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Executive summary
Adolescent pregnancy is a public health priority due to the risks it poses to the health and wellbeing of adolescent girls, and their babies. In many contexts, adolescent pregnancy is closely linked to child marriage and early union. The child-marriage rate in Lao People’s Democratic Republic (PDR) is the highest in the region (UNICEF and UNFPA, 2022). Analysis of nationally representative data from Lao PDR revealed that among women aged 20–24 who gave birth before the age of 18, two-thirds conceived in the context of union, but more than one in four (27 per cent) conceived outside of union (Harvey et al., 2022). Data also suggests that pregnancies outside union are becoming more common in Lao PDR (UNICEF and UNFPA, 2022).
In light of these challenges facing adolescent girls, it is worth noting that the Lao Government recognizes the multi-faceted dimensions that make girls vulnerable. Since 2016, the Lao Government has adopted the Noi Framework as a national response. The framework is a holistic approach toward advocacy, programming and evidence generation around adolescent girls to ensure their needs, such as avoiding early pregnancy, are integrated into the Lao Government’s Sustainable Development Goals (SDGs) implementation plans (UNFPA, 2019). The United Nations Population Fund (UNFPA) invests in building systems for capacitating young people to address child marriage and adolescent pregnancy, including the integration of comprehensive sexuality education (CSE) curricula at all education levels, and provision of sexual health information and services, mental health and psychosocial support, and protection services for survivors of gender-based violence.
To generate new insights to complement this existing landscape, this qualitative study helps fill the research gaps on adolescent girls’ pathways to adolescent pregnancy in Lao PDR, particularly those that occur outside of union.
This study aimed to 1) understand the different drivers and pathways to adolescent pregnancy, and 2) co-develop, with adolescents, policy and programming recommendations to effectively address adolescent pregnancy. The findings of this study can help inform strategic investments and interventions that address specific pathways and drivers of adolescent pregnancy, thereby enabling girls to make informed decisions for their relationships and life trajectories.
While the study on pathways to adolescent pregnancy was conducted in four countries, this report discusses the study implementation and findings only from Lao PDR.
Using a participatory, qualitative approach, the study design placed adolescent perspectives at the forefront, using primary data collected with adolescent girls aged 16–20 who experienced pregnancy or birth at age 18 or younger. Study implementation was guided by a working group comprised of representatives from UNFPA and the United Nations Children’s Fund (UNICEF), and two youth advisors from the study country. Data collection was conducted in two provinces and one prefecture – the province of Vientiane, the prefecture of Vientiane (which is the capital city) and Luang Namtha. Each site represents median (Vientiane province and capital city) and high (Luang Namtha) adolescent fertility and premarital conception.
During the first round of data collection, an in-depth, timeline interview approach was used. Framework analysis was applied during preliminary data analysis, and candidate pathway typologies were developed based on girls’ life stories and contributing factors in their pathways to adolescent pregnancy. During the second round of data collection, follow-up interviews were conducted with selected girls to validate and clarify study findings and interpretations and gather girls’ recommendations for programmes and policy.
Through in-depth interviews using a timeline approach with 57 girls, eight pathways to adolescent pregnancy were identified. These pathways were differentiated primarily according to the timing of pregnancy relative to union. Outside-union pregnancy pathways were differentiated further by the context of sex preceding pregnancy (consensual, pressured, forced) and pregnancy intention (unplanned, planned, partner-led). Within-union pregnancy pathways diverged according to pregnancy intention (unplanned, planned) and who initiated the union (couple- or girl-led, or parent- or partner-led). Cross-cutting factors contributing to girls’ pathways to adolescent pregnancy included barriers to sexual and reproductive health (SRH) information and contraceptive access and use; partners’ control over reproductive decision-making; prevalence of pressured and forced sex; community acceptance of child marriage and early union; and attitudes and norms regarding sex and pregnancy outside of union.
During 20 follow-up interviews, adolescent girls recommended that programmes and policies should ensure that girls have access to detailed, easy-to-understand SRH information, help girls to have better access to non-judgemental health care in safe spaces, support girls to access and use contraceptives, teach girls about negotiating sex and contraceptive use (and include boys and parents in discussions), and work toward changing community perspectives that support child marriage and discourage contraceptive use.
The findings show that adolescent girls in Lao PDR follow diverse pathways to adolescent pregnancy and require support at different decision points in their lives. Many adolescent pregnancies occurred outside of formal marriage or cohabiting union despite the persistence of conservative social ideals that disapprove of sex and pregnancy outside of union. Adolescent girls’ experiences of sex and pregnancy were often influenced by a lack of knowledge about SRH (including contraception), power imbalances with their partners, and girls’ lack of agency over if and when to have sex, use contraceptives and begin childbearing. These were also occurring within sociocultural contexts where parents, community members and adolescent girls viewed child marriage and early union as a socially acceptable alternative to education or work, and as the most acceptable resolution to a pregnancy outside of union.
Toward achieving the Government of Lao PDR’s commitment to the the International Conference on Population and Development (ICPD) Agenda, especially to end the high unmet need for family planning among adolescents, it is imperative to address the barriers adolescent girls face to SRH information and contraceptive access and use.
As expressed by adolescent girls, girls and boys need access to straightforward and consistent SRH information, especially regarding pregnancy risk and contraception options. Specifically, this will involve strengthening age-appropriate comprehensive sexuality education (CSE)/life skills education (LSE) both within and outside school settings, delivered in-person and online. In support of this, it is also recommended to ensure that adolescent girls and boys are aware of existing services available to young people (e.g. helpline counselling), and have access to non-judgemental, adolescent-responsive health care, complemented by increased availability of and easier access to affordable contraception (especially condoms).
Programmes and policies to focus on expanding the content and strengthening the delivery of CSE/LSE are also recommended, with a focus on empowerment initiatives to help girls make informed choices in their relationships, alongside initiatives to help boys respect girls’ choices and bodily autonomy. Also recommended is investment into interventions aimed at challenging community perceptions that SRH information (including about contraceptives) is not appropriate for unmarried adolescents, supporting all girls (whether in a union or not) to access and use their chosen contraceptive method, and addressing individual and social attitudes that contribute to misconceptions regarding contraceptives and male resistance to condom use.
Future research could explore:
• ways to make CSE/LSE sessions and learning materials more relatable for adolescents
• drivers of gender inequality in different socioeconomic and ethnolinguistic contexts
• adolescent girls’ health and well-being needs following experiences of sexual violence
• contraceptive knowledge, attitudes, and practice and reproductive preferences of adolescent girls’ partners (including their motivations for desiring pregnancy soon after union), and
• culturally responsive approaches to transforming harmful norms on child marriage and early union in similar settings.
The qualitative nature and scope of this study also had some limitations, such as not being representative of all the diverse ethnic groups in Lao PDR. While this study was able to generate rich qualitative data from a small sample of participants, not all ethnic groups in Lao PDR were represented. It is possible that other pathways featuring novel contextual and crosscutting factors may still emerge if more data is continuously collected.
It would be beneficial to map the prevalence of the different pathways to adolescent pregnancy at the national scale to better tailor interventions to girls’ specific needs and contexts, including the cultural practices among all the diverse ethnic groups in Lao PDR.