Objectives
WHO guidelines on preventing early pregnancy and poor reproductive outcomes among adolescents in developing countries aims to improve adolescent morbidity and mortality by reducing the chances of early pregnancy and its resulting poor health outcomes.
The publication's two main objectives are to:
identify effective interventions to prevent early pregnancy by influencing factors such as early marriage, coerced sex, unsafe abortion, access to contraceptives and access to maternal health services by adolescents; and
provide an analytical framework for policy-makers and programme managers to use when selecting evidence-based interventions that are most appropriate for the needs of their countries and contexts.
Rationale
Adolescent maternal mortality and morbidity represent a substantial public health problem at the global level. Adolescents who are 15–19 years of age are twice as likely to die during pregnancy or childbirth compared to women over 20 years of age; adolescents under 15 years of age are five times more likely to die during pregnancy or childbirth (1). An estimated 2.0–4.4 million adolescents in developing countries undergo unsafe abortions each year (2). Additionally, adolescent mothers are more likely to have low birth weight babies who are at risk of malnourishment and poor development. Infant and child mortality is also highest among children born to adolescent mothers (3).
Policy-makers and programme managers in developing countries have requested guidance from the World Health Organization (WHO) on the most effective interventions to reduce maternal mortality and morbidity among adolescents and to prevent early pregnancies. These recommendations allow policy-makers and programme managers to determine the best next steps in policies and programming. Guidance on effective interventions is also critical to: achieving the Millennium Development Goals (MDGs); improving the health and well-being of adolescent mothers; and strengthening the health of families and communities.
Target Audiences
The primary audience for the recommendations is policy leaders/planners and programme managers from governments, nongovernmental organizations (NGOs) and donor organizations working in developing countries. The recommendations are also of interest to health-care providers and researchers at global and country levels, officials from ministries of health, professional associations, programme managers, technical and implementing agencies and advocacy groups.
Recommendations
The following pages contain a summary of the recommendations for each of the six major outcomes presented in this guideline. Both action and research recommendations are listed.
Reduce marriage before the age of 18 years. Strong recommendations: Encourage political leaders, planners and community leaders to formulate and enforce laws and policies to prohibit marriage of girls before 18 years of age.
Reduce pregnancy before the age of 20 years. Strong recommendations: Advocate for adolescent pregnancy prevention among all stakeholders through interventions such as: information provision, sexuality and health education, life skills building, contraceptive (more...)
Increase use of contraception by adolescents at risk of unintended pregnancy. Strong recommendations: Undertake efforts with political leaders and planners to formulate laws and policies to increase adolescent access to contraceptive information and services, (more...)
Reduce coerced sex among adolescents. Strong recommendations: Continue efforts with political leaders, planners and the community to formulate laws and policies that punish perpetrators of coerced sex involving adolescent girls, to enforce these laws (more...)
Reduce unsafe abortion among adolescents. Strong recommendations: Ensure that laws and policies enable adolescents to obtain safe abortion services.
Increase use of skilled antenatal, childbirth and postnatal care among adolescents. Strong recommendations: Provide information to all pregnant adolescents and other stakeholders about the importance of utilizing skilled antenatal care.
Methodology
The recommendations reflected in these guidelines were developed based on a systematic review of evidence of the effectiveness of interventions from low- and middle-income countries combined with an external expert panel consultation.
In 2009, the Child and Adolescent Health department of the World Health Organization (WHO) initiated a systematic review entitled “Preventing too-early pregnancies and poor reproductive outcomes among adolescents in developing countries” in collaboration with the departments of Reproductive Health and Research (RHR) and Making Pregnancy Safer (MPS). The group commissioned key technical institutions, including the Guttmacher Institute, the International Center for Research on Women (ICRW), the United Nations Population Fund (UNFPA), Family Health International (FHI), the Population Council and Centro Rosarino de Estudios Perinatales (CREP). Further review was provided by the United States Agency for International Development (USAID), UNFPA and the International Planned Parenthood Federation (IPPF), as well as other organizations included in the expert panel (see Annex 1).
Key steps in the systematic review process1
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| KEY STEP | TIMELINE |
|---|
Proposal for WHO Guidelines Review Committee
| Approved April 2009 |
- 2.
Scoping:
| January 2009–April 2009 |
- 3.
Formation of and consultation with the expert panel
| May–August, 2009 (Internet) |
- 4.
Implementation of a step-by-step methodology following GRC guidelines: Score critical outcomes and refining key questions Develop and implement search strategies in electronic databases Screen, abstract and review full text of relevant systematic reviews, individual studies and grey literature relevant to key questions Synthesize and grade the evidence Develop recommendations using GRADE 1 criteria
| May 2009–October 2010 |
- 5.
Meeting of global panel of experts
| November 2010 |
- 6.
Final guidelines report
| December 2010 |
- 7.
Clearance by Guidelines Review Committee
| First Quarter 2011 |
- 8.
Publication and dissemination
| 2011 |
In November 2010, an expert panel meeting (see Annex and 2) was organized by the WHO CAH/RHR/MPS departments.
Summary of declaration of interest
During the guidelines development process, all authors including the expert panel, affirmed that they have no conflict of interest concerning the subject or materials, and individually completed the requisite Declaration of Interest form.
During the expert panel meeting, following an explanation of the declaration of interest process, each participant was asked to stand and make a declaration of interest (declaring a conflict of interest or no conflict of interest). Consultants who participated in the systematic reviews declared their participation in the process and therefore abstained from further commenting on the evidence and from articulating the recommendations. Other experts who were not responsible for data collection and synthesis mentioned that, while they had no specific conflicts, they were actively engaged in scholarly or professional work in one or more of the topic areas that were discussed.
Dissemination plan
WHO/CAH outlined a plan to disseminate the recommendations developed through the systematic review and expert panel process. The immediate plan is to disseminate the guidelines once approved, to identify the gaps in the evidence and areas for further research; and to develop guidance tools for developing priorities for action and research. The long-term objectives are to mobilize support to produce evidence at the country level and promote policy changes with respect to information, services and training at the global level.
Changes to the scope
There are no anticipated changes to the scope of this document.
Plan to review and update the guidelines
These guidelines should be reviewed and updated five years after publication. Between the publication and the review date, organizations may request WHO to revise specific aspects of the recommendations based on new evidence.
