De Dr. Matilde Maddaleno Herrera,
Dr. Carolina Orellana,
Dr. Pablo Villalobos Dintrans et
Dr. Fernando González Escalona
Chile is a success story in terms of diminishing adolescent pregnancy in the world. Lessons can be drawn from Chile’s experience by countries that still struggle to reduce the number of births to adolescent females as part of the Sustainable Development Goals; on the other hand, the country needs to rethink its goals for the next years and design new policies to address the coming challenges to promote equity and ensure universal access to sexual and reproductive health-care services for everyone.
Adolescent
pregnancy in adolescence is a social problem, which reveals inequity and
vulnerability. It has multiple consequences in the lives of adolescents, and
their kids and family. It is linked to multiple social determinants, as well as
inequity in access to sexual and reproductive health services, reflecting in
many cases the absence of opportunities to develop a life project other than
early motherhood (Pántelides, 2004; UNICEF, 2011; Svanemyr et al., 2015;
Rodríguez, 2017).
It (adolescent pregnancy) is linked to multiple social determinants, as well as inequity in access to sexual and reproductive health services, reflecting in many cases the absence of opportunities to develop a life project other than early motherhood.
Chile’s success story
As the country entered the new
millennium, Chile’s struggle for becoming a “developed” country became
more and more evident: while per capita income continued increasing,
transforming the country into a “high-income country”, other indicators,
such as income inequality, remained stagnant at “developing” levels
(Cattaneo et al., 2020). By 2000 the country still exhibited relatively
high rates of adolescent pregnancy: the proportion of live births of
under-19 mothers in Chile was 16.2% (higher than in 1990) and the
expected goal of reducing this indicator by 45% by 2015, as part of the
Millennium Development Goals (MDG) was not achieved (Gobierno de Chile, 2005).
However,
particularly since 2009, the country shows a sustained decrease in the rate of
births of women between 10 and 19 years, mainly driven by the reduction in
fertility in the ages 15-19 (Ministerio de Salud, 2022;Instituto Nacional de Estadísticas, 2022): in the period 2000-2017, Chile experienced a 51% reduction
in the proportion of births to mothers aged under 19 (Chandra-Mouli et al., 2019). This decreasing trend has continued with a reduction of 18.5% between
2020 and 2021 (Ministerio de Salud, 2022).
The Chilean Road to reducing adolescent pregnancy
How was this result obtained? Chile started by acknowledging the problem and committing several actions to address it in the short and long run. At the regional level, the country adopted the Andean Plan for the Prevention of Pregnancy in Adolescents (PLANEA), during the XXVIII Assembly of Ministers of Health of the Andean Area (REMSAA) of the Andean Health Organization - Hipólito Unanue Agreement (ORAS-CONHU) in 2007, which considers this problem as both a cause and an effect of inequalities in the region (ORASCONU, 2008; Chandra-Mouli et al., 2019). Since 2010, other organizations such as the Pan American Health Organization and the United Nations Population Fund have joined this initiative; the Plan was updated for the period 2017-2022 (ORASCONU, 2018). In 2014, the member countries of ORASCONU established the Andean and Central American Week for the Prevention of Adolescent Pregnancy (Semana Andina y Centroamericana de Prevención del Embarazo en Adolescente), celebrated every year in September to raise awareness of the topic in the region.
At the national level, the engagement was operationalized by including a reduction of 10% in the fertility rate in adolescents between 10 and 19 years as one of the impact objectives of the National Health Strategy 2011-2020 (Gobierno de Chile, 2011;Chandra-Mouli et al., 2019). This goal was achieved earlier than expected since this rate decreased from 51.9 in 2011 to 40.5 and 19.2 in 2015 and 2019, respectively (Ministerio de Salud, 2022).
Advocacy was key to overcoming resistance to change, for example, the provision of contraception.
Additionally, the country committed resources to strengthening the National Comprehensive Health Program for Adolescents/Youth and its Strategic Action Plan (Chandra-Mouli et al., 2019). This strategy considers the increase in the provision of several specifically designed healthcare services for adolescents at different levels, including the implementation of Friendly Spaces (Espacios Amigables), spaces designed to provide sexual and reproductive health and mental health services for adolescents between 10 and 19 years (DIPRECE 2019; 2022). These spaces have increased in the country from 54 in 2008 to 375 in 2022 (Ministerio de Salud, 2022).
Several legal changes have also been introduced to support the strategy and increase its sustainability over time. Among these, it is relevant to highlight Law 20,418 (2010) which sets norms on information and services for fertility regulation, including the right to choose the contraceptive method and access, including access to emergency contraception for adolescents younger than 14 years (including notification to parents after) (Art. 2), the right to confidentiality (Art. 3), and the explicit responsibility of the State of Chile in guaranteeing these rights (Art. 4). Other important legal advances include the Law 20,987 (2017) that changes the procedure for the HIV exam in people under 18 years, the Law 21,030 that permits abortion under three causes, the modification of norms to regulate fertility (2017), and the Strategy on Sexual and Reproductive Health (2018) (Biblioteca del Congreso Nacional de Chile, 2022).
All these changes, together with the improvement in the general conditions of living in the population, including reduction of poverty and increase in years of education of women explain part of this success: the share of the population that presents multidimensional poverty—that measures education, health, work and social security, and housing—has diminishing from 27,4% in 2009 to 18,6% in 2017 (Ministerio de Desarrollo Social y Familia/ PNUD, 2018) and the percentage of female enrollment in tertiary education has increased from 24% in 1993 to 33% in 2000 and to almost 100% in 2019 (World Bank, 2022). The improvement of structural factors—social determinants of health—as well as the implementation of specifically targeted policies have increased the coverage of the use of contraception in adolescents from 17% in 2012 to almost 25% in 2019 (Ministerio de Salud, 2022), impacting directly the rate of adolescent pregnancy in the country.
The improvement of structural factors—social determinants of health—as well as the implementation of specifically targeted policies have increased the coverage of the use of contraception in adolescents from 17% in 2012 to almost 25% in 2019, impacting directly the rate of adolescent pregnancy in the country.
Lessons, challenges, and next steps
Despite this story of achievement, the road traveled by Chile was not exempt from difficulties. Other countries embarked on this challenge should be aware of these problems to anticipate solutions for increasing the likelihood of success. One of the main issues faced by policymakers has to do with the need of introducing cultural and social changes: all the described initiatives—including laws, regulations, and programs—required that parents and adolescents understand the problem and agree on the solution. In this context, having detailed statistics is key to provide information for adolescents, parents, and society, to acknowledge the existence of the problem and promote the adoption of evidence-based policies. Advocacy was key to overcoming resistance to change, for example, the provision of contraception (Chandra-Mouli et al., 2019).
One of the main issues faced by policymakers has to do with the need of introducing cultural and social changes: all the described initiatives—including laws, regulations, and programs—required that parents and adolescents understand the problem and agree on the solution.
The COVID-19 pandemic threatens some of these achievements, particularly considering its impact on the interruption of healthcare services, mostly those targeted to adolescents, such as contraception services (Villalobos Dintrans et al., 2021) and the prolonged periods of lockdown experienced in the country. Also, regional inequities persist, and should also be addressed to ensure balanced progress. It is important to monitor the evolution of adolescent pregnancy in the country—particularly those in the youngest group—, as well as implement new strategies to continue improving in this matter.
Notwithstanding the success, there are several challenges ahead. Yes, the number of Friendly Spaces and the Health Program for Adolescents should continue growing to increase access to services and coverage like Long Acting Reversible Contraception (LARC).
But also, the country needs to find new ways to make policies for adolescents. Some challenges needs to be addressed, as the incorporation of sexual education in schools and the use of new technologies to prevent pregnancy. Additionally, a focus on the quality of services is required as well as the implementation of policies with more participation of the adolescents and incorporating new languages and cultural ways of relating—including sexual and other diversities—, acknowledging the existence of new forms of interaction. This is the new step of the Chilean health policies for adolescents, building initiatives for and with the people.
References
Biblioteca del Congreso Nacional de Chile (2022). Ley Chile. Available at: https://www.bcn.cl/leychile/(accessed on 24 Aug 2022).
Chandra-Mouli, V., Plesons, M., Hadley, A., Maddaleno, M., Oljira, L., Tibebu, S., Akwara, E., and Engel, D. (2019). Lessons learned from a national government-led efforts to reduce pregnancy in Chile, England and Ethiopia. Early Childhood Matters. Available at: https://earlychildhoodmatters.online/wp-content/uploads/2019/05/ECM2019_scaling_03-1.pdf (accessed on 23 Aug 2022).
Ministerio de Salud. (2022). Departamento de Estadísticas e Información en Salud. Santiago: MINSAL. Available at: https://deis.minsal.cl/ (accessed on 23 Aug 2022).
Svanemyr, J., Amin. A., Robles, O. J., and Greene, M. E (2015). Creating an enabling environment for adolescent sexual and reproductive health: a framework and promising approaches. J Adolesc Health 56(1 Suppl): S7-14. doi: 10.1016/j.jadohealth.2014.09.011 https://pubmed.ncbi.nlm.nih.gov/25528980/
Dr. Matilde Maddaleno Herrera, MD, MPH.
Pediatrician, Specialist in Adolescent Medicine, and Master in Public Health
from George Washington University. Dr. Maddaleno has served as Regional Advisor
to the Pan American Health Organization, Regional Office of the World Health
Organization, She was in charge of the International Relations Office of the
Ministry of Health of Chile and is currently the head of the Center for Public
Health Program and director of the Magister in Public Health of the Faculty of
Medical Sciences of the University of Santiago. Email
Dr. Carolina Orellana, MD.
Obstetrician-gynecologist from the University of Santiago, sub-specialist in
Child and Adolescent Gynecology from the University of Chile. Dr. Orellana in
the Gynecology Unit of the Roberto Del Río Children’s Hospital and Clínica
Santa María; she is also associate professor at the University of Santiago de
Chile, director of the Chilean Society of Gynecology and Obstetrics. She is
Expert in Forensic Sexology (certified by St Mary's SARS in Manchester-UK) and
has worked updating normative documents in the area between 2014 and 2016. In
2022, she assumed the position of Head of the Comprehensive Health Program for
Adolescents and Young People in the Chilean Ministry of Health. Email
Dr. Pablo Villalobos Dintrans. MA, DrPH. Economist from the Pontificia Universidad Católica de Chile with a master in economics from Boston University, and a doctoral degree in public health (DrPH) from the Harvard T.H. Chan School of Public Health. In Chile, he has worked for the Ministry of Economy, Ministry of Finance, and Ministry of Health. Currently, he works as a consultant, in areas such as health policies, health financing, health systems, population aging, and long-term care. Email
Dr. Fernando González Escalona, MD, MPH, Pediatrician and Master in Public Health from the University of Chile. He has postgraduate training in Social Pediatrics from the University of Barcelona, and a fellowship in child's health at the Great Ormond Street Hospital, London. He has been professor at the Department of Public Health, Universidad de los Andes and in Pediatrics at the Faculty of Medicine of the University of Chile. In 2020, he was in charge of the National Child Health Program, where he supported the response to the pandemic and later became UNICEF Chile's Health and Early Childhood Development officer. Currently is the head of the Division of Disease Prevention and Control at the Ministry of Health. Email
Les programmes gouvernementaux montrent un large succès : exemples du Chili et de l'Éthiopie
