Ann-Marie, 16, knew about condoms from school. "When used
correctly, they can help prevent HIV transmission and unwanted
pregnancy," the teacher had told them.
"But children your age should abstain from sex," the health
educators cautioned. "Only 'big' people can use condoms while
married people should stay faithful," they emphasised.
The problem is Ann-Marie, like many of her peers, was already
sexually active. Unfortunately, she was not using condoms. The
only time she and Fredo attempted to use a condom, he had stolen
it from his older brother and it burst, but they had sex anway.
Now a mother of a three-month-old baby and out of school,
Ann-Marie is one of the many adolescents excluded from the
benefits of modern family planning methods. For her and others
like her, fear and embarrassment stops them from seeking these
"I know of a boy whose father stopped paying fees for him because
he found condoms in his suitcase. That meant that he was already
having sex," says Annette Nabuduwa, a social worker.
"Others know about the family planning methods but don't know how
to use them well and where to get them," Nabuduwa adds. "And our
own health providers have not made it any easy for our
youngsters. Rather than offer educative counselling, they lecture
them on why they are having sex 'early' which discourages
adolescents from seeking family planning services."
Nafissatou Diop, an international adolescent reproductive health
advocate, says the biggest issue is to overcome social cultural
barriers and open family planning services to young people.
"We need to recognise that opposition to family planning
programmes is higher when it addresses young people under the age
of 20 because they are not supposed to have sex," Diop says,
adding: "and if they have sex, it should be within marriage, and
if they are married and have sex, then they should be having
Diop, the country director of Population Council in Senegal who
has worked for decades on issues of reproductive health, HIV/AIDS
plus safe motherhood in Africa, says a lot of sexual activity
goes on among adolescents.
"And those girls - even if they are married - sometimes don't
want to have children. We also need to realise that many
marriages in sub-Saharan Africa are forced. So most of those
girls do not want children as soon as they get married," she
Young people aged 10-24 years constitute a third of the total
population, with 24% aged between 10 and 19 years, according to a
2006 report, 'Adolescent Sexual and Reproductive health in
The report says there is early initiation of sex, with about 30%
of 12-19 year-olds having sexual intercourse. However, the study
says, adolescents are poor users of contraceptives, despite high
levels of knowledge and approval.
"Ninety six percent of adolescents aged 15-19 reported knowledge
of at least one contraceptive method, but only 22% women reported
ever using it. The most common methods they know are male
condoms, the pill and injectables," it states.
The publication observes that health services targeting
adolescents are often limited to schools. It regrets that these
services are limited to curative services and information on
growth and development through films, plays and seminars.
Consequently, sexual and reproductive health services like modern
family planning methods are more theoretical, not youth-friendly
and have not attracted many adolescent clients where they are
Many adolescents have been found to fear the risk of pregnancy
more than HIV. To them, death is a farfetched reality.
"We have to realise that young people are having sex. Education
is good, but we need to deal with the reality that young people
need family planning services," Diop says. "Most adolescents are
fearful and embarrassed to seek such services. This implies lack
of adolescent friendly services as well as community support for
adolescents to seek contraception," she adds.
Dr. Peter Ibembe, from Reproductive Health Uganda, says they
provide family planning services to adolescents seeking them,
"We often counsel them first, like we do with everybody else," he
says. "But we are moving into friendlier adolescent health
services. We have recruited many young professionals who can
easily identify with adolescents," he says.
"We need family planning services for the youth because many
unwanted pregnancies end in risky abortion and its consequent
complications. We don't want this," Ibembe says.
The Uganda Demographic and Health Survey 2006 indicates that 24%
of Ugandan girls have had sex by the age of 15 and the teenage
pregnancy rate is at 24%.
The fertility rate, estimated at 6.9% has been attributed to low
levels of education, low incomes and social status, early
marriages, low contraceptive use, religious beliefs, as well as
the need for old-age security. Contraceptive use among teenagers
is as low as 23% and 50% of the population marries before the age
of 18, says the Population and Housing Census 2003 report.
Statistics from the ministry of labour and social development
indicate that teenage pregnancy rate in Uganda stands at 31% for
the nations over 3 million female teenagers. It adds that this
undermines the efforts of young people to effectively contribute
towards national development.
Pregnancy is a significant cause of death for girls aged 15-19,
with complications of child birth and unsafe abortion being the
An estimated 297,000 induced abortions are performed every year
in Uganda, according to the Guttmacher Institute study on
unintended pregnancy and induced abortion in Uganda. Adolescents
are the most affected.
Ibembe says friendly adolescent reproductive health programmes
ensure that teens know where to find the services, guarantee
confidentiality and anonymity; and must be affordable. "Once
these three conditions are met, other secondary factors influence
teens to make an initial visit like location, ease of
transportation, convenience of clinic hours, length of
appointment wait and ease of admission by the health workers," he
Dr. Anthony Mbonye, the assistant commissioner reproductive
health in the ministry, says the Government is emphasising
adolescent-friendly services by retraining health workers in
counselling, creating special corners for adolescents in health
facilities and recreation facilities to occupy them.
"We have reduced adolescent pregnancy from 43% in 1995 to 325 in
2001 and 25% in 2006," he says.
"In school, we just give them information on sexuality and safer
sex practices. We cannot provide them with condoms," he says.
Nonetheless, critics argue that while adolescents in some parts
of the country have benefited from such friendly services, there
are few or even no models of youth-friendly services that are
"Many of them rely on donor funding for survival," says Liz
Kobusinge, an advocacy officer on health and nutrition. "A major
consideration in the development and scaling up of
adolescent-friendly services is the need for long-term investment
by the Government and/or international donors," she adds.
Sustainability is the ability of an institution to continue
providing quality services and products for the young people,
even when donors phase out funding.
Any reproductive health programme for adolescents deserves to be
sustainable. Such a programme is able to continue with its
activities and meet its objectives every year, to make plans for
the future and carry them out, despite changes in the external
However, reproductive health programmes for adolescents are
challenging because they operate in an ever-changing environment.
Apart from changes in source and level of funding, the consumers'
demands also change.
What should be done?
Existent policies supporting the provision of youth-friendly
services should be strengthened. Adolescents should be involved
in the design, implementation and evaluation of programmes,
Kobusingye argues. She says in both public and private
programmes, ensuring satisfaction of the young people is
important for increasing demand for the services.
"Health workers should be provided with specific training to be
able to communicate with adolescents and to build competence in
handling their health concerns.
"Above all, adolescent health programmes and policies should be
interdisciplinary and reach beyond the health sector. Efforts
should be scaled up to adequately confront the enormous health
challenges facing adolescents," Kobusingye advises.
Ibembe describes optimal family planning services for adolescents
as those that include accessible, comprehensive and
multi-disciplinary care provided in confidence by no judgmental
staff with good counselling and communication skills.
"It could be approached from those seeking post-abortion care to
avoid a repeat risk of an unwanted pregnancy, doing voluntary HIV
counselling and testing, antenatal and post-natal clinics,
pregnancy testing," he notes.
"Some policy makers feel that family planning services should not
be totally free, so that teenagers must take some responsibility
for the provision. Nonetheless, they should be low-cost for
adolescents, as they have limited financial resources," says
He adds: "Like with HIV counselling and testing, outreach
adolescent programmes on family planning can mark an entry point
for family planning services for high risk adolescents like
school drop outs, sex workers, small industry employees and
adolescents in unions. They also bring parents and the general
community on board to respect adolescents' reproductive health
rights other than reprimanding them for their decisions," he
Hormonal methods are generally appropriate for all youth. World
Health Organisation places no restrictions on the oral use of
contraceptives, combined injectables, or implants on the basis of
age. The guidelines also place no restrictions on the use of
progestin-only injectibles for persons at least 18 years old.
Because of limited evidence that these injectibles decrease bone
mineral density on younger adolescents, those younger than 18 can
still use them, but should have access to counselling and medical