Sexual reproductive health has long been front and centre of adolescent health. With new understandings of epidemiology we now know the road traffic injury is the leading cause of death. Mental health problems are the leading cause of disability. Yet in low income settings sexual and reproductive health Including HIV, remain an overwhelming area of health need, with the burden falling disproportionately on adolescent girls. In this series of lectures I will again refer to the conceptual framework we've been using throughout the course. In this first lecture, I will be focusing on the major health outcomes, or areas of health service focus. In later lectures I'll be turning my attention to relevant health risk behaviours. As well as risk factors in the broader social determinants of sexual and reproductive health that are the focus of policy and preventive action. So what are the major health needs in adolescent sexual and reproductive health? These are five major areas that health services focus on in this area. I will focus separately on HIV and sexually transmitted infections in the next lecture. And the current lecture, I want to begin by focusing on pregnancy and parenthood, including maternal health. I mentioned in earlier lectures that one of the clear trends in high income countries has been the delay in marriage and first pregnancy to later ages. What that means is that 95% of teenage births are now, to young women living in low or middle income countries. Over half these births are unintended. With adolescents more than any other age group likely to experience an unexpected pregnancy. There are many risks associated with adolescent pregnancy. Maternal mortality tends to be higher in the first pregnancy. And in most parts of the world, this first pregnancy is during the adolescent years. The risk of infant mortality is also higher when mothers are in their teens. Adolescent girls are also more likely to have complications in childbirth and are slower to recognise the warning signs. But the broader life impacs of the adolescent pregnancy are even greater. The failure to complete education, inability to make a transition into work, all have long-lasting economic consequences for an individual woman, a family and the broader community. This global map illustrates adolescent fertility rates, or birth rates, in countries across the globe. The deeper shades represent those countries with the highest adolescent birth rates. Countries of Western and Central Sub-Saharan Africa have the highest global rates. The lowest are in today's higher income countries, with those in Western Europe and East Asia having some of the lowest rates. The following slide illustrates, in a different form, the huge variation in teenage birth rates across a selection of countries. So the highest rates today are in countries such as Niger and Chad, where birth rates were around 200 per 1000 girls per annum, are around 40 times higher than in Japan and the Netherlands. This image on maternal mortality ratios across all ages is drawn from the 2010 global burden of disease study. Images such as these are available from the website of the Institute of Health Metrics and Evaluation. The maternal mortality ratio measures the number of deaths as a proportion of the number of live births within any given age group. This shows a maternal mortality ratio globally across ages since 1990 with projections through to 2030. Because national death registration is poor in most settings where maternal mortality's high, these data largely derive from interviews and surveys like the Demographic and Health Surveillance System, or DHS. The maternal mortality ratio can therefore been seen as an index of the safety of pregnancy for women. The blue and orange lines show trends in 15-19 year olds and 20-24 year olds respectively. Both age groups have seen gains since 1990, though perhaps not as much as those in older age groups. The global burden of disease study commonly uses 21 sub-regions to describe patterns of disease burdens across the globe. Those 21 sub-regions are illustrated again in this slide. Now we will use the 21 sub-regions in the next slide to illustrate where the major burden of maternal health problems lies. I will use the concept of DALYs, that I introduced in a previous lecture. A DALY is a measure of years of life lost the due to premature death, and years of life lived with a disability arising from a specific health problem. Although preventing maternal death has been the major focus of attention of global health action, other nonfatal consequences of pregnancy and childbirth, such as fistulae and incontinence, are major sources of ongoing health problem for women in many middle income countries. The bubble charts on the left of this slide considers where the major burden of maternal disease lies in 15 to 19 year olds. The deeper colours represent higher DALY rates, whereas the size of the bubble represents the total number of DALYs in the particular sub-region, and reflects the number of adolescent girls in any particular sub-region. For that reason, South Asia has the highest number of DALYs due to maternal health problems. But Central and Western Sub-Saharan Africa have the highest rates. The right of the slide shows maternal mortality rates per 100,000 women at risk for 15 to 19 year olds per annum. It illustrates the great variation across countries within a single region. Where rates in Chad are approximately 100 times higher than in South Africa. This huge variation illustrates well, the extent of which maternal deaths are preventable. When discussing maternal mortality, there are a range of different causes that contribute. Around two thirds of deaths occur around the time of childbirth and include, haemorrhage, obstructed labor, and maternal hypertension, sometimes known as eclampsia, as prominent causes. Other causes such as sepsis or postpartum infection, or the complications of unsafe abortion, tend to occur outside this immediate phase of giving birth. This slide illustrates DALY rates for different maternal causes across regions where there are higher rates of maternal health problems in 15 to 19 year olds. Both hypertensive deaths and those due to unsafe abortion are somewhat higher in adolescent girls than in older women of childbearing age. Many of these causes, the maternal disease burden, have relatively simple and effective responses. Hypertensive disorders or preeclampsia, as I mentioned, they're commoner in first pregnancy. And here the complications of convulsion are easily treated with magnesium sulphate if identified on an antenatal visit. Postpartum haemorrhage is less predictable and requires emergency treatment where it occurs. This is feasible where births take place, in a well resourced medical facility but not when births happen at home, as is the case for many adolescents in many Sub-Saharan African countries. Puerperal sepsis or postnatal infection is generally easily treated, but does require a post natal checkup to ensure early identification. Perhaps the most important complication of pregnancy in younger adolescent mothers is obstructed labor. It's a major cause of maternal and fetal death. It is a particular problem in this younger adolescent age group where a girl's pelvic size has not yet reached its adult proportion. Obstetric fistula, a major problem for those who survive obstructed labor. This is particularly likely in girls who have experienced stunting, malnourishment, where pelvic growth is much slower. Reconstructive surgery to repair fistulas is expensive, but the use of all these catheters to manage small fistulas can lead to spontaneous healing without a need for surgery. If we look at DALYs due to unsafe abortion in 15 to 19 year olds, the bubble diagram again illustrates both high rates of complications of unsafe abortion in central and western Sub-Sahara and Africa. But with the greatest disease burden on total DALYs from unsafe abortion in South Asia due to the large number of adolescent girls in that sub region. The diagram on the right illustrates the extraordinary variation in DALY rates due to unsafe abortion across GBD sub regions. If we now consider broader responses to maternal mortality and disease burden, we can consider these responses on three levels. Policy initiatives that include the implementation of legislation around age of marriage. Investments in modern contraception and access to safe abortion when needed. As well as the promotion of education in girls, at the same time, supporting the families of girls seeking education are some of the most important investments a country can make in reducing maternal debts and disease burden. At a community level, important initiatives include the creation of economic opportunities for girls, including the opportunity to stay in education. This might mean challenging community attitudes that girls only role in society is that of becoming a mother. Health services have very important roles to play both prior to conception and post conception. If a girl does become pregnant, prior to conception, access to modern contraception to allow the delay in first births and greater spacing between births are essential. Treating protein energy and malnutrition and micronutrient deficiency, such as iron deficiency anaemia, are essential aspects of health care in settings where maternal health problems remain high. For the girl that does become pregnant, early, frequent antenatal visits and quality healthcare during the delivery are essential. I want to finish this lecture by mentioning female genital mutilation. This has been a neglected sexually reproductive health problem. It refers to the practice of cutting a girl's genitalia and generally removing some flesh. It's mostly undertaken by traditional practitioners, and occurs most commonly in a swathe of countries across Western, Central, and Eastern Africa. The timing of female genital mutilation varies across these countries with around half focusing on cutting girls below the age of five. And in the others, between the ages of 5 and 14. It can lead to complications such as vaginal narrowing, which in turn leads to complications in later childbirth. There is considerable variation in rates of female genital mutilation between countries. Even within a country, there tends to be great variation generally by ethnic group. This is illustrated here in Senegal where rates vary from almost zero to over 80% in different regions. This variation illustrates the extent to which female genital mutilation is embedded in a social and cultural context. Prevention will necessarily involve a mixture of approaches, ranging from legislation, through to the education of community leaders to change long held cultural attitudes.
