsafe abortion are concerns for 
adolescent women worldwide, this paper will focus on adolescent women living 
in the developing world, in order to emphasize the disproportionately high level 
of the problem there: according to R. Blum, writing in the Journal of the 
American Medical Association, by the year 2000, 83% of the world's youth will 
live in developing countries; and an estimated two million adolescent women in 
developing countries have illegal, unsafe abortions each year.
 
Although the international health community has acknowledged the need for 
increased attention to adolescent reproductive health, adolescent sexuality, 
contraceptive use and HIV/AIDS education, little effort has been made to study 
the intersection of adolescence and unwanted pregnancy in the age of AIDS; 
furthermore, the issues surrounding abortion, especially unsafe abortion among 
adolescent women and the AIDS-related health hazard involved have remained 
unexplored.  A review of data reported at the XI International Conference on 
AIDS and results from an informal survey IPAS conducted at the African 
Forum on Adolescent. Reproductive Health (Addis Ababa, Ethiopia 1997) 
reveal that health professionals, researchers, policy makers and educators in 
developed and developing countries involved in adolescent reproductive health 
and/or HIV/AIDS initiatives, have yet to seriously examine the implications of 
the connections between adolescent unwanted pregnancy, HIV infection and 
unsafe abortion.
 
Social Factors Contributing to HIV and Unwanted Pregnancy
 
The vulnerability to HIV infection and pregnancy that young women face in 
developing countries is strikingly similar and stems from myriad factors often 
beyond their control, including: physical violence and other forms of coercion; 
an earlier age of sexual initiation for girls than boys; so-called "sexual mixing" 
wherein young girls may have sex with older men for a variety of cultural and 
economic reasons; social pressures faced by young girls; the lack of access to 
formal education including sex education; the lack of access to contraception 
and reproductive health services; the high-risk sexual behavior of adolescent 
females' male partners; and young women's lack of power to negotiate the terms 
of sex with their partners. 
 
A large percentage of rape and sex abuse incidents are perpetrated against girls 
15 years old or younger; girls under 10 years old experience a disturbing rate of 
sexual assaults.  Women and girls are the most frequent victims of violence 
within the family or between intimates, and many young girls are subject to 
incestuous relationships which put them at risk for STDs/HIV and unwanted 
pregnancies.  Even when young women are in relationships with boyfriends, 
they are often threatened with rape if they are not willing to have sex.  Berer 
and Ray observe in Women and HIV/AIDS: An International Resource Book, 
that forced sex is almost always physically rough which puts young girls at 
higher risk of HIV infection, as ripping and tearing of the vaginal wall 
facilitates HIV transmission.
 
Additional studies indicate that girls often experience sexual intercourse at a 
younger age than boys, and they may have sex before menarche and with older 
men who have had multiple sex partners, increasing the risk of STDs/HIV and 
unwanted pregnancy.  Even if the vaginal wall is not damaged during 
intercourse, the United Nations Development Program (UNDP) reports that the 
immature genital tract of adolescent women puts them at risk for acquiring 
STDs/HIV, as it is a less efficient barrier to infection than that of older women.
 
Many girls engage in intercourse out of economic necessity and material gain.  
Some young women, for example, engage in sex with what are known in sub-
Saharan Africa as "sugar daddies": older men who seek out adolescent 
schoolgirls for sex in exchange for money or gifts.  Reportedly, the underlying 
reason many of these girls have these relationships is for money, which is often 
used to pay for their school fees, lunches or transportation.  Families often 
place a lower priority on educating their daughters than their sons, so girls may 
have to find ways to finance their own education.
 
Girls are often sought out by older, men for reasons in addition to sexual 
gratification: in many parts of the developing world it is believed that sex with 
a virgin can cure a man's STDs, including HIV.  In addition, older men seek 
out young girls based on the belief that girls with little sexual experience are 
less likely to have STDs/HIV.  A man who believes that a girl will take the 
STD/HIV from him when they have sex is unlikely to wear a condom, leading 
to another factor that increases the girls risk of contracting STDs/HIV, as well 
as becoming pregnant.
 
    
The socio-sexual expectations placed on adolescent women also contribute to 
their vulnerability.  Pressure to remain a virgin can paradoxically contribute to 
girls' risk of STD s/HIV and can act as a barrier to their adoption of preventive 
behaviors.  In much of the developing world, a high value is placed on a girl's 
virginity before marriage.  Girls who have sex before marriage may not be 
respected and may have difficulty in finding a husband.  ICRW interviewed 
adolescents from Recife, Brazil, who reported additional negative consequences 
of losing one's virginity: negative gossip; pressure from boys to have sex; and 
neighbors not allowing their daughters to play with non-virgins.  In instances 
where girls' virginity is highly valued, alternative sexual practices may be 
substituted for vaginal intercourse (breaking of the hymen is seen as the loss of 
virginity).  For example, in Brazil and Guatemala, adolescents practice anal sex 
as a means to protect a girl's virginity and prevent pregnancy.  This practice, 
however, provides a mode for HIV transmission that is often more efficient 
than infection transmission through vaginal intercourse.  In other cultures, girls 
are expected and encouraged to have vaginal sex at an early age, placing them 
at risk of infection.  The Alan
Guttmacher Institute reports that traditionally, in some parts of sub-Saharan 
Africa, sex before marriage is encouraged because young women are expected 
to prove their ability to bear children before establishing a union.
 
It is nearly impossible for adolescent women to protect themselves from HIV 
infection and unwanted pregnancies if they are not able to negotiate mutually 
agreed-upon terms under which sexual intercourse may occur: furthermore, 
adolescent-focused reproductive health care consistently suffers where there are 
biases on the part of adults and health providers regarding adolescent sexual 
activity.  If there are clinics willing to see unmarried adolescents, there are 
barriers that prevent these young women from seeking care, such as 
inaccessible location of services; cost; hours of operation; and judgmental 
behavior from health workers.  In addition, young and unmarried women are 
also reluctant to visit clinics for fear of seeing parents or friends there.
 
Even where adolescent women have access to education and reproductive 
health services, the sexual behavior of their partners and their own lack of 
power in relationships contribute to their risk of contracting HIV and becoming 
pregnant.  Young girls are often partnered with much older men.  As 
mentioned, the gap appears to be increasing as older men seek out younger and 
younger girls in the hope of avoiding AIDS.  Older men usually have had more 
sex partners than younger men and therefore have a greater chance of being 
infected with STDs/HIV.  In addition, non-monogamous heterosexual or 
homosexual behavior of men increases their partner's likelihood of contracting 
infection.  Due to the lack of acceptance of homosexuality in many cultures and 
the high value placed on having children, many men who engage in 
homosexual activity get married or have steady female relationships.  The 
hidden sexual activity outside of their relationships puts their partners at 
increased risk of infection.  Kost and Forrest, writing in Family Planning 
Perspectives, conservatively estimate that women are roughly at equal risk of 
exposure to STDs through the non-monogamous behavior of their male partner 
as they are through their own non-monogamous behavior.  The risk for 
adolescent women is especially high: Palloni and Lee told an experts group 
meeting in Vienna on HIV/AIDS and Women that a woman's probability of 
contracting HIV increases dramatically as her age at first intercourse goes 
down and/ or the age difference between her and her partner goes up.  
Adolescent women who are paired with older men have even less power than 
older women in the relationship and have more to lose; therefore, they may be 
afraid to confront their husband's or partner's extramarital affairs.  Women 
throughout the developing world express a sense of helplessness over their 
inability to change their partner's sexual behavior.
 
This lack of power goes even further as females are not able to negotiate the 
terms of sex with their partners.  Condom use is important for women, as it 
may prevent pregnancy as well as STD/HIV transmission.  However, the 
decision to wear a condom is often solely that of the man, and women are often 
not able to convince their partners to use condoms, let alone introduce the topic 
of condom use.  The availability of a female condom should increase the 
prevention options available to women, and the UNFPA periodical Populi 
reported that P. Plot, Director of UNAIDS, has announced results of feasibility 
research that suggest it can be practical in developing countries.  However, 
acceptance/ use by adolescent women has not been studied.  Regardless of 
which sex partner uses a condom, the pervasive social and cultural barriers that 
prevent women from raising the subject of condom use with their partners are 
particularly acute during adolescence.  These barriers include: emotional issues, 
fear of abandonment; physical abuse; and accusations of infidelity. Population 
Reports found that men and women from the Caribbean, sub-Saharan Africa 
and Sri Lanka were in agreement that the use of condoms symbolized distrust 
between partners, rather than care and concern.  Some men believe that a 
woman's desire to use any form of birth control means she intends to be 
unfaithful.  The connection to infidelity is even stronger regarding condom use, 
which is widely associated with promiscuity, prostitution and disease in many 
parts of the world.  Women widely believe that their requesting condom use 
either implies their own promiscuity or is interpreted as an accusation of 
promiscuity on the part of their partners.  Such inferred accusations may trigger 
violent reactions.  Adolescent women may experience even more difficulty in 
raising the issue of condom use: they have less negotiating power with their 
partners, fewer communication/negotiation skills and, therefore, are more likely 
not to confront the issue of using condoms.
 
Adolescent Unwanted Pregnancy, Unsafe Abortion and HIV/AIDS
 
Young women resort to illegal, unsafe abortion for a number of reasons: fear of 
not meeting societal and familial expectations; strict anti-abortion laws; lack of 
financial and health resources; a strong desire not to have a baby; and lack of 
education and misinformation from peers and some adults.  Young women who 
give birth before marriage may be disowned by their families and left with the 
responsibility of raising the child by themselves.  The level of education a girl 
receives may also be affected if her unwanted pregnancy results in a birth.  In 
many developing countries, a girl who becomes pregnant is expected to assume 
a role based solely on care for her baby, which presumes she will not be 
attending school: pregnant girls are frequently expelled from school and are 
usually strongly discouraged from continuing with their education.  Of the 50 
million induced abortions worldwide every year, more than one-third are 
illegal, and nearly half of all abortions are performed outside of the health care 
system.
 
In developing countries, almost one-third of women live in countries where 
abortion is legally available only to save a woman's life.  Laws and policies that 
restrict abortion generally have the effect of providing barriers to safe abortion 
care.  Even where abortion laws are less restrictive, abortion services are not 
always available to women, let alone to adolescent women.  In India, where 
abortion has been legal since 1972, limited availability and poor quality has 
kept many women from receiving safe abortion care.  S. Jejeebhoy revealed in a 
recent ICRW working paper that unmarried Indian adolescents constitute a 
disproportionately large proportion of abortion seekers in rural and urban areas.  
In addition, at least half of unmarried women seeking abortions are 
adolescents, many of whom are under 15 years old.  Furthermore, in many 
countries, adolescents often do not have the money or transportation necessary 
to obtain abortions, or they must receive parental consent.
Providers may be biased against adolescents, imposing moral judgments instead 
of providing them with the health care they need.  Adolescent women are also 
discouraged from seeking care for fear of providers lack of confidentiality.  
Adolescents worry that their parents, relatives or friends might find out about 
services or procedures they have obtained.  Adolescents are part of the group of 
women who do not have access to abortion services, therefore also suffering 
from complications of unsafe abortion.  Not only are safe abortion services 
scarce in the developing world, but the International Center on Adolescent 
Fertility found that, where abortions are provided, adequate post-abortion 
counseling and contraceptive services are not available, thus increasing the 
probability of repeat abortions.
 
The typical adolescent seeking abortion in developing countries is likely to be 
in her late teens or early twenties, although she could be as Young as 10 or 11 
years old.  The younger she is, the greater the chance that abortion will occur 
after the first trimester with a non-medical provider, or that it will be self-
induced.  Adolescent women delay obtaining an abortion until later stages in 
their pregnancies, due to difficulty in finding a provider or obtaining financial 
resources for the procedure, and they are slower to seek medical care once 
complications arise.  Delaying abortion has been shown to increase risk to 
health.  B. Barnett pointed out in Network that there are many adolescent 
women who suffer complications of unsafe abortion who never arrive at 
hospitals; dying en route or at home.
 
Due to the lack of resources for abortion care, adolescent women often resort to 
whatever options are available to them to end their pregnancies.  This often 
involves receiving misinformation as well as utilizing information about 
procedures that are dangerous and sometimes deadly.  Adolescent women may 
seek advice from traditional healers or local village  "experts" on how to 
terminate their pregnancies.  In attempting to self-abort, they may resort to 
taking a wide range of poisonous chemicals, or they may insert sticks or roots 
into their cervixes.  Others may submit their bodies to untrained practitioners 
who use unclean instruments to scrape out their uteri.  As a result of these 
unsafe practices, many women suffer crippling medical complications, the most 
common being incomplete abortion, sepsis, hemorrhage, uterine perforation 
and cervical trauma.  Even if adolescent women survive unsafe abortion 
procedures, they still have the potential risk of having been infected with HIV 
through the unsterilized instruments used during procedures.  The demand for 
abortion services could grow as more women discover their HIV status and 
understand the risk of perinatal transmission.  E. Preble, et al., writing in AIDS 
CARE, hypothesized that without safe abortion services, the increased demand 
for abortion from women with HIV/AIDS could lead to more septic abortions, 
resulting in severe morbidity and death.  Noble, et al, found that in some 
countries complications from unsafe abortions are the leading cause of death 
among adolescent women: in Chile and Argentina, more than one-third of 
maternal deaths among adolescents are a direct result of unsafe abortion; a 
Ugandan study found that almost 60% of abortion-related deaths are among 
adolescent women; one-third of women in Peru hospitalized for abortion 
complications are adolescent women ages 15-24 years, and it is the third 
leading cause of maternal death.
 
Existing epidemiological data provides substantial evidence that the health 
risks adolescent women face relative to unwanted pregnancy and unsafe 
abortion are certain to be exacerbated by the AIDS epidemic.  A 1996 U.S.A 
Department of Commerce report on trends in adolescent fertility and 
contraceptive use in the developing world estimates that one-half of all HIV 
infections affect women who are under 25 years old; 40 to 50% of these 
infections occur in those between 15 and 19 years olds.
 
In addition, the Family and Reproductive Health unit of WHO implicates 
female genital mutilation (FGM) as a threat for HIV infection.  Girls who live 
in cultures where FGM is prevalent usually undergo the procedure between four 
and twelve years of age.  According to WHO, complications include: bleeding, 
which can lead to hemorrhage; exposure to infection; urine retention; and 
shock.  Furthermore, infibulated women must undergo the process of cutting 
and restitching; they must be cut in order to have intercourse and a larger cut is 
necessary to allow childbirth.  FGM is often performed in non-clinical settings, 
by unskilled practitioners, and with unsterile instruments including scissors, 
razors and broken glass. Although there is no evidence that FGM is a major 
contributor to the spread of HIV infection, the risk still exists, as group 
circumcisions using the same unclean instruments are common.  Repeat cutting 
and stitching also poses a risk for infection from unclean instruments, as well 
as increases the possibility of anal intercourse due to the closed vaginal 
opening, which increases the risk of AIDS.
 
The work of J. Wasserheit and others has established that the likelihood of HIV 
transmission may increase three to fivefold for those who have another STD.  
Adolescent women, who often do not have access to resources and reproductive 
health care, are especially at risk of having untreated STDS.  Women are at a 
greater risk than men of having an untreated STD because many STDs are 
asymptomatic in women.  WHO estimates that 50% of women with 
trichomoniasis, and up to 80% of women with gonorrhea or chiamydia, have no 
symptoms and are thus less likely to receive treatment.  furthermore, Noble, et 
al, conclude that adolescent women exposed to HIV through sexual intercourse 
prior to genital maturation face a greater risk of infection due to the physical 
immaturity of their reproductive system.  There has been a lack of information 
on pregnancy and abortion-related outcomes in HIV-positive adolescent 
women, but studies using older women point to negative outcomes.  One brief 
but significant published communication by Kuman et al, reported on AIDS in 
pregnancy among tribal women in India.  The women studied who were 
diagnosed with AIDS at the beginning of their pregnancies ranged in age from 
16 to 32 years the mean age was 17 years.  Within this group, 16% of the 
women died within 14 weeks of an uneventful (legal and safe) first trimester 
abortion: 41% died undelivered between 30-34 weeks gestation.  In an attempt 
to provide a comparative group with pregnancy as the variable, an equal 
number of women with AIDS who were not pregnant were followed during the 
study.  Overall, 27% of these women died during the time frame of the study 
compared to 56% of the pregnant women with AIDS.  The study also reported a 
negative outcome for the pregnancies that resulted in live deliveries, with 82% 
of the infants who died within six weeks of birth being diagnosed with an 
AIDS-defining illness.  The degree of observed infant mortality adds credence 
to reports of HIV-positive women being forced to have abortions.  There is 
anecdotal evidence of HIV-positive women being given false information about 
HIV/AIDS to convince them to agree to abortion.  These reports are certainly 
plausible in the developing world where health care providers observe a high 
death rates among infants born to HIV-positive women.  Conversely, Berer and 
Ray point out that when HIV-positive women who are not coerced request 
medical abortions they are frequently turned down by providers who refuse to 
treat patients with HIV.  This in particular could be devastating for adolescent 
women, leading them to pursue unsafe abortion practices.  In addition, 
adolescent women are at an even greater risk of complications related to HIV 
and pregnancy.  For example,  a 1995 Lancet article by D Verkuyl reported that 
30% of 15 - 19 year old pregnant girls studied in Zimbabwe were HIV positive 
in a country where 80 - 90% of adolescents live in rural areas and where 
community-based health care facilities do not provide contraceptive services to 
unmarried people, it is nearly impossible for adolescents to protect themselves 
from STDs/HIV and unwanted pregnancy as a result.  Adolescent women are 
unrelentingly faced with the triple jeopardy of HIV, unwanted pregnancy and 
unsafe abortion.
 
Examining the Unmet Need
 
The XI International Conference on AIDS provided a forum for confirming 
much of what was known or projected about the global response to the AIDS 
epidemic - as of 1995, nearly 98% of new HIV infections have occurred in 
developing countries, however, as of mid-1996, almost 100% of AIDS 
treatment-based medical/scientific research still occurs in developed countries.  
Epidemiological reports released at the conference further document this 
disparity between the countries most affected by the epidemic and the countries 
where research has been  conducted.   As of mid-l 996, 60% of all people with 
HIV infection live in sub-Saharan Africa, where the epidemic has progressed to 
its most devastating level.  The official Satellite Symposium Final Report at 
Vancouver, "The Status and Trends of the Global HIV/AIDS Pandemic" points 
out that the rate of newly acquired HIV infections in sub-Saharan Africa is 
highest among adolescents 15-24 years old, with most of these infections 
occurring among females 15-19 years old.  Nonetheless, a review of the two 
volumes of abstracts from Vancouver reveals that sub-Saharan African 
adolescents have been virtually excluded as a participant group in treatment-
based studies and as a group in need of future treatment study participation.
 
The proceedings from the Vancouver conference did, however, contain some 
incipient discussion on abortion as an AIDS-related factor.  This shift in focus 
may be partly attributed to the impact of the proceedings of the International 
Conference on Population and Development (ICPD, Cairo 1994) where the 
public health threat posed by unsafe abortion was officially recognized, 
followed by the Platform for Action adopted at the Fourth World Conference on 
Women (Beijing 1995), emphasizing the portions of the ICPD platform that 
had a strong emphasis on HIV/AIDS and pregnancy.  In February 1997, J. 
Liljestrand, the Director-designate of the WHO Maternal Health and Safe 
Motherhood Program, used the UNFPA's Populi periodical to propose 
operationalizing portions of the ICPD Cairo Program of Action by focusing on 
six components of reproductive health in addition to the traditional 
maternal/perinatal care and family planning.  Adolescents, abortion and STDs 
including HIV/AIDS were among the components discussed.  An 
epidemiological review article in the April 10, 1997, New England Journal of 
Medicine recommended a combination of approaches to prevent the sexual 
transmission of HIV, including addressing pregnancy in women and 
sociological factors within various societies.  While these acknowledgments of 
the importance of intersecting factors represent hopeful signs, the need remains 
for a consistent, coherent international voice calling for the development of an 
understanding of the dimensions surrounding the intersection of adolescent 
unwanted pregnancy, HIV/AIDS and abortion and formulating a response to 
this problem.
    
 
International forums and conferences addressing one or more of these issues 
could play an important role in calling attention to the intersection and 
formulating a cohesive response.  For example, the 1997 Adolescent 
Reproductive Health Forum convened by the UNFPA Africa Division, held in 
Addis Ababa, Ethiopia provided the opportunity for networking and the 
building of new knowledge to address adolescent reproductive health 
throughout Africa and has taken recognition of the intersection one step closer 
to official acknowledgment.  Over 500 participants - both adolescents from 48 
sub-Saharan African countries and health care professionals from around the 
world - attended the conference.  Although no references to the connections 
between adolescents, HIV/AIDS and unsafe abortion were included in the 
approved final draft statement from the Forum, the document did contain two 
significant statements regarding abortion, with some connection to HIV/AIDS.  
Under "Policy and Legislation:" Governments should therefore formulate 
comprehensive adolescent reproductive health policies and integrate them in 
existing policies [by addressing] issues affecting adolescents such as: easing 
restrictive abortion laws, [and] preventing discrimination against certain 
groups, e.g. people with HIV/AIDS, gays and lesbians.  Under "information, 
Education and Communication (IEC) Activities:" [IEC materials must] include 
all relevant issues, such as sexuality, STD/HIV/AIDS, unwanted pregnancies 
and early childbearing, unsafe abortion, contraception, and responsible 
behaviour.
 
In addition, an attempt to assess the need for examining the links between 
adolescents, HIV/AIDS and unsafe abortion was made at the Forum.  IPAS 
conducted a four page sample survey among conference participants: one 
survey was specifically designed for youth participants and another for health 
professionals.  Eighty surveys were distributed; 40 for youth and 40 for 
professionals; 42 surveys were returned before the Forum concluded, for a 
return rate of 53%.  In the context of the survey, an adolescent was defined as a