Introduction
The World Health Organization (WHO) (2019B) defines adolescence as the period between 10 and 19 years of age, when children transition into adults. In 2020, there will be an estimated 1.25 billion adolescents in the world, with almost 90% of them residing in low- and middle-income countries (LMICs). Adolescence is a phase marked by both biological changes and brain development. However, the biological maturity often precedes psychosocial maturity, affecting how young people respond to the new risks and opportunities that also emerge in adolescence (World Health Organization, 2019A). The unique physical, cognitive, social, emotional, and sexual development that takes place during adolescence requires special attention in national development policies, programs, and plans (World Health Organization, 2017B). Adolescence represents a time when young people experiment with independence, forge new relationships, develop social skills, and learn behaviors that will last the rest of their lives (World Health Organization, 2019B). If they are engaged in meaningful ways and supported in all aspects of their lives, adolescents are more likely to grow into thriving adults, making lasting contributions to their families and society. Investing in adolescent health and well-being brings a triple dividend of benefits that affect not only the future adult life of those adolescents but also the next generation of children (Patton et al., 2016).
In sub-Saharan Africa, for example, where births by adolescents and young adults (15–24 years of age) contribute significantly to fertility, access to comprehensive SRH could lead to declines in fertility. This decline could result in changes in the age structure of the population, which would allow countries to benefit from of a window of opportunity for economic growth, thus harnessing the first demographic dividend (Prata, 2017). Given the high return on investment, adolescent health is firmly on the global agenda and prominent in many initiatives. There is widespread recognition that the Sustainable Development Goals (SDGs), which seek to achieve global economic, social, and environmental sustainable development by 2030, will not be realized without investments in adolescent health and well-being (World Health Organization, 2017B). A report, Health for the World’s Adolescents, was released by the WHO in 2014 and showed that the considerable gains already made from investments in maternal- and child-health programs would not be sustained without corresponding investments in adolescent health (World Health Organization, 2014). This is particularly the case when it comes to adolescent sexual and reproductive health (ASRH). In all regions of the world, young people are reaching puberty earlier, often engaging in sexual activity at a younger age, and in many places marrying later. As a result, young people are sexually active for longer before marriage than at any other time in history (Bearinger, Sieving, Ferguson, & Sharma, 2007; Blanc, Tsui, Croft, & Trevitt, 2009; Chen et al., 2007; Morris & Rushwan, 2015).
The gap between first sex and marriage has implications for program and policies in supporting ASRH. Yet various political, economic, and sociocultural factors continue to restrict the delivery of ASRH information and services, failing to recognize the rights of adolescents to make independent decisions surrounding sexual activity and marriage. At the same time, healthcare workers often act as a barrier to care by failing to provide young people with supportive, nonjudgmental, youth-appropriate services (Morris & Rushwan, 2015). The ASRH disease burden is concentrated in LMICs. Despite steady declines in the global number of HIV-related deaths, among adolescents and young people the number of HIV-related deaths increased by 50% between 2005 and 2017 (United Nations Children’s Fund, 2017). The highest adolescent AIDS mortality rate is found in sub- Saharan Africa, with 17 deaths per 100,000 adolescents in African LMICs (World Health Organization, 2017B). This can be largely attributed to a generation of children infected with HIV perinatally who are now adolescents. About two thirds of adolescents living with HIV in 2015 acquired the disease during their mothers’ pregnancies or deliveries or in the first months of life, whereas the remaining one third of adolescents living with HIV were infected as adolescents (Joint United Nations Programme on HIV/AIDS, 2016). Adolescents are less likely than adults are to be tested for HIV and less likely to be linked to services, whether they test positive or negative (World Health Organization, 2013). In addition to HIV risk, sexually active adolescents have a particularly high risk of acquiring other sexually transmitted infections (STIs) compared to other age groups as a result of increased exposure, biological susceptibility to infection, and relatively poor access to or use of health services. Data on STIs are limited and inconsistent between and within regions and countries, particularly data disaggregated by age and sex (World Health Organization, 2017B). However, existing data on women of reproductive age (15–49 years) indicate the highest concentration (31%) of herpes simplex 2 virus (HSV-2) cases in sub- Saharan Africa (Looker et al., 2015). Meanwhile, the peak time for acquiring HSV-2 for both males and females is shortly after a person first becomes sexually active, which typically happens during adolescence (World Health Organization, 2017C).
For older adolescent girls between the ages of 15 and 19 years, complications related to pregnancy and childbirth are the leading cause of death globally, with the adolescent maternal mortality rate highest among African LMICs (World Health Organization, 2018). Estimates from 2016 indicate that each year approximately 21 million girls and young women aged 15–19 years will become pregnant in LMICs (Darroch et al., 2016). Pregnant adolescents face maternal health challenges that are specific to their physical and psychological immaturity and limited autonomy (World Health Organization, 2017B). They are also more likely to have a repeat pregnancy within a year of giving birth, which can place them and their children at risk (Lopez, Grey, Hiller, & Chen, 2015; World Health Organization, 2017B). About half of pregnancies among adolescent women aged 15–19 years living in LMICs are unintended, and every year, approximately 3.9 million girls in this age group undergo abortions in unsafe conditions (Darroch, Woog, Bankole, & Ashford, 2016).
Though these data are alarming and signal the need for immediate action, they do not paint the full picture. Although adolescence is a time of increased SRH risk, it is also a time when young people find their voice and agency. Adolescents around the world are using this voice to champion access to high-quality, comprehensive SRH information and services. The early 21st century has been characterized as a time when adolescents have demanded that their fundamental rights be recognized and when the world seemed— more than ever before—poised to act.
This article highlights the status of adolescents’ SRH in LMICs, providing information on the following: the unmet need for SRH services (see “ADOLESCENT SEXUAL AND REPRODUCTIVE HEALTH AND RIGHTS”), key social determinants of SRH (see “SOCIAL DETERMINANTS OF ASRH”), challenges and opportunities for sexuality education (see “SEXUALITY EDUCATION”), existing implementation strategies for preventing poor reproductive health outcomes (see “PREVENTION OF POOR REPRODUCTIVE HEALTH OUTCOMES DURING ADOLESCENCE”), and the need for modern contraception (see “CONTRACEPTION”). In each section, a description of key challenges, opportunities, and research gaps is revealed, as are examples of what has worked in the past in terms of policies and programs.
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