Adolescent sexual and reproductive health in developing countries: an overview of trends and interventions.

EARLYMARRIAGEANDSEXUALACTIVITY Early marriage and early marital sexual activity present reproductive health risks for young women. Early marriage can lead to pregnancies that put young women at risk for obstetric fistulae,14 and can be a risk factor for HIV infection.*15 The risks for young girls conferred by early marriage may involve older male partners—who have often been sexually active for many years—“bringing” HIV to the marriage. Thus, evidence suggesting that age at marriage is rising in most developing country settings16 is welcome; not so welcome, however, is evidence that the proportion of young people engaging in premarital sexual activity is also increasing.17 Adolescent sexual activity, within or outside of marriage, can lead to negative reproductive health outcomes.18 Unprotected sexual activity can expose young women to the risks of unintended pregnancy, unwanted childbearing and abortion, as well as HIV and other STIs. In addition to being a human rights concern, coerced or unwanted sex is associated with these same adverse reproductive health outcomes.19–23 Findings from a nationally representative sample of females aged 13–24 in Swaziland, for example, indicated that 33% had experienced sexual violence before the age of 18.24 This prevalence falls within the reported range for other Sub-Saharan African countries.25 Sexual coercion has also been reported by boys in Africa26 and other developing country settings.27 The outcomes related to early sexual activity are not just health-related and are often complex. For example, at least in some settings, adolescents who stay in school longer are less likely to engage in sexual risk behaviors.28 It is unclear, however, whether adolescents who stay in school are less likely to engage in risky sex or whether sexually active adolescents who engage in risky sex are more likely than others to drop out of school, and are missed in schoolbased studies. In some settings where premarital sex is taboo, sexual activity may be distracting or provoke negative responses from teachers, adversely affect school performance and lead to dropout.29 Moreover, sexual activity may result in adolescent pregnancy and birth, and thereby lead to school dropout or expulsion, since the school policy in many developing countries is unfriendly to pregnant