Youth/Adolescents

Sexual and Reproductive Health

In the Middle East

 

 

 

Working Paper

 

 

Presented at the

 

 

Arab African Parliamentarians’ Meeting on Youth

 

 

 

 

Morocco, Dec 3-5, 2003

 

 

 

 

 

 

 

 

Prepared by:

Alissar Rady, MD, MSc, MPH

(RH Consultant, CST Amman)

 

 

 

 

 

 

 

 

 

 

 

1. Introduction

 

The global target for Reproductive Health (RH) set by the international community was to reduce maternal mortality ratios by 75% over 25 years, and that by reaching a 50% reduction by the year 2000, and another 50% by the year 2015 (ref 40). At the current rate of progress, these targeted reductions may not be reached during the time period set, particularly so in the Middle East.

 Globally, while many health indicators have improved over the past two decades, Maternal Mortality Rates (MMR) has shown little improvement. Every minute 110 women experience a complication in their pregnancy, and a woman dies because of pregnancy or childbirth. It is estimated that more than 80% of maternal deaths are due to five direct causes: hemorrhage, sepsis, unsafe abortion, obstructed labor and hypertensive disease of pregnancy, all of them highly preventable (ref 36).

 Evidence for Violence against women is increasing as demonstrated by several population–based surveys across the world. In fact, 10-69% of women report being physically assaulted by an intimate male partner at some point in their lives. There is also growing evidence about abuse of children and young people, estimating about 20% of women and 5-10% of men worldwide to have suffered sexual abuse as children (ref 38). The devastating effects of violence on RH of women and Youth are well established.        Based on that, RH services are now moving towards improving access to counseling, especially on unwanted pregnancies, family planning, abortion risks, complications from high risk pregnancies, sexually transmitted diseases and HIV, and psychological problems due to gender–based violence (ref39). It is also well established that in order to enhance all aspects of sexual and RH, including family planning, care of children and prevention of HIV transmission, there must be more involvement of men and boys as partners who take responsibility for their sexual behavior and who respect the rights of women and girls (ref40).

            The situation in the Middle East warrants particular attention on issues related to Population and RH. In fact, during the second half of the 20th century, the population in the Middle East and North Africa (MENA) region has increased 3.7 times, more than any other region in the world, with a total population increase from around 100 million in 1950 to around 380 million in 2000 (ref 14). The immediate consequence of this growth is known as the phenomenon of “population momentum”, whereby each generation of young people enters the childbearing age in greater numbers than the previous generation, so as a whole they produce a larger number of births. This phenomenon translated into the fact that around one third of the population in the MENA region is currently under age 15. This proportion will reach its childbearing age in the coming 15 years, therefore doubling the number of women of childbearing age (15-49years) in the next 30 years.

            In view of this demographic situation, it became evident that providing quality Reproductive Health (RH) services, mainly family planning (FP), is a key issue in slowing the population growth in the region. Subsequently, over the past few decades, most of the countries of the region supported the provision of RH/FP services and information, directly or indirectly, as part of their Primary Health Programs. However, the MENA region still faces major RH issues including high Maternal Mortality Ratios (MMR) in several countries, and increasing prevalence of Sexually Transmitted Diseases (STDs) and HIV/AIDS.

            Although major RH concerns pertaining to Young people such as high teenage fertility and early marriage were raised over the past decade, most of the interventions in the MENA region have focused on the bio-medical aspects of RH and neglected the other dimensions of the problem, such as Sexual health, RH Rights and Unmet needs of youth.

 

2. Definition of Youth/Adolescents

 

            Youth is a broad category, and there is still no clear consensus as to what age groups are included under the youth category. Most of the time, Young people are referred to interchangeably with Adolescents, Teenagers and Youth.

            The age group referred to as Youth varies and some types of data may be available on selected age groups but not on all. Most of the time health indicators related to children and youth such as Infant Mortality rate, Children Mortality rates, are calculated for the age groups less than 1year or less than 5 years of age. Data regarding older children or adolescents per se are commonly merged as children more than 5 years or youth less than 15 years, or adolescents less than 18 years. Based on the developmental transition and its implications (biological and psychological), Youth is sometimes defined as the age group 6 to 24, which includes children more than 5 years (6-9 years), late childhood (10-12years), early adolescence (13-15years), late adolescence(16-19years) and early adulthood (20-24years). Some references stretch the Youth group up to 34 years of age.

            However, and for the sake of simplifying this review, Young people /Adolescents will be referred to using the WHO definition adopted by the International Planned Parenthood Federation (IPPF), and that includes all young people between the age10 to 24 years.

 

3. Realities of RSH of Adolescents in the Middle East

 

            There is a general perception that youth have the least health problems and are considered generally healthy. However, this may not be true when it comes to issues related to young people’s RSH. Although most international agencies, NGOs and governments consider Youth as a priority group to be addressed at all levels (social, health, education and development), facts are still indicative of unmet needs with respect to RSH, for women and men, worldwide, more so for Youth in the Middle East.

             In fact, according to the Global Burden of Disease done in 1990, reproductive ill health (including reproductive and peri-natal conditions), accounted for 22% of the global disease burden among women of reproductive age (15-44), and 3% for men. In the Middle Eastern Crescent, the burden of reproductive ill health constituted 12.5% of the total burden of disease in the region (ref 35). These figures are believed to under-represent the real situation, especially in the Middle East where data is not readily available and updated. Since Youth and Adolescents represent the biggest proportion of the population in the Middle East, it is expected that the burden of ill RSH is to a great extent actually born by and reflected on the Youth in this part of the world.

            However, accurate data on youth related to perception of health status and prevalence of diseases and prevalence of health risk behaviors as well as awareness about health risks among youth is often not available and incomplete in the region. Therefore it has been quite difficult to design effective interventions targeting adolescents RSH and responding to their unmet needs in that area.

 

            The IPPF in its Strategic Planning Framework for Adolescents (ref 41) has described the main challenges in addressing Youth/Adolescents RSH as follows:

            -Young people are not a homogeneous group but have different needs due to the diverse socio-cultural and political circumstances within which they live

            -Young women in particular face many socio-cultural, economic and political barriers which disproportionately affect their SRH

            - The SRH concerns of the young people are not integrated into the wider development agenda.

 

            There are many factors that affect the RSH of Young people and adolescents in this region. Although these factors could be internal (individual), or external (societal, environmental, political), they are all interrelated and quite impossible to be dissociated from one another. These factors often determine the RSH outcomes of the adolescents and can be described as follows:

 

3.1. Changing Adolescent Behavior:

 

There is growing evidence that many health risk factors for adult diseases including sexually transmitted diseases stem in the youth period where certain health risk behaviors (such as unprotected sex, substance use and abuse) are initiated and maintained throughout life. Some of these behaviors bear a particular risk for pregnancy related complications as well as acquiring STDs including HIV, particularly initiating sexual activity at an early age.

In general, there is tendency towards earlier sexual activities in most countries of the region, reflecting into a larger size of Adolescents getting into Sexual and Reproductive life, with all the possible implications on their physical and psychological health, be it in the context of marriage or outside this context. For example, 28.7% of ever-married women in Oman got married before the age of 15 years, and around 42% of Sudanese women and 50% of Egyptian women are married before the age of 20 years (ref1). In Lebanon, a national Knowledge Attitudes and Practices (KAP) study revealed that 47% of the general population interviewed had their first sexual encounter before the age of 20, and that 48% of those aged 15 to 24 had had sex outside the marriage, and only 42 % of them used condoms, while more than 33 % had multiple partners already (ref41). Data related to sexuality and sexual behavior among secondary school students in Lebanon (ref 44, 45) revealed that approximately 15% of the students (age 15-18) included in the study reported that they had at least one sexual encounter during their life time so far, and that 8.4% were currently sexually active, with on average more prevalence of sexual activity among males than among females. Data from a KAP study on Youth in Djibouti revealed that around 56% of Youth interviewed, aged 15 years and above, have regular sexual activities, with around 7%of them having sex with prostitutes, while 61% of them never use condoms (ref 43).

 There is a significant variation as to the age at first marriage: it is increasing in some countries while it is still low in many countries. For example, in Tunisia, age at first marriage is estimated at 29.2 years for women and 33 years for men (ref 1). Similarly, in Lebanon and Morocco, age at first marriage is estimated at 27 years for women and 31 years for men (ref 9). This means, if combined with the general observation of earlier sexual activities that many of the Youth population is engaging into a more permissive sexual behavior, often outside the context of marriage. Therefore, an increase in the prevalence of STDs /HIV and unwanted or teenage pregnancies is to be expected.        Although data regarding unwanted pregnancies among youth is not available because of the social norms, teenage pregnancy (recorded mainly in the context of marriage) still presents a significant problem in the Middle East. Data shows that overall, 3% to 27 % of young women in the MENA region have their first child by age 18 and 15%to 30% of births to young women in the region are unplanned (ref 8). Moreover, reports indicate that around 18% to 20 % of women in Bahrein had their first child between 11 and 15 years of age, and around 43% between 16 and 19 years of age(ref8). Similarly, in Oman, around 16% to 18% of women had their first child before the age of 15, and 70% between that age of 15 and 19 years (ref8). The same is observed in Saudi Arabia where 45% of women are estimated to have had their first baby before the age of 20 (ref8)

Moreover, epidemiological data available from the National AIDS Programs (NAP) in the Middle East region reveals that the majority of the HIV/AIDS reported cases are among young adults, 25 to 35 years of age, who acquired HIV through sexual transmission. Knowing the progress and the course of this disease, infection with HIV in most of these cases has been probably acquired in the youth period, most often due to the practice of unsafe sexual behavior.

At the same time, due to several factors, mainly unemployment, post war situations, and perhaps globalization, drug abuse seems to be rising among Youth across the region, which is also another potential risk for sex trade and STDs/HIV to this population. More attention should be given also to develop socio-behavioral studies and determine the changing patterns observed, in order to tailor more appropriately the necessary interventions.

 

            3.2. Access to Information on SRH

 

There is growing evidence in the Middle East that access to information for youth is probably insufficient. In fact many  KAP studies (ref  42,43,45) revealed that there is a lot of misconceptions among youth regarding HIV and STD transmission and relatively low risk perception and even relatively lower rates of practice of safe behaviors (abstinence, condom use…).  Data collected through the NAP Hotline in Egypt (ref 46) illustrates the need felt by youth for additional RSH information: 40% of those who called were less than 25years old, 60% of them were single, more than 37% needed specific information on sexual practices risks, and 63% wanted general and specific information on HIV transmission and testing and symptoms.

 A study conducted by the Lebanese Family Planning Association (ref 50), revealed that for youth (aged 14 to 24) the concept of sexual health concentrated mainly around the capacity to have healthy babies, and to a lesser extent the capacity to enjoy safe sex, normal deliveries and absence of diseases related to reproductive organs. The majority expressed need for information about conception and contraception to both sexes, and around 85% needed more information about STDs and HIV, and almost 70% requested additional discussions and information about safe abortion. Along the same line, data related to RSH and STDs (ref 41,42,44,45) revealed that there is a significant proportion (around 60%) who still had misconceptions, more frequently among those out-of-school than those in schools. Data from some countries also indicates that the most common sources of health information for youth, TV and mass media in general were the most widely accessible awareness diffusion tools for secondary schools students (93%), compared to conferences in schools or clubs (47%), friends (32%), teachers (31%), parents (38%), doctors (19%), and books (9.6%) (ref42,43,44), and that that youth prefer to have information on reproductive health from doctors or specialized books (ref 50).

            Although several countries have introduced HIV in their school curricula, most of the information on STDs/HIV is still obtained from Media (written as well as audio visual), and lately from internet. Still, in a region where the illiteracy rate is still relatively high (up to around 40% overall),  and where sometimes the bare essentials of Communication means such as TV and radios are considered luxury items (Sudan, Somalia, Djibouti), raising awareness about RSH presents a difficult outreach challenge and alternative strategies and means of education and awareness need to be applied.

             

3.3. Access to and utilization of Health and Social Services

 

Utilization of the services depends on several factors, including the need for the service, the type of service offered, the credibility of the provider, and the confidence and satisfaction of the user in the quality of the care provided, as well as to the affordability, sustainability and accessibility of the service. This is particularly pertinent for youth, who usually have limited resources and large needs in the area of RSH.

In the Middle East, there is a clear evidence for the need of RSH services. The types of services offered vary, depending on the level of development of the health system in each country. In fact, while some countries suffer from poor health care system infrastructure such as Yemen, Sudan, Somalia and Irak, others benefit from better developed and more comprehensive RH services infrastructure such as Tunisia, Lebanon and Morocco. Therefore, the spectrum of RH services varies in the region and affects the availability of these services. Most countries offer subsidized Family Planning services, only a few have developed counseling services, even fewer have STDs/HIV care and some do not have even Emergency Obstetric Care. Many countries are overwhelmed by the demand for RSH services to the extent the health system does not allow adequate coping (Yemen, Somalia).

None of the countries has a well established RSH system of services tailored to responds to the Youth needs in that area. Therefore, overall, the utilization of RSH services, when available, remains quite limited in most countries of the region. For example, utilization of PHC/RH services by the age group less than 15 years in Lebanon did not exceed 3% and by the age group 15 to 19 years, it did not exceed 8% (ref 55). In morocco, for example, only 51% of those ever pregnant had ever used a family planning method, although more than 99% of them knew at least one method of contraception (ref 9). This low utilization of RSH services could be due to several factors, including: Knowledge about the existence of such services, inconvenient working hours at the RSH services centers, fear of social stigma, affordability of these services, geographic inaccessibility, perception of the quality of the services rendered, and confidentiality. Unfortunately, data is not available on such issues.

At the same time, most countries of the region suffer, in general, from a weak social support system. Access to social assistance and family support is often insufficient, erratic and depends on the civil society and the NGOs volunteer interventions. Some countries (Morocco, Lebanon) have a more expressive and active civil society that could partially compensate for the need to a social safety net. In some countries, social support and counseling on RSH and STDs/HIV is almost exclusively provided by the NGOs (Lebanon). Some countries (Morocco, Lebanon, Egypt) have established “Hot telephone lines” to answer and anonymously counsel Young people on issues related to sexuality, RH and STDS/.HIV. Attempts at reinforcing this sector are initiated in some countries (Jordan), but still remain relatively shy and inconsistent.

 

3.4. Sexually Transmitted Diseases (STDs) and HIV/AIDS

 

            Special consideration should be given to the problem of Sexually Transmitted Diseases (STDs) including HIV among youth in particular due to the possible repercussions on adolescent health and on pregnancy and fertility outcomes.

Although data on STDs and HIV remains scarce and incomplete in the region, STDs seem to be quite prevalent in this region. This has a special influence on the RSH of Youth, who have generally inadequate access to information and protection means. Despite the fact that most of the studies done are on women attending gynecological or antenatal clinics and subsequently a significant proportion of STD patients (namely men and asymptomatic women) are not accounted for, studies and clinicians’ observations do suggest that STDs are on the rise in the region.

            In fact, selected studies (ref 48) from Egypt, Morocco, and Tunisia suggest that the incidence of all curable STDs (excluding Candida and HIV) is not less than 8%. Studies on special groups estimate that Syphilis serology prevalence has reached as high as 36% and 42% in selected groups (prostitutes and prisoners, respectively), in some countries (ref 48). In other countries such as Algeria, studies reveal that 40-70% of the people in their reproductive age acquire at least twice STD in their life time (ref 47).

 

            There is growing evidence that HIV epidemic is also spreading among Youth in this region, as described in the following Table 1

 

 

 

 

 

 

 

Table 1-HIV/AIDS statistics in selected Arab states (ref 52,53,54)

Country

Total HIV/AIDS

reported

Estimated HIV

 

%Female

 

Average age of infection

%transmitted by heterosexual contact

Algeria

NA*

NA

30

NA

38

Bahrein

216

500

13

NA

16

Djibouti

30,000

 

55

15-30

95

Egypt

1552

5,000

12

20-40

44

Iraq

277

NA

 9

NA

9

Jordan

281

500

26

20-45

45

Kuwait

835

1300

16

NA

NA

Lebanon

613

2000

21

20-40

54

Morocco

722

NA

NA

NA

77

Oman

600

1200

30

NA

59

Palestine

48

NA

20

NA

39

Qatar

NA

300

44

NA

10

Saudi Arabia

NA

1100

34

NA

72

Sudan

7867

400,000

33

20-45

97

Syria

230

800

21

15-40

73

Tunisia

608

NA

20

NA

32

United Arab emirates

2300

NA

NA

NA

NA

Yemen

874

NA

33

15-49

75

 

*NA: data is not available

Note: -the data shown in this table is obtained mainly from the official data reported by National AIDS Programs. Missing information is completed from other sources (Ministries, publications and field reports) when available.

                  -the percentages shown in the last column of the table do not add up to 100% in the countries, mainly due to unspecified modes of transmission

 

As shown in the table above, HIV spread is a reality among the youth population, and it is mainly spreading in the region through sexual contacts. Taking into consideration the changing RSH behavior of adolescents in this region, and the evidence of a potential more serious and widespread epidemic among the youth, the prevalence of STDs/HIV warrants special attention.

 

3.5. Gender issues and Socio-cultural Practices and Attitudes

 

In societies like those in the MENA region, where religion and religious norms bear a significant influence on social attitudes, sexuality and RSH are considered taboo subjects rarely discussed openly.

For example, HIV is considered an "immoral" disease, brought to people by their own "immoral behavior" (ref 49). Young people in particular are usually so afraid to acknowledge their risk behavior that they end up losing the precious opportunities of being properly counseled, or discussing ways of prevention with their partners. Many a times STDs and HIV remain unaddressed because of fear and stigma.

Certain harmful practices such as Female Genital Mutilation (FGM), with the serious RSH complications ranging from sexual dysfunction to bleeding and labor obstruction and fistula formation, are widely prevalent in some countries of the region (Egypt, Sudan, Djibouti, Somalia, Yemen, Mauritania), and reach up to 99 % of all women in some of those countries (ref 51). It is estimated that around 140 million women have undergone FGM and that around 2 million girls will undergo FGM each year (ref1). Interestingly, and surprisingly, such harmful practices are perpetuated by women themselves (ref 51). A great majority of young men and more than 85% of young women, in Egypt and Oman believe that FGM is important and necessary. At the same time, 91% and 88.5% of young boys and girls respectively believe that a woman should take her husband’s permission on everything (ref 1).

Most of these social attitudes and practices are actually dictated by Gender discrimination especially against young girls. In fact, there are two times more illiterate young girls than young boys all over the region, 23.5% and 12.2% respectively (ref24). This makes young girls at a great disadvantage from accessing health information, especially that related to RSH. In countries where early marriages are the custom, fathers and not daughters are the final decision makers in marriage choices in 60 % of cases (ref1). Preferences to boys reflects in the fact that, in some countries like Oman, around 38% of young men and 30 % of young women believe a woman should keep trying until she gets a male child (ref1).

 

3.6. Consequences of Conflict and Displacement

 

The frequent conflicts and wars experienced over the past few decades in many countries of the region has resulted in massive displacement of populations in this region.  For example, it is estimated that there are around 2 million refugees of war in Sudan, around half a million in Somalia, around 100,000 in Djibouti, living in refugee camps in poor sanitary and living conditions (ref 54). It is also estimated that nearly 47% of the households in Lebanon have at least one member who migrated outside the country over the past three decades, most of them in their prime sexual and reproductive life (ref10).

Travel, displacement and migration are well known social factors that increase the risk of adopting behaviors that could be detrimental to health. However, travel and migration entails separation of families, adding to the psychological stress and the economic stress that could drive people into seeking stress relief through casual sex or sex trade, respectively. No studies are available regarding changing behavior of the populations in the Middle East region in times of war, but changing social and cultural norms are definitely observed in countries post or during conflict, adding to the risk of HIV, such as increase IVDU or prostitution. For instance, rape and assault in refugee camps against women and girls have been reported in almost all camps in Somalia, which raises serious concern regarding rapid spread of STDs, increased rate of unwanted pregnancies which, associated with stigma and social expulsion, increases RH vulnerability of women (ref 56).

Mobility therefore has been associated with increased spread of STDs and HIV in this part of the world. Risk becomes more serious when movement of population is towards or from countries with high prevalence of HIV. For example, in Lebanon, 47.6% of all HIV cases reported are migrants or frequent travelers, most often to West African countries (ref 52). In Yemen,, it is estimated that around two million Yemenees are working  in Africa( East and Sub-Saharan), returning home quite frequently (ref 54). In Jordan, 69 % of the cases reported are among travelers/migrants who acquired the HIV infection outside the country and in Saudi Arabia, more than 60% of cases reported are among non Saudis(ref 52,54) Other countries, such as Morocco, and Tunisia, are observing the same phenomenon.

Therefore, travel and migration presents main RSH risks for youth including disruption of social norms calling upon strong coping mechanisms that may not always be available, which often leads to increased possibility of casual sexual partners because of abuse or stress relief, and subsequent potentiation of the RSH problematic consequences such as STDs/HIV and unwanted teenage pregnancies. This could add tremendously to the vulnerability of youth in RSH.

 

3.7. Poverty and economic dependence

 

Poverty seems to be a common factor affecting RSH of youth in particular. In the MENA region, poorer countries seem to be more affected, where economic deterioration is an important factor adding to the high RSH risk behavior. In fact, poverty denies access to Education and to Care and Counseling. Poverty drives into sexual abuse, prostitution and drug abuse.  Poverty is a fertile ground for wars and conflicts; and the vicious cycle goes on.

 

 4. Reproductive and Sexual Health (RSH): Rights and Obligations

 

 The relationship between population growth, development slowdown and poverty exacerbation were addressed by the United Nations (UN) as early as 1954.  With the creation of the United Nations Population Fund (UNFPA) in 1969, the idea of fertility control was introduced through Family Planning programs which soon became synonymous to Population programs. However, Family planning/Population programs proved to be insufficient to address all dimensions of RH and sexual health, especially when development and youth were targeted.

This brought about the broader definition of RH during the International Conference on Population and Development (ICPD) in 1994. RH was defined for the first time in an International Policy document, and covered a large spectrum of conditions ranging from ones directly and clearly related to RH such as pregnancy, to the most sensitive and subtle issues such as violence related to sexual behavior and associated mental ill health. RH in this wider definition deals with the three aspects of life that are intimate and culturally very diverse, and most difficult to discuss openly, namely sex, birth, and death.

RH as defined in the paragraph 7.2 of the ICPD Program of Action reads as follows:

“RH is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity, in all matters related to reproductive system and to its functions and processes. RH therefore implies that people are able to have a satisfying and safe sex life, and that they have the capability to reproduce and the freedom to decide if, when and how often to do so. Implicit in this condition are the right of men and women to be informed and to have access to safe, effective, affordable and acceptable methods of family planning of their choice, as well as other methods of their choice for regulation of fertility which are not against the law, and the right of access to appropriate health care services that will enable women to go safely through pregnancy and childbirth and provide couples with the best chance of having a healthy infant .In line with the above definition of RH, RH care is defined as the constellation of methods, techniques and services that contribute to RH and well- being by preventing and solving RH problems. It also includes sexual health, the purpose of which is the enhancement of life and personal relations, and not merely counseling and care related to reproduction and sexually transmitted diseases “(ref 20).

 

On the other hand, several UN international conferences on development, covering issues pertinent to RH, were organized over the past few decades, including: World Population Conference (Bucharest, 1974), World Summit for Children (New York, 1990), Conference on Environment and Development (Rio de Janeiro, 1992), World Conference on Human Rights (Vienna, 1993), World Summit for Social Development (Copenhagen, 1995), and Fourth World Conference on Women (Beijing, 1995).

In all these conferences, Young people were considered a priority group that needed special targeting and attention. Most international conventions and conferences stress the need to ensure the rights as well as quality services in Adolescent sexual and reproductive health matters.

The following highlights the issues pertinent to Young/adolescent Sexual and RH as described in the recommendations of selected international conferences.

 

4.1-Sexual and Reproductive Health (SRH) Rights

 

The International Conference on Population and Development (ICPD), held in Cairo, Egypt in 1994 is considered a landmark international event that raised concern over RH beyond fertility regulation and reiterated the scientific necessity to probe into social and behavioral aspects of health in general, and of sexual health in particular. The Cairo ICPD resulted in the development of a Program of Action which was adopted by 178 countries, and which stated empathically that the protection and exercise of human rights must be among the primary principles shaping population and development policies (ref17)

The definition of RH clearly refers to Reproductive and Sexual Health (RSH) as a right. Moreover, based on the ICPD recommendations, sexual health must be recognized as a human condition that affects RH.

One of the innovative approaches of the ICPD is the introduction of debatable issues related to rights, equity, empowerment, self-determination and responsibility in relationships, and not only RH needs and services (ref 25). These issues were specially emphasized for Adolescents (explained in section E, paragraphs:7.41,7.42,7.43,7.44, ref 20). In fact, the ICPD Plan of Action recognizes the negative effects of poor education, economic dependence and sexual exploitation in increasing adolescent unwanted pregnancies rates and subsequently adolescents Mortality and Morbidity; it also acknowledges the pressures put on adolescents to engage earlier into sexual activities, increasing their risks of acquiring Sexually Transmitted Diseases (STDs) and HIV.

 

4.2-the Right to RSH Information

 

It is well established that information plays a crucial role in ensuring that people can make and implement meaningful choices about their reproductive and sexual lives from within their families, their communities and states of which they are a vital part (ref17).

The ICPD Plan of action also reiterates the need to make information on sexuality and protection means readily available and accessible to the young people (ref 20). As stated in Paragraph 7.3:

“Reproductive health eludes many of the world’s people because of such factors as inadequate levels of knowledge about human sexuality and inappropriate or poor-quality RH information….Adolescents are particularly vulnerable because of their lack of information”

The first goal in the IPPF Vision 2000 strategic plan is to “advance the basic human right to make free and informed choices regarding their own sexual and reproductive health, and advocate for the means to exercise these rights” (ref1).

The right to information necessary to make appropriate SRH choices stems from several internationally recognized human rights, including (ref 17):

-the right to freedom of expression and information

-the right to equality and non-discrimination

-the right to life

-the right to health

-the rights to respect for human dignity, bodily integrity, personal security and individual liberty

-the right to make free and informed decisions about fundamental aspects of one’s private and family life

The main international treaties and customs from which the right to RH information and choice originate are (ref 17):

-The UN Human Rights Covenants (The Civil Covenant and the Economic Covenant)

-The Convention on Elimination of all forms of Discrimination against Women

-The Convention on the Rights of the Child

-The Universal Declaration of Human Rights.

 

 

 

4.3-The Right to RSH services

 

            Acknowledging the fact that the abstract right to make a decision becomes concrete only  if the conditions needed to carry it out  exist, the ICPD Plan of Action states that “ the provision of appropriate services and counseling specifically suitable for that age group” is a main objective in addressing .and improving adolescent sexual and RH (ref 20)

There is no doubt that RSH services are needed, and must be accessible to all people, especially the most vulnerable, and delivered with a high quality. RH services have already been defined to include: family planning, safe abortion (within countries’ legal framework), cervical cancer screening, delivery by trained birth attendants, emergency obstetric interventions, and sexually transmitted infections (STI) counseling and prevention (ref 25).

The ICPD Plan of Action, in Paragraph 7.5, recommends that a main objective is to ensure that “a full range of RH care services, including family planning, are accessible, affordable, acceptable and convenient to all users”(ref 20).

This presents also the double challenge of defining appropriate RH interventions that prove to be effective from a biomedical point of view, but also cost-effective.

 

            4.4-Obligations to Governments

 

            In the ICPD Plan of Action, governments are urged to put perspectives for promotion and prevention in RH in general with more attention to sexual health according to their “sovereign right consistent with national laws and development priorities, with full respect for the various religious and ethical values and cultural background of its people, and in conformity with universally recognized international human rights” (ref 25, 14)

            In that sense, governments have the positive obligation to protect SRH rights by preventing others from violating them, or to fulfill those rights by issuing rules and regulations and laws meant to secure the effective enjoyment of these rights. At the same time, governments have the negative obligation not to violate the SRH rights by issuing any regulations or interventions that prevent the full exercise of these rights (ref 17).

            These obligations translate into duties that can be summarized as follows:

 

1-Not to interfere with the communication of SRH information

2-Not to discriminate in providing information and counseling to vulnerable groups (for example based on marital status, gender or age)

3-Ensure that all are given equal opportunities to express opposing views on issues of public debate

4-Not to perform, encourage or permit interventions without free and informed consent

5-Take measures to prevent private groups or individuals from interfering with the communication of SRH information

6-Ensure that information relevant to client’s health is not withheld

 

           

 

            - Recommendations

 

            -priority areas of focus

            -political commitment

            - resources

 

 

 

5. Conclusion and Recommendations

 

            As described in the above sections, Youth in the MENA region have many unmet needs that need to be addressed. There is need for additional awareness on RSH, for improved access to adapted quality services that respond to youth expectations, and for narrowing the gaps due to gender biases among young girls and boys with respect to information, availability and accessibility to RSH services. These needs are acknowledged by the international society as well as by the governments who ratified the international conventions and recommendations. There is an urgent need to translate the acknowledgement of these rights into rules and regulations that secure the Youth RSH right for information and quality services.

            The IPPF has perhaps most adequately summarized all these needs and rights by stating the goal of the Adolescents RSH Strategic Planning Framework (ref 41) as follows:

            “All young people should be empowered to make informed decisions and choices regarding their sexual and reproductive health and well- being”

 

            The ICPD-4 has also recommended some basic actions to be taken by countries to respond to the objectives stated in paragraph 7.44 (ref20). These actions should mainly focus on: protection and promotion of the rights of youth for RSH, development of programs especially tailored to respond to youth needs in RSH, building the capacities of all who have to deal with issues related to youth/adolescent RSH.

 

            In the last meeting for the Arab African Parliamentarians held in Cairo in June 2003, the recommendations for further actions in the Arab Countries included also supporting governments in the elaboration of population policies, improve and upgrade the family planning and population programs to include safe motherhood, RSH rights and more involvement of men, capacity building for management of RSH programs (ref8).

 

Based on the above situation description and the previous recommendations of the various International and Regional meetings, it is suggested that improvement in youth RSH in the Arab Countries should focus on the following areas:

 

            -securing the rights of youth in RSH

            -ensuring access to information on RSH

            -ensuring access to quality, youth adapted RSH

            -improve data regarding determinants of youth sexual behavior

            -improve data related to youth RH seeking behavior

            -improve data collection regarding youth RH indictors

 

This could be done through the following:

-         - establish and reinforce the implementation of regulations that secure and protect - youth  right for RSH, right to RSH information, and right to RSH services develop RSH programs based on thorough analysis of Youth needs, targeting youth in the formal and informal sectors (schools and out-of-schools), using peer education techniques and outreach activities, as well as counseling services

-         review and upgrade the school curriculae to integrate RSH education

-         integrate HIV and STDs counseling and education and services in all youth RSH programs and activities

-         implement social and behavioral research addressing youth sexual and RH behavior

-         share research results and expertise through a regional network for youth RSH

-         develop a system of data collection that allows monitoring of programs and progress made in youth RSH indicators

-         develop programs for training NGO s and teachers and government officials on issues pertaining to youth RSH

-         advocate among various stakeholders the need to address more appropriately the unmet needs of the young population

 

            These recommendations could be implemented only if there is a strong political commitment to improve youth RSH, involvement of various sectors concerned in youth health and education, respect of the MENA cultural specificities, and proper mobilization and allocation of resources.

 

 

 

 

 

 

 

 

 

 

List of References

Arab Parliamentarian meeting

Morocco, Dec 3-5, 2003

 

 

1- An Overview of the Sexual /reproductive health of Young People in the Arab World Region: an IPPF perspective. Lina Chichakli .June 2003

 

2*- Realities and challenges for Bahreini Youth:  an introduction to the African Arab parliamentarians meeting. Parliament of the Kingdom of Bahrein. Cairo, July 2003

 

3*- Youth in Tunisia: an introduction to the African Arab parliamentarians meeting Parliament of Tunisia. Cairo, July 2003

 

4*- Youth in Morocco: an introduction to the African Arab parliamentarians meeting. Parliament of Morocco. Cairo, July 2003

 

5*- Youth in Mauritania: an introduction to the African Arab parliamentarians meeting. Parliament of Mauritania. .Cairo, July 2003

 

6*- The Rabat Declaration on Youth and Reproductive Health. National Population Councils in the Middle East. Rabat, Morocco, October 2001

 

7*- Youth in the Sultanate of Oman: an introduction to the African Arab parliamentarians meeting. National Health and Social Committee in the Sultanate of Oman. Cairo, July 2003

 

8*- Features and particularities of Populations in the Arab World: an introduction to the African Arab parliamentarians meeting. United Nations Population Fund. Cairo, July 2003

 

9*- Youth in Morocco: a document paper for the African Arab parliamentarians meeting. Aziz Ajbilou.  Cairo, July 2003

 

10*- Youth in Lebanon: a document paper for the African Arab parliamentarians meeting. Parliament of Lebanon. Cairo, July 2003

 

11- Advocacy guide for Sexual and Reproductive Health and Rights. International Planned Parenthood Federation. August 2002

 

12- Post Cairo Reproductive Health Policies and Programs: a comparative study of eight countries. Karen Hardee et al. USAID policy project, September 1998

 

13*- The family, Gender and population policies: opinions from the Middle East. International Populations Council. 1995

14- Population Trends and Challenges in the Middle East and North Africa. Population Reference Bureau.  October 2001

 

15- Making pregnancy safer: a health sector strategy for maternal and perinatal morbidity and mortality. World Health Organization.  Geneva, 2000.

 

16- Dr Fred Sai speaks out. International Planned Parenthood Federation.  1994

 

17- The right to Know: human rights and access to reproductive health information. Edited by Sandra Coliver. University of Pennsylvania press. 1995

 

18*- Idhafat soukania. Directorate of Population Councils at the Arab League. May 2003.

 

19- Charting the Progress of Populations. United Nations Economic and Social Affairs. 2000

 

20- International Conference on Population and Development: a program for action United Nations, Cairo, September 1994

 

21- Sex ,Population and Politics. Martin Sagrera. Editorial Fundamentos, 1990.

 

22- Declaration of Commitment on HIV /AIDS. United Nations General Assembly Special Session on HIV/AIDS. June 2001.

 

23- The Status and Trends of the HIV/AIDS Epidemic in the World. 13th International AIDS Conference, Barcelona, July 2002

 

24- The State of Children and women in the Middle East and North Africa. UNICEF Regional Office for the MENA. September 2001

 

25- Interpreting Reproductive Health: ICPD+5 Forum at the Hague. World Health Organization, Geneva. February  1999

 

26- The World Health Report 2002: reducing risks, promoting healthy life. World Health Organization, Geneva, 2002

 

27- Lebanon National report at the ICPD 1994. United Nations Population Fund, Beirut, 1994.

 

28- Reproductive Health: achieving clarity and setting priorities. C. Myntti. Beirut, 2000.

 

29- Reproductive Health: Strategy for the African region 1998-2007. World Health Organization, AFRO, 1998.

 

30- The Impact of HIV/AIDS: a population and development perspective. United Nations Population Fund, series number 9, 2003.

 

31*- Working towards Improving Adolescents Health. WHO, UNICEF and UNFPA regional offices for the Middle East. 1995

 

32*- Adolescent Health. The Scouts Movement in Yemen and WHO. 1999

 

33*- Towards Focused Strategies in Reproductive Health and Family Planning: policies, rights and socio-cultural attitudes. Toufic Osseiran. Lebanese Family Planning, Beirut, 1999.

 

34*- The Right to Chose: reproductive rights and reproductive health. United Nations Population Fund. 1999.

 

35- DALYs and Reproductive Health: a Report of an Informal consultation-WHO- April 1998

 

36-Fast Facts about Maternal Mortality and Morbidity-UNFPA website document (http://www.unfpa.org/gender) -October, 2002

 

37-Reducing Risk by Offering Contraceptive services-UNFPA website document (http://www.unfpa.org/gender) -October, 2002

 

38-World Report on Violence and Health- WHO-2002

 

39-Ending widespread Violence against Women-UNFPA website document (http://www.unfpa.org/gender) -October, 2002

 

40-Promoting a new vision of Masculinity-UNFPA website document (http://www.unfpa.org/gender) -October, 2002

 

41- Strategic Planning Framework For Adolescents.-IPPF Governing Council, IPPF, May 2003.

 

      42- Knowledge, Attitudes and Practices related to HIV among General population-                NAP Lebanon, (1996)

      43- Etude des Connaissances, Attitudes, Pratiques des Jeunes et leur  Particiaption     a la Promotion de leurs activites et de la PreventionVIH/MST a Djibouti Ville.          Ministeres de la Sante, de la Jeunesse et de L'Education, ADEPF, et UNICEF.   Djibouti, -(May 2001)

 

     44- Youth Health Risk Behavior Survey among secondary School Students in     Lebanon: Prevalence and Clustering of Risk Behaviors. A. Sibai and N.Kanaan,            Beirut, February, 1999.

45- Knowledge, attitudes Practices and Beliefs related to HIV/AIDS among secondary      school students in Lebanon. Ministry of Public Health, National AIDS Control Program, Beirut, 1994

 

46- Annual AIDS Hotline report- Egypt, MOHP/NAP (2000)

 

47- Processus de Planification Strategique- Algerie, 2002-2006 (January 2002)

 

48- Regional Committee for the Eastern Mediterranean Region, Progress Report of the 48th session. –WHO (July 2001)

 

49- Report on the Global HIV/AIDS Epidemic- UNAIDS,(June 2000)

 

50- Survey on Youth and Reproductive Health. Dr Z. Hatab for the Lebanese Family Planning Association, Beirut, 1996

 

51- Textual report on the Survey of Adale district to questions relating to Female Genital Mutilation. SAACID Somalia. May 2003

 

52**- Selected country reports from National AIDS control Programmes in the region-December 2000-2002

 

53- Global summary of HIV/AIDS epidemic. UNAIDS/WHO report-December, 2002

 

54- Overview of HIV/AIDS situation in the Middle East and North Africa and East Mediterranean region. Main report by the World Bank, WHO and UNAIDS-June 2002.

 

55- Reproductive Health sub-programme: second quarterly report, 2002- Lebanon, MOPH, 2002

 

56- Analysis paper on the IDP situation in Somalia. OCHA RSO-CEA/ SL.