Adverse consequences of uninformed adolescent sex in Jamaica: from STIs to pregnancy, abortion and maternal death/ Consecuencias adversas del sexo adolescente desinformado en Jamaica: e las Enfermedades de Transmision Sexual (ETS) al embarazo, aborto y muerte materna/Les consequences nefastes de la sexualite chez les adolescents non informes en Jamaique: des IST a la grossesse, l'avortement et au deces maternel.
Jamaica's adolescent fertility rate remains comparatively high, so it is against this background that teenage attitudes toward sex, safe sexual practices, the use of abortion, and maternal mortality are reviewed. The research found that while boys were more concerned about preventing STIs (sexually transmitted infections) and HIV, girls" main preoccupation was avoiding pregnancy. One in five Jamaican adolescents having a baby has had an abortion already, according to one survey. Complications from abortions were the leading cause of adolescent maternal deaths from 2004 to 2006. While condom use has risen, adolescent access to illegal medical abortions, without proper counselling and aftercare, has increased mortality risk. Comprehensive reproductive care for Jamaican girls should include early, age-appropriate family life education and access to safe abortion services. This, however, requires legal reform. The article concludes by discussing the barriers that Jamaican adolescents face in accessing comprehensive reproductive health care.
Dada la relativamente alta fertilidad adolescente, se presenta una revision de las actitudes de los adolescentes hacia el sexo, las practicas sexuales sanas, el uso del aborto, y la mortalidad materna. La investigacion ha descubierto que, mientras los varones se muestran mas preocupados con la prevencion de ETS/VIH, las hembras prefieren evitar el embarazo. Una de cada cinco adolescentes que han tenido un bebe reportan un aborto previo. Los abortos han resultado en complicaciones que han sido la causa conducente a la muerte materna de adolescentes (2004-6). Aun cuando ha aumentado el uso del condon, el acceso de los adolescentes al aborto medico ilegal, sin los consejos adecuados ni cuidados posteriores, ha conllevado al aumento de los riesgos de la mortalidad. El cuidado reproductivo integral debe incluir una educacion familiar temprana y adecuada segun la edad, asi como el acceso a los servicios de un aborto sin peligros. Esto no obstante requiere de una reforma legal. El articulo concluye con una discusion sobre los obstaculos que afrontan los adolescentes jamaiquinos para lograr el acceso a una atencion medica reproductiva integral.
Etant donne le taux de fertilite relativement eleve chez les adolescents en Jamaique, cet article examine l'attitude des adolescents face au sexe, aux rapports sexuels sans risques, au recours a l'avortement et a la mortalite liee a la maternite. L'etude a revele que si les garcons etaient plus preoccupes par la prevention des infections sexuellement transmissibles (IST) et du VIH, les filles de leur cote etaient plus soucieuses d'eviter la grossesse. Une adolescente mere sur 5 declare avoir deja subi un avortement, dont les complications sont au premier rang des causes de deces maternel (2004-6). Bien que l'utilisation du preservatif soit en hausse, l'acces des adolescents a des methodes illegales d'avortement sans conseil et suivi medical appropries a entraine une augmentation du risque de mortalite. Les soins de sante genesiques devraient comporter un enseignement de la vie familiale des le jeune age et adapte a chaque age ainsi que l'acces a des services d'avortement sans risque. Cela necessite toutefois des reformes legislatives. Pour finir, cet article se consacre a une discussion des obstacles qui se dressent sur la route des adolescents jamaicains en quete d'un systeme de sante genesique exhaustif.
Early sexual debut
With 75 births per 1,000 women aged 15-19 years in 2009, Jamaica has one of the highest adolescent fertility rates in the Caribbean, surpassed only by Belize, at 76 per 1,000. Trinidad and Tobago reports the lowest rate in the region at 34 per 1,000 (United Nations 2010). Jamaica's high fertility rate is not surprising, as 44% of Jamaican adolescents 15-19 years report that they have already had their sexual debut. Two-thirds of those who become pregnant (67%) report that the pregnancy was "mistimed", while 15% clearly state the pregnancy was unwanted (National Family Planning Board 2008). Aside from pregnancy, others contract STIs, including HIV. Reported HIV rates are higher among adolescent and young women than men of the same age (National HIV/STI Programme 2008a). Jamaican studies of whether and how music influences adolescent reproductive health views and practices found that social norms encourage teenage sexuality and risky practices (Holder-Nevins 2009), such as unprotected and transactional sex (Mmari and Blum 2009).
This paper reviews local evidence on teenage attitudes toward sex and related behaviours, and the adverse outcomes of unsafe sexual practices in this population, ranging from STIs to use of (illegal) abortions to maternal death. Specifically, the need for universal access to comprehensive reproductive health care for this age group is discussed.
Quantitative and qualitative data on adolescent reproductive health in Jamaica was reviewed, drawing on published sources, grey literature and databases held by the co-authors. Studies eligible for inclusion had to address the target population of young persons under 20.
Published reports for which the authors could not access the primary data had to have:
i. A clearly defined target population, which included but was not limited to our target population of adolescents 1019 years;
ii. Sample selection strategies which would ensure a nationally representative sample.
Studies that met our inclusion criteria were:
a) National reproductive health surveys conducted in 2008, 2002 and 1996 by/on behalf of the National Family Planning Board. In 1996, a young adult (15-24 years) component was introduced and sampled both males and females (NFPB 2008).In 2008 adolescents (15-19 years old) comprised 52.5% of 2,343 women and 59.6% of 2,775 men interviewed for the young adult survey. The 2002 young adult survey included 1,926 females, 2,437 males; 1996: 1,991 females, 2,279 males with adolescent females accounting for 54.7% (2002) and 52.4% (1996) respectively; and adolescent males 57.3% (2002) and 43.5% (1996).
b) The Jamaica Youth Risk and Resiliency Surveys 2005-6 (Fox and Gordon-Strachan 2007) interviewed 3,003 in school youths aged 10-15 years--l,581 females and 1,422 males.
c) The Jamaica Health and Lifestyle Survey 2006 (Wilks et al. 2007) sampled 2,848 persons aged 15-74 years, 521 of whom were aged 15-24 (336 females, 185 males).
d) The Knowledge, Attitude, Practice and Behaviour Survey (2008) of the National HIWSTI Control Programme (2008b) sampled 1,800 persons, 894 of whom were aged 15-24.
e) Routine surveillance information reported by the Ministry of Health on sexually transmitted infections, including HIV/AIDS (National HIWSTI Control Programme 2008a). Primary data which the study team had access to:
f) Studies undertaken by public health students in the Department of Community Health and Psychiatry which included adolescents, namely:
1) Dental health and pregnancy outcome of antenatal mothers (Alexander 2009)
2) Women admitted with complications of early foetal loss (Taitt 2007)
3) Adolescent perception and values about sexual and reproductive health (Holder-Nevins 2009).
4) Routine surveillance on maternal deaths reported to the Ministry of Health (McCaw-Binns et al. 2007).
Supportive information from grey and published literature included reports in newspaper articles on the subject matter or the population of interest.
In order to contextualise our findings, permission was sought from the Senior Medical Officer of an urban hospital to conduct qualitative interviews with patients 15-17 years admitted with complications of induced abortion or who had live births. Of five adolescents approached, three consented to be interviewed after being told the purpose of the interview and assured of the right to refuse without any loss of access to services during their stay in hospital or any subsequent stays. Ward nurses witnessed the consent process. Four main areas of concern were explored in these interviews: readiness for parenthood, abortion as an option, family support and use of misoprostol (Cytotec). After each interview the content was summarised orally to the interviewees to ensure validity of the issues captured. With these themes forming a framework for analysis, sub-themes emerging from the interviews were manually coded, grouped and summarised by independent reviewers, who then agreed on the final issues evident in the scripts.
Sexual debut, attitudes and contraceptive practice
The 2006 Youth Risk and Resiliency Survey (Figure 1) found that among 10 to 19-year-olds, one in five had initiated sexual activity by age 14; 55% by age 16; and the majority (86%) by age 19 (Wilks et al. 2007). Similar findings are reported by the 2008 Reproductive Health Survey (NFPB 2008).
Adolescent males were at higher risk of having an early sexual debut and multiple sexual partners, while females were more likely to have experienced forced sex; have been diagnosed with STIs, including HIV, due to adolescent exposure. Figure 2 demonstrates the wide gender differences in sexual debut among the youngest members of the age cohort (Fox and Gordon-Strachan 2007), with relative prevalence 3.8 higher among 10-year-old boys compared to girls (males 6.1%, females 1.6%), and 2.6 times greater at age 15 (males 43.6%, females 16.9%).
[FIGURE 2 OMITTED]
Evidence indicates that social norms encourage teenage sexuality and risky practices. Young males see nothing wrong with having a regular girlfriend and having another on the side for more fun. They, however, bought the messages regarding condom use to protect themselves from contracting STIs, particularly HIV, but were less concerned about preventing pregnancy, the occurrence of which actually confirms their masculine identity among their peers (Holder-Nevins 2009). Some of their feedback comments were:
Well, if you have one girl who you love and one who you use to 'buss out,' nothing wrong with that. We hear the condom thing every day from all comer, so if we don't hear, we will feel. The pregnancy part don't matter, but the AIDS thing is serious!
Girls, on the other hand, wanted to avoid pregnancy, which was perceived as limiting their achievement of life goals, such as completing their education (Holder-Nevins 2009). Their comments included:
I see too many girls whose life 'turn sour' because they chose to have a child before getting a life. ... I must concentrate on my lessons and take my mind off boyfriend because I can't manage that and baby.
Use of contraception on sexual debut has steadily increased among young Jamaican women, from 43% in 1993 to 79% by 2008. Figure 3 shows the practice is more common the older the adolescent is at first coitus. In 2008, 86% of 18 and 19-year-old females reported using a contraceptive method during their first sexual encounter, compared to 51% who initiated sexual activity before the age of 14. Consistent with male attitudes expressed earlier, fewer males reported contraceptive use the first time having sex, ranging from 35% to 79% with increasing age of debut (National HIV/STI Control Programme 2008b).
[FIGURE 3 OMITTED]
Risky sexual practices
Figure 4 demonstrates that of adolescents 15-19 years interviewed in the Youth Risk and Resiliency Survey (2006), between 4% and 10% reported experiencing forced sex at some time. Most, however, engaged in consensual sex for the first time with someone within five years of their own age (NFPB 2008; Holder-Nevins 2009; Wilks et al. 2007; Fox and Gordon-Strachan 2005); 8-23%, however, reported either getting pregnant or impregnating their partner at some time during their adolescence.
Multiple partnership was defined in the 2008 Knowledge, Attitude and Behaviour Survey as having more than one sex partner in 12 months. Of the responding adolescents and young adults (15-24 years), three out of four males and one in five females reported having had multiple partners. Of those with more than one partner, 77% of the males but only 57% of females had used a condom during their last sexual encounter. Transactional sex, i.e. the exchange of sex for gifts and/or money, was reported by 39.2% of sexually active youth aged 15-24 (National HIV/STI Control Programme 2008b).
[FIGURE 4 OMITTED]
Consequences of unprotected sex
Unprotected sex exposes adolescents to infection and unwanted pregnancy. Between 2006 and 2008, the number and rate of adolescents seen with genital discharge syndrome at public STI clinics increased steadily (National HIV/STI Control Programme 2008a). While half of the reported cases were due to candidiasis or bacterial vaginosis, which may not always be sexually transmitted, gonorrhoea, which is sexually transmitted, was included in this group. Reported rates of syphilis were higher among young women than young men, but this difference may be associated with antenatal surveillance.
Figure 5 shows that while the cumulative case-load of reported AIDS cases occur more frequently in males than females, a worrying trend is the higher rate of diagnosis among women 15-29 years, suggesting exposure during adolescence. Again, while this higher diagnostic rate may be related to antenatal screening, the presence of the disease among adolescent females may be due to exposure of this age group to older males or 'sugar daddies' within the context of transactional sexual relationships and could explain the observed age-gender gap.
[FIGURE 5 OMITTED]
Over time there has been an encouraging trend of decreasing teen (and young adult) fertility, although Jamaica's adolescent fertility rate remains high. Factors associated with the decline include the relative increase in age of sexual debut, and more frequent use of contraceptives, especially condoms, but also emergency contraception (Figure 6).
In 2008, half of all reproductive age women, but only 18% of adolescents, described their pregnancies as planned. With 15% clearly saying the pregnancy was unwanted, unlike previous years where more described them as "mistimed" (NFPB 2008), this indicates a qualitative shift in attitude toward adolescent fertility. This is further demonstrated by a growing practice among young women to control the consequences of unwanted pregnancy through medical abortion.
[FIGURE 6 OMITTED]
One in five teenagers and more than one in three women having their first baby in 2004-5 reported a previous abortion (Alexander 2009), not counting spontaneous abortions. These rates are consistent with a later study of women admitted to the Victoria Jubilee Hospital from 2006-7 for complications from an incomplete abortion (Taitt 2007). Then, 20-30% reported a history of induced abortion. Significantly more adolescents (22%) compared to older women (20-29 years--18%; 30-39 years--11%; 40+ years--0%) admitted they had tried to terminate the pregnancy using misoprostol, a steroidal preparation marketed for the treatment of peptic ulcers, but which has been found to be an effective abortifacient.
Use of misoprostol to terminate pregnancies is well known, though illegal, in Jamaica. The Sunday Observer of 29 May 2011 quotes the head of Obstetrics and Gynaecology at the University Hospital of the West Indies, Professor Horace Fletcher, as admitting that "... many doctors and patients nonetheless use ... misoprostol to terminate pregnancies...." (Hussey-Whyte 2011). A 16-year-old interviewed on the ward after admission for complications of an early fetal loss admitted to using misoprostol that was not prescribed and without the knowledge of her family.
A buy the pill dem from a lady but it never work so good that's why I have to come here when the pain and the bleeding get bad.
Socio-economic background of teenage pregnancy
Of the three adolescents who consented to be interviewed after their pregnancy ended (one had had an abortion, the others had live births), two lived with their mothers and the third with the extended family of her mother. Only one of the three had completed high school. One stated she currently had a boyfriend/"baby father", but the others had broken off the relationship. Their unplanned pregnancies were dealt with in different ways, despite knowledge of the option to abort using misoprostol. Of the two who admitted to considering the abortion option, only one chose to do so, in spite of the fact that they both had severed ties with the fathers and initially had not revealed their condition to any family member. The teen who chose the option of abortion stated that her decision was supported by the estranged father, who provided the funds. The teen who rejected this option eventually sought family support.
The two interviewees who had chosen to have their first child provided the following comments to a question about their readiness to have a child.
A wasn't ready emotionally. A didn't want a child right now because it cut your freedom and you have to think about a whole heap a things for the child. Is really a accident how mi get pregnant; me an mi boyfriend use condom but one a the time it come (slip) off.
Thus, in today's world of increased choices, early childbearing will more often occur in a supportive home environment, regardless of whether the father will be a part of the child's life. And this is the challenge for the long-term development of the child.
When maternal deaths were first monitored in the 1980s (Figure 7), age-specific rates showed adolescents with a higher mortality ratio (79/100,000 live births) compared to women 20-24 years (71/100,000), the age group with the lowest risk (Walker et al. 1986). Resulting policy changes directed all adolescents to hospital for delivery (Ashley and McCaw-Binns 1986). Over the next 20 years adolescent maternal mortality declined steadily and by 2004-6, it reached the lowest recorded level of all age groups, 33/100,000 (McCaw-Binns et al. 2007).
[FIGURE 7 OMITTED]
In the 2004-6 triennium (Figure 8), however, abortion replaced hypertensive disorders as the leading cause of direct deaths among adolescents and was the second leading cause among women 20-29 years of age (McCaw-Binns and Bell 2010). Deaths from medical complications of pregnancy among adolescents were associated with lifestyle disorders from growing adolescent obesity, namely gestational diabetes and heart disease (Jackson et al. 2002).
[FIGURE 8 OMITTED]
The revolving door of adolescent fertility
Adolescent parenthood has negative social consequences for the young parents who must now juggle their pursuit of personal development goals with the demands of parenthood. In the USA, seven out of 10 adolescent mothers drop out of school without completing their education. Similarly, young fathers finish an average of 11.3 years of school by age 27, compared with 13 years for men who delay fatherhood until age 20 or 21 (Maynard 1997). Social supports, such as those provided by the Women's Centre of Jamaica, need to be expanded to ensure that young parents can delay further adolescent childbearing, complete their education, improve their opportunities to earn a decent wage to support their child, and improve their chances of breaking the intergenerational cycle of teenage parenthood.
In addition to the impact on parents, adolescent motherhood carries risks for the newborn, who is more likely to be born preterm and/or have a low birth weight, and be at higher risk of infant death or disability. These babies are often born into poorly resourced homes, which limit their development potential and carry long-term risk of poorer health (Samms-Vaughan 2008).
The undesirable nature of the birth sometimes also results in child abuse and neglect, poorer academic performance and negative relationships with parents. These effects are demonstrated by a greater propensity of children born to adolescent mothers in the United States to run away from home when they reach adolescence (Maynard 1997). Evidence also indicates that the offspring of Jamaican adolescent mothers did not perform as well academically as children born to older mothers (Jackson et al. 2002). The intergenerational effects of these deficits tend to repeat themselves, with the offspring of adolescent mothers themselves beginning childbearing in their teens, continuing the cycle of poverty, poor health and limited developmental opportunities (Maynard 1997).
Adolescent sexuality and social conditioning
While most adolescents agreed to having sex the first time, up to a quarter of girls reported being forced to have sex, with another 12% allowing sex to occur without consenting to it. This suggests a passivity and powerlessness in female sexual decision-making which needs to be addressed by family life education to empower girls and women to effectively communicate their interest in sexual activity; negotiate the use of condoms and contraception; and more effectively reduce their risk of contracting STIs and having unwanted pregnancies. Formal reporting, adequate investigation and prosecution of the perpetrators of rape and carnal abuse could potentially reduce the incidence of these types of abuse, but girls and women need to be educated about the choices which are available to them.
Sexuality is intricately bound up with male-female power relationships and women very often lack the power to insist on the practice of safe sex by their partners. Traditionally, the Jamaican woman has been socialised to show deference to the man on the basis of her expectations of economic support (Leo-Rhynie 1995). These power conflicts extend to many forms of sexual violence. Some Jamaican men feel they have an inherent right to sexual satisfaction and the woman's consent is secondary. Others believe that women expect them to be aggressive and domineering as an expression of their love, and violence is an accepted expression of affection and love (Chuck 1994).
Family life education and reducing teen pregnancies
STI clinic attendees have included abused children under 10 years old (National HIV/STI programme 2008a). This suggests the need for age-appropriate family life education (FLE) beginning in preschool, which addresses issues such as appropriate touching by adults, including caretakers. It also suggests that more vigilance is needed to ensure the enforcement of laws regarding child abuse. Improved FLE through schools and various media, including music, has been effective in promoting messages such as abstinence, use of condoms and family planning to prevent STIs and pregnancy (Holder-Nevins 2009; Pilgrim and Blum 2012). More research is needed to inform policy and ensure that condoms and other contraceptives are accessible and used correctly and consistently once adolescents choose to engage in sexual activity.
Adolescents are often shy about seeking contraceptive advice or purchasing supplies, even though these are readily available at most retail outlets in Jamaica. Others may feel too intimidated by salespersons when they try to buy contraceptives. Other adolescents have misconceptions about the risk of pregnancy, and often report asking friends instead of adults for advice. Some are convinced by partners or may believe they cannot get pregnant the first time they have sex, or if they only have sex once in a while (Pilgrim and Blum 2012).
Sexually active adolescents need continuous education about appropriate and effective use of contraceptives to avoid unintended pregnancy and STIs. With little difference in effectiveness between the diaphragm and male condom in typical use, women who want some control may consider the diaphragm as an option to improve condom effectiveness. In addition, the pill or injectable contraceptive and the intra-uterine device should be considered for adolescents who may not have a regular relationship.
Adolescents, especially younger girls, are vulnerable to sexual violence,
rape and sexual abuse, even by close family members, including parents who may encourage them to participate in transactional sex. When they conceive, these children do not recognise the signs of pregnancy; or if they know, they conceal the fact until the pregnancy is quite advanced. When, even if they have the support of relatives, they decide to try to end the pregnancy, it may be too far along, increasing the likelihood of complications (Singh et al. 2010). If they have had bad experiences in previous interactions with health providers, when problems develop, they may also be reluctant to seek care, increasing the risk of maternal death.
Community knowledge is improving, with the message spreading that girls should head to the hospital when complications from an abortion arise as demonstrated by the 16-year-old interviewed on the ward by the authors. This is one way to ensure survival rates improve. Shame, however, can make girls try to hide the symptoms of pain, fever and bleeding, resulting in adolescent deaths among those who stay home too long (McCaw-Binns et al. 2007).
Safe abortion services: ethical and public health dilemmas
The World Health Organization (WHO) defines unsafe abortion as a procedure for terminating an unwanted pregnancy by persons lacking the necessary skills or in environments lacking minimal medical standards. In the Americas, abortion rates tend to be highest where the procedure is illegal. Thus, the abortion rate in the Caribbean is 35/1,000 among women aged 15-44 years, with 45% of these conducted under unsafe conditions, compared to North America where the abortion rate is 21/1,000 among women aged 1544 years and where these services are legal. As safe abortion services become more accessible, alongside improved access to counselling and contraceptive services, the overall abortion rate declines (Shah and Ahman 2010).
Decreased teenage fertility in Jamaica has been associated with better FLE, but has been complemented by increased use of unsafe abortion, often provided without proper counselling, absent post-abortion care, and increasing mortality exposure in a low-risk age group. With one in 12 maternal deaths in Jamaica due to abortion in the years 2004-7, and it being the leading cause of maternal death among adolescents, there is a need to address the unregulated provision of these services.
As the demand for abortions continues without regulation, consequences will escalate. In 2005 the Minister of Health set up an Abortion Policy Reform group which presented their report to Parliament in 2008, with suggested guidelines on modernising the abortion law to make services legally and safely available and prevent abuse of the procedure as routine contraception. The lack of action on the group's recommendations has been fuelled by objections from the religious community.
Derrick Aarons (2009), a Jamaican bioethicist, gives a balanced view of the difference between moral beliefs and public health issues (See Aarons' article in this issue).
Some would argue that the moral beliefs of some persons on the matter of abortion (even if they are in the majority) should not serve as laws that would impose those beliefs on everyone in the society. In a democratic society, as they do as voters in elections, individuals should be moral agents acting freely on the basis of their own understanding and perceptions (Aarons 2009).
History has taught that abortion policies based on religious principles which favour criminal condemnation only result in illegal and unskilled abortion practice, contributing to women's deaths, and among survivors, infection and impairment of future reproductive capacity.
The terms of the debate surrounding abortion have changed over time, as did the debates about family planning and contraception, which began in the 1960s. The response to an unplanned or unwanted pregnancy and its emotional, economic and social impact on the lives of women and their families in Jamaica in the 21st century is less an issue of ethics and turns more on practical considerations. The choice to abort is linked to concerns such as freedom to choose and freedom from responsibilities of child-rearing as well as the perceived benefits or lack thereof of child-bearing, such as providing ties to a financially successful male partner, or notions of the child being an "old age pension". Gender and cultural norms, including shame in being childless, earning a negative label of "mule", or important perceived milestones in a woman's life, such as the ticking of the "biological clock" as she approaches the peak of her reproductive cycle are important variables in the decision-making process. Moral and religious considerations operate primarily among those at the extreme end of the continuum of persons whose lifestyle is guided by faith-based principles, such as fundamentalist Christians, Roman Catholics and Rastafarians.
The argument of abortion as a public health problem is relevant in the Jamaican context even though it is difficult to quantify the adverse consequences of unsafe abortions. The costs of unsafe abortions are borne not only by the woman and her family, including its long-term impact on her future reproductive choices, but also her work environment if productivity is lost. The society as a whole is affected when avoidable maternal deaths occur. This reflects negatively on the responsiveness of the health sector to women's reproductive health needs.
Facilitating the transition to adulthood
Comprehensive reproductive health care should begin with age-appropriate family life education in pre-school. Parents and clinicians should be enabled to discuss the positive reasons of delaying sexual activity with preteens and adolescents. Adolescents should be provided with information on strategies to prevent pregnancy and avoid HIV and other STIs; the importance of positive goals; the advantages of forming relationships with a long-term committed partner in lieu of short-term encounters; how to develop self-reliance; and the capacity to articulate and work toward achieving personal goals within relationships. Adolescents should be supported to acquire and adhere to moral and spiritual values, meet family expectations, complete high school and pursue tertiary education or other training to acquire marketable skills so they can be productive adults.
Limitations of the study
This paper attempts to synthesise evidence from a range of cross-sectional studies which have mainly examined the health consequences of sexual activity among adolescents. As is the practice when conducting descriptive reviews, the authors have aimed to clearly state their purpose; outlined the criteria for inclusion of the selected studies; drawn what conclusions were possible from the available evidence; and identified areas for future research (Huth 1999).
The principal weakness of the evidence is that most included studies focused on the outcomes, except for the Holder-Nevins study (2009), which aimed to understand how one social stimulant--music- influences reproductive choices. Few documents even scratch the surface of the underlying social determinants of early sexual activity that reflect normative environmental behaviour.
While fertility is correlated with women's socio-economic status, these studies, like other data sets such as the Jamaica Survey of Living Conditions (Planning Institute of Jamaica 2011) do not include income data, as Jamaicans are generally unwilling to share such information, leaving researchers to rely on proxy measures of social class such as education, housing quality and possessions. The findings in this study show that daughters of single mothers more often become teenage mothers. UNICEF (2005) reports that of more than 11,000 adolescents aged 12-16 not in school in Jamaica, 12.6% cited pregnancy and 23% reported money problems as reasons for dropping out. While 94% of 15- and 16-year-olds from the wealthiest quintile were still enrolled in school, only 68% of those from the poorest quintile were in school. Social class and wealth are therefore important determinants of adolescent exposure to risk of early sex and child-bearing. However, for this study there was limited evidence available to discuss this important aspect of the problem and as such we had to rely on other studies and qualitative evidence to fill in some of these details.
In light of the study criteria of national representativeness, we ended up excluding smaller intervention studies which may have attempted to modify some of the behaviours of interest. This is a gap for future reviews to fill, to bring together evidence on what works to modify these behaviours in the Caribbean context. Messages about prevent HIV transmission have also reduced adolescent fertility--as a positive side-effect of condom use in pregnancy prevention. There are lessons to be learnt from HIV interventions before the benefits wane in the era of antiretroviral therapy (ART), which may have dampened the "seriousness of the AIDS thing", as one participant remarked. There is, however, need for operations research aimed at developing, testing and identifying effective interventions to reduce the incidence of early sexual debut. As teenage parenthood has intergenerational components linked to social norms, changing this phenomenon will require long-term social re-engineering.
Boys more likely to have multiple partners
Jamaican male adolescents are at higher risk of early sexual debut and having multiple sexual partners, while females are more likely to have experienced forced sex and have been diagnosed with STIs, including HIV, due to adolescent exposure. The older adolescents are when they experience their sexual debut, the more likely they are to report safe sexual practices such as condom use, and less risky behaviour such as having multiple partners. Religious exposure was associated with later debut and less risky behaviour. Adolescents raised in stable home environments with a mother and a father figure were more likely to delay sexual initiation, and less often experience the adverse outcomes of unprotected sex. Boys who grew up with only their father, however, were more likely to accept risky values such as having multiple sexual partners. Temporal increases in condom use have been associated with decreasing adolescent fertility. However, the risk of adverse outcomes such as unsafe abortions have changed little, with more girls reporting pregnancy terminations than 10 years earlier, and more abortion-related maternal deaths.
Adolescent reproductive health services must provide confidential, non-judgmental access to family planning and emergency contraception for sexually active adolescents. The judicious provision of state-sponsored pregnancy termination services recognises that not all sexual acts are consensual; that contraceptive failure occurs; and would help adolescents safely achieve their personal and reproductive health objectives. With continued improvements in educational and employment opportunities for the youth of Jamaica, replacement fertility and better reproductive outcomes for mothers and children are possible.
Research is needed to improve the delivery of comprehensive, adolescent-friendly sexual and reproductive health services in Jamaica. Operations research is also needed to document what works in motivating adolescents to delay early sexual initiation and reduce the risk of the adverse consequences described in this paper. Contextual research is also needed to explore the relationship between self-actualisation for adolescents through appropriate training and job opportunities, especially for females who experience higher unemployment rates than their male counterparts, despite being better trained and educated (PIOJ 2010). Boredom will contribute to sexual activity merely to pass the time. Others may feel constrained to turn to transactional sex, and in extreme circumstances, even commercial sex work, to meet their personal needs.
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Figure 1: Initiation of sexual activity, adolescents 10-19 years, Jamaica: 2006 Had sex 10 3.8 11 5.5 12 4.9 13 13.6 14 21.2 15 31.6 16 54.9 17 68.9 18 81.7 19 86.1 Source: Jamaican Youth Risk and Resiliency Survey, 2006: 10-15, 15-19 year olds Note: Table made from bar graph.