6-16 Reynolds.qxp

International Family Planning Perspectives In parts of the developing world where fertility rates are high, teenage pregnancy and early marriage are common. Worldwide, adolescents have more than 14 million births each year, and more than 90% of these occur in developing countries.1 The proportion of teenage women who are mothers or are currently pregnant is greatest in Sub-Saharan Africa (20–40%).2 The proportions are lower in other regions: 6–21% in Asia—with Bangladesh an outlier at 35%—and 13–25% in Latin America. As a result of high levels of early childbearing in developing countries, pregnancy and childbirth are the leading causes of death among women aged 15–19.3 Compared with older women, teenagers are at increased risk for poor maternal and infant outcomes,4 particularly maternal death and having an infant who is low-birth-weight or dies.5 The risk of maternal death during childbirth is 2–4 times as high among adolescents younger than 18 as among women aged 20 or older.6 Compared with babies born to women aged 20–29, babies born to women younger than 20 have a 34% higher risk of death in the neonatal period, largely because of their increased risk of being low-birth-weight,7 and a 26% higher risk of death by age five.8 Determinants of poor maternal and infant outcomes include poverty; cultural factors that restrict women’s autonomy, promote early marriage or support harmful traditional practices; nutritional deficiencies; reproductive factors such as young age at first birth; distance to health services; and inadequate health care behavior or use of services.9 Pregnant adolescents are disproportionately affected by these factors.10 Programs to delay first births to adolescents would mitigate risks to maternal and infant health associated with maternal factors such as short height, low weight and inadequate nutrition, but it is not clear how delaying first births would affect the social advantages or disadvantages of early childbearing. For example, adolescents who become pregnant may cut their education short because they are forced to leave school. Yet early childbearing may improve a woman’s social status because in some cultures it is an important step toward marriage. For all women, use of health care services is a key proximate determinant of maternal and infant outcomes,11 including maternal and infant mortality.12 Moreover, the benefits of health care–seeking and positive health behaviors are relatively strong in settings and subgroups where socioeconomic and public health resources are constrained.13 Timely and appropriate care can provide an opportunity to prevent or manage the direct causes of maternal mortality—hemorrhage, obstructed labor, unsafe abortion, infection and hypertensive disorders—and to reduce fetal and neonatal deaths related to obstetric complications.14 A R T I C L E S