International Journal of Gynecology and Obstetrics 128 (2015) 185–186
Contents lists available at ScienceDirect
International Journal of Gynecology and Obstetrics journal homepage: www.elsevier.com/locate/ijgo
FIGO COMMITTEE REPORT
Ethical issues in adolescent pregnancies FIGO Committee for the Ethical Aspects of Human Reproduction and Women’s Health
The FIGO Committee for the Ethical Aspects of Human Reproduction and Women’s Health considers the ethical aspects of issues that impact the discipline of obstetrics, gynecology, and women’s health. The following document represents the result of that carefully researched and considered discussion. This material is intended to provide material for consideration and debate about these ethical aspects of our discipline for member organizations and their constituent membership. B. Dickens, Chair FIGO Committee for the Ethical Aspects of Human Reproduction and Women’s Health E-mail: figo@figo.org Website: www.figo.org Bernard Dickens University of Toronto Faculty of Law 84 Queen’s Park Toronto M5S 2C5, Canada Tel.: +1 416 978 4849 Fax: +1 416 978 7899 E-mail: [email protected]
Background 1. Adolescence is the timeframe during which a combination of physical, psychological, and social changes occurs. According to the United Nations, each year 16 million girls under the age of 18 years give birth, accounting for more than 10% of births worldwide. 2. Adolescent pregnancies occur because of early exposure to sexual activity, especially in high-income regions or within early marriages in certain cultures and ethnic groups. Lack of knowledge of contraception and of access to quality reproductive and sexual health information, and lack of access to reproductive health services that respond to needs of adolescents, both female and male, add to the risk of unwanted pregnancies. 3. Adolescent pregnancies accounted for approximately over 70 000 maternal deaths (i.e. 25% of total maternal deaths) in 2013. 4. The vulnerable groups belong to the low socioeconomic strata of societies, and include adolescents who do not complete their education or have low levels of education, victims of domestic violence, the mentally challenged, those with easy access to substances they abuse, and quite often those whose parents have themselves married during their teenage years. 5. Adolescent pregnancies may be unplanned or within early marriage, as seen by the 2.2 to 4 million (10%) teenage girls every year who obtain abortion services. Unplanned adolescent pregnancies in single mothers contribute greatly to unsafe abortions, maternal mortality, and maternal morbidity. Pregnancies that are continued to birth are usually those that occur within marriage or that are detected late in pregnancy by uninformed single adolescents. 6. Evidence suggests that pregnancies, particularly in the very young, have a negative impact and contribute to higher dropout rates from school, affecting girls’ education. This limits their job opportunities and financial self-sufficiency, leading to poverty and an increased risk of repetitive pregnancies. 7. Adolescent pregnancies cause adverse outcomes, especially in the 13 − 16-years age group, with the risks being higher in younger adolescents with poor nutrition and immature physical development. 8. Pregnancies during the adolescent period have adverse effects on both the mothers and the children. Besides anemia and a low nutrition status, there are added complications such as pregnancy-induced hypertension, obstructed labor, obstetric fistula, postnatal depression, and other morbidities that are mainly due to the biological and gynecological immaturity of this age group. Continuation of pregnancies often leads to premature deliveries, low birth-weight babies, and increased neonatal morbidity and mortality. 9. There is evidence that teenage mothers often have mothers who themselves had adolescent pregnancies. There is a risk of this cycle repeating itself. The offspring of adolescents are known to have poorer cognitive development, lower educational achievement, and a higher rate of criminal activity. As children, they are also at a higher risk of suffering abuse, neglect, and behavioral problems. 10. In certain cultures, unmarried adolescents fear harsh consequences of disclosing their pregnancies to their parents, such as social ostracism. They therefore seek abortion, or may develop suicidal tendencies. Abortions in adolescents can be legal or illegal, with varying morbidity and mortality depending on the laws in the countries in which they reside.
http://dx.doi.org/10.1016/j.ijgo.2014.10.006 0020-7292/© 2014 Published by Elsevier Ireland Ltd. on behalf of International Federation of Gynecology and Obstetrics.
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B. Dickens / International Journal of Gynecology and Obstetrics 128 (2015) 185–186
11. Their unawareness of contraceptive options and lack of access to legal and safe abortions may expose pregnant adolescents to the risks of unsafe abortions. Recommendations 1. Healthcare professionals, along with governmental and nongovernmental organizations, should ethically ensure reproductive and sexual health education, and advocate such education both inside and outside schools. This education should be comprehensive and easily accessed by adolescents and their parents to increase their awareness about the risks of unprotected sex and unwanted pregnancies, the complications associated with pregnancies at such an early age, and availability of early and safe abortion where legal. 2. Health professionals should advocate for pregnant adolescents’ opportunities to complete their schooling to maximize their chances of achieving self-sufficiency in the future. 3. Adolescents’ access to reproductive and sexual health information and services should be made available, and outreach programs should be developed in rural areas, supporting adolescents to make decisions over their own bodies.
4. According to the UN Convention on the Rights of the Child, parental consent should not be necessary for termination of pregnancy of young girls intellectually capable of giving informed consent themselves, though it would be advisable with their agreement to involve their parents in their decision-making. Healthcare workers should attempt discussions with pregnant teenagers regarding their future, including their needs for completion of education, financial stability, and good health. 5. Adolescents should be provided with access to quality reproductive and sexual health services, along with postabortion and postpartum care. 6. Adolescents should be assured that their needs for appropriate care will be met and that their rights to confidentiality will be respected. 7. Professional societies should work with governmental health departments to encourage inclusion of adolescent-friendly health service protocols in the pre- and in-service training curricula of all levels of health service providers. London, March 2014
Contents lists available at ScienceDirect
International Journal of Gynecology and Obstetrics journal homepage: www.elsevier.com/locate/ijgo
FIGO COMMITTEE REPORT
Ethical issues in adolescent pregnancies FIGO Committee for the Ethical Aspects of Human Reproduction and Women’s Health
The FIGO Committee for the Ethical Aspects of Human Reproduction and Women’s Health considers the ethical aspects of issues that impact the discipline of obstetrics, gynecology, and women’s health. The following document represents the result of that carefully researched and considered discussion. This material is intended to provide material for consideration and debate about these ethical aspects of our discipline for member organizations and their constituent membership. B. Dickens, Chair FIGO Committee for the Ethical Aspects of Human Reproduction and Women’s Health E-mail: figo@figo.org Website: www.figo.org Bernard Dickens University of Toronto Faculty of Law 84 Queen’s Park Toronto M5S 2C5, Canada Tel.: +1 416 978 4849 Fax: +1 416 978 7899 E-mail: [email protected]
Background 1. Adolescence is the timeframe during which a combination of physical, psychological, and social changes occurs. According to the United Nations, each year 16 million girls under the age of 18 years give birth, accounting for more than 10% of births worldwide. 2. Adolescent pregnancies occur because of early exposure to sexual activity, especially in high-income regions or within early marriages in certain cultures and ethnic groups. Lack of knowledge of contraception and of access to quality reproductive and sexual health information, and lack of access to reproductive health services that respond to needs of adolescents, both female and male, add to the risk of unwanted pregnancies. 3. Adolescent pregnancies accounted for approximately over 70 000 maternal deaths (i.e. 25% of total maternal deaths) in 2013. 4. The vulnerable groups belong to the low socioeconomic strata of societies, and include adolescents who do not complete their education or have low levels of education, victims of domestic violence, the mentally challenged, those with easy access to substances they abuse, and quite often those whose parents have themselves married during their teenage years. 5. Adolescent pregnancies may be unplanned or within early marriage, as seen by the 2.2 to 4 million (10%) teenage girls every year who obtain abortion services. Unplanned adolescent pregnancies in single mothers contribute greatly to unsafe abortions, maternal mortality, and maternal morbidity. Pregnancies that are continued to birth are usually those that occur within marriage or that are detected late in pregnancy by uninformed single adolescents. 6. Evidence suggests that pregnancies, particularly in the very young, have a negative impact and contribute to higher dropout rates from school, affecting girls’ education. This limits their job opportunities and financial self-sufficiency, leading to poverty and an increased risk of repetitive pregnancies. 7. Adolescent pregnancies cause adverse outcomes, especially in the 13 − 16-years age group, with the risks being higher in younger adolescents with poor nutrition and immature physical development. 8. Pregnancies during the adolescent period have adverse effects on both the mothers and the children. Besides anemia and a low nutrition status, there are added complications such as pregnancy-induced hypertension, obstructed labor, obstetric fistula, postnatal depression, and other morbidities that are mainly due to the biological and gynecological immaturity of this age group. Continuation of pregnancies often leads to premature deliveries, low birth-weight babies, and increased neonatal morbidity and mortality. 9. There is evidence that teenage mothers often have mothers who themselves had adolescent pregnancies. There is a risk of this cycle repeating itself. The offspring of adolescents are known to have poorer cognitive development, lower educational achievement, and a higher rate of criminal activity. As children, they are also at a higher risk of suffering abuse, neglect, and behavioral problems. 10. In certain cultures, unmarried adolescents fear harsh consequences of disclosing their pregnancies to their parents, such as social ostracism. They therefore seek abortion, or may develop suicidal tendencies. Abortions in adolescents can be legal or illegal, with varying morbidity and mortality depending on the laws in the countries in which they reside.
http://dx.doi.org/10.1016/j.ijgo.2014.10.006 0020-7292/© 2014 Published by Elsevier Ireland Ltd. on behalf of International Federation of Gynecology and Obstetrics.
186
B. Dickens / International Journal of Gynecology and Obstetrics 128 (2015) 185–186
11. Their unawareness of contraceptive options and lack of access to legal and safe abortions may expose pregnant adolescents to the risks of unsafe abortions. Recommendations 1. Healthcare professionals, along with governmental and nongovernmental organizations, should ethically ensure reproductive and sexual health education, and advocate such education both inside and outside schools. This education should be comprehensive and easily accessed by adolescents and their parents to increase their awareness about the risks of unprotected sex and unwanted pregnancies, the complications associated with pregnancies at such an early age, and availability of early and safe abortion where legal. 2. Health professionals should advocate for pregnant adolescents’ opportunities to complete their schooling to maximize their chances of achieving self-sufficiency in the future. 3. Adolescents’ access to reproductive and sexual health information and services should be made available, and outreach programs should be developed in rural areas, supporting adolescents to make decisions over their own bodies.
4. According to the UN Convention on the Rights of the Child, parental consent should not be necessary for termination of pregnancy of young girls intellectually capable of giving informed consent themselves, though it would be advisable with their agreement to involve their parents in their decision-making. Healthcare workers should attempt discussions with pregnant teenagers regarding their future, including their needs for completion of education, financial stability, and good health. 5. Adolescents should be provided with access to quality reproductive and sexual health services, along with postabortion and postpartum care. 6. Adolescents should be assured that their needs for appropriate care will be met and that their rights to confidentiality will be respected. 7. Professional societies should work with governmental health departments to encourage inclusion of adolescent-friendly health service protocols in the pre- and in-service training curricula of all levels of health service providers. London, March 2014
