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