Adolescent fertility is an important indicator of the state of ASRHR. Although there are many components of ASRHR, we focused on adolescent fertility for the purpose of summarizing the key challenges faced today:

• Regional disparities: Since 1960, the global adolescent fertility rate has declined by half, but notable disparities exist today at the regional level.¹⁰  These disparities are most pronounced in sub-Saharan Africa, where the fertility rate is higher than in all other regions and more than twice the global average.
• Unique barriers: Several factors contribute to adolescent fertility and reveal the unique barriers that adolescents face because of their age. These include child marriage, lack of access to contraception, and lack of accurate and complete sexual and reproductive health (SRH) information.
• Long-term impacts: Girls who become pregnant are more likely to experience health complications before and during childbirth, and their children are at a much higher risk of infant mortality. In the long term, young mothers are more likely to suffer from social bias, limited education, and reduced economic prospects.

Regional disparities:

Sub-Saharan Africa

Since 1960, the global adolescent fertility rate has declined by half, from 86 births per 1,000 adolescents to 42 in 2019.¹⁰ Across regions, adolescent fertility rates have been declining for decades. For example, in sub-Saharan Africa the fertility rate declined by 35%, from 154 to 100.¹⁰ The rate in South Asia fell even more sharply, by nearly 80%, to 23 births per 1,000 adolescents, and in Middle East and North Africa, it declined about 72% to 39 births per 1,000 adolescents between 1960 and 2019.

Even as the fertility rate falls in sub-Saharan Africa, the total number of adolescent girls giving birth is increasing as the population in the region swells. About 5.8 million adolescent girls ages 15–19 gave birth in sub-Saharan Africa in 2019, compared with 1.7 million in 1960.¹⁰

Unique barriers:

Contraception services and SRH information

Lack of access to contraception services and accurate SRH information is one of the leading drivers of adolescent fertility. Among women in low- and middle-income countries who did not want to become pregnant, about 43% of adolescent girls said they had an unmet need for modern contraception, higher than 24% of all women ages 15–49.⁵ In sub-Saharan Africa and South Asia, for example, less than half of adolescent girls who expressed a need for family planning had that need met using modern contraceptive methods.¹¹ This is despite the fact that women ages 15–24 in sub-Saharan Africa are more likely to report intention to use contraceptives than those ages 35 and older (3.72 higher odds, according to one study).¹²

Adolescents face more barriers to accessing care and information due to social norms and biases surrounding their age and marital status.¹³ Services could require parental or spousal consent and be cost prohibitive, and confidentiality may not be guaranteed.¹⁴

Child marriage

Adolescent fertility is higher in communities where child marriage is more common, such as in sub-Saharan Africa and South Asia.

Percentage of women aged 20–24 married or in union before age 18

Adolescent girls who marry early have less decision-making power over their reproductive choices compared with peers who marry later, and more are subjected to intimate partner violence.¹⁵

They also face different barriers to accessing modern contraception amid greater societal pressure to prove their fertility and reduced autonomy to negotiate family planning choices with their partners.

Comprehensive sexuality education

Comprehensive sexuality education equips adolescents with the knowledge and ability they need to make healthy choices. Yet access is unequal, and many students say their school does not teach the subject well.¹⁶

Although 85% of 155 countries surveyed by UNESCO (United Nations Educational, Scientific and Cultural Organization) had policies or laws in place relating to sexuality education, the quality and range of topics covered varied greatly, undercutting its effectiveness.¹⁶ Some of this variation was due to differing ideas between and within countries as to what constitutes sexuality education. Other reasons included insufficient teacher training and teaching materials.

Even among students who received quality education, many would have preferred having the sexuality curriculum introduced in school sooner.¹⁶ The power of sexuality education is also weakened when young people are unable to act on the information because they lack access to services including modern contraception or safe abortion.

Long-term impacts:

Health risks

Pregnancy and childbirth complications are the leading cause of death of adolescent girls ages 15–19 worldwide.¹⁰ Pregnant adolescents are more likely than women ages 20–24 to experience complications and mortality during childbirth due to physiological reasons, poor nutrition, and lack of access to health care. The list of possible complications for pregnant girls is long, particularly in low- and middle-income countries where access to quality prenatal care is challenging. In addition, abortions are often performed in unsafe conditions. Babies born to adolescents are also at higher risk of low birth weight and severe neonatal conditions.

Top five causes of death for female adolescents globally

Education

Adolescent pregnancy perpetuates poverty because it forces many young women to leave school, thereby decreasing their opportunities for economic advancement and reducing their lifetime earnings.¹⁰

Lack of education is also a cause for adolescent pregnancy. When girls are not in school, their opportunities for personal and professional growth are curtailed, thus increasing the likelihood they will marry and have children early and have more children overall.¹⁷ Thus, there is a strong relationship between educational attainment and adolescent fertility rates across countries.

Female mean years of schooling as a function of adolescent fertility rate (2021)

We share the global goals set by the Family Planning 2030 partnership and the UN Sustainable Development Goals: to support and safeguard adolescent rights to sexual and reproductive health (SRH) services, including access to modern contraception.¹⁸

FP2030 commitments emphasize the importance of educating adolescents about SRH, supporting their ability to make and act on their decisions, improving their access to SRH services, and building an SRH-friendly policy and social environment.¹⁸

The UN Sustainable Development Goal target 3.7 on sexual and reproductive health states: “By 2030, ensure universal access to SRH services, including for family planning, information and education, and the integration of reproductive health into national strategies and programs.”¹⁹ This goal is measured by tracking two indicators: the proportion of women of reproductive age (15–49) who have their need for family planning satisfied with modern methods, and the adolescent birth rate (ages 10–14 and 15–19) per 1,000 adolescents.

There is also a need to treat adolescent health as its own standalone subject, as outlined in the Global Accelerated Action for the Health of Adolescents guidance from the World Health Organization. The guidance seeks to make adolescent health and development an integral part of public health programs and outlines adolescent-specific goals, including a focus on SRH.

ASRHR is also important for achieving progress across other health issues. Exemplars in Global Health research teams across various topics have found that decreases in adolescent fertility can explain progress in stunting, neonatal and maternal mortality, and under-5 mortality,²¹ for example.

Our partners are leading research on ASRHR in Exemplar countries to understand the drivers behind progress in this area, including health care, education, and policy interventions. This research will also explore the strategies used to address ASRHR among vulnerable adolescents, including very young adolescents (ages 10–14), adolescents with disabilities, and hard-to-reach adolescents in remote areas.