Millions of youth in Sub-Saharan Africa have lost one or both parents to the HIV epidemic, leaving them vulnerable to numerous adverse health, educational and socioeconomic outcomes. However, few studies have investigated whether orphans have an elevated risk of adolescent pregnancy, and their results have been mixed. In addition, the explanation for such an association is unclear. Some researchers have speculated that socioeconomic deprivation makes orphans vulnerable to sexual exploitation or coercion, and therefore to risky sex and unwanted pregnancy.

In the lead article of this issue of International Perspectives on Sexual and Reproductive Health, Rachel Kidman and Philip Anglewicz use data from the Malawi Longitudinal Study of Families and Health to explore whether Malawian orphans are more likely than nonorphans to have adolescent pregnancies and, if so, why [see article]. Some 26% of the 15–25-year-old respondents had lost their father and 15% their mother. Fertility was elevated among young women whose father had died more than five years earlier, and among young men whose mother had died in the past five years or earlier. Respondents whose mother had died in the past five years desired more children than did those whose mother was still alive. Being an orphan was not associated with sexual risk-taking. The authors suggest that for orphans in Malawi, pregnancy may be intentional and represent an attempt to achieve a sense of normalcy, acceptance and love.

According to survey data from sexually active urban Senegalese women aged 15–29, 20% of married women and 27% of sexually active unmarried women were using modern contraceptives; the levels of unmet need for contraception—mostly for spacing—were 19% and 11%, respectively. Given the low prevalence among young women, Estelle Sidze and colleagues used service data from family planning providers to examine the frequency with which providers impose eligibility restrictions based on age and marital status [see article]. Although official policies set no restrictions based on age, 57% of the public-sector providers surveyed applied such restrictions to provision of the pill and 44% to provision of the injectable—two of the methods most often used by young women in urban Senegal. Those proportions in private facilities were 49% and 41%, respectively. The median minimum age for contraceptive provision was typically 18. In addition, 12–14% of public-sector providers refused to supply the pill and the injectable to unmarried women. The authors recommend that official protocols state clearly that adolescents and young people have a right to contraceptive services, and that health providers be trained not to impose age and marital status restrictions.

Jeffrey Bingenheimer and Elizabeth Reed bring a contextual approach to their analysis of sexual coercion and sexual violence. Using two waves of data from female respondents aged 13–14 or 18–19 in southeastern Ghana, they find that 18% had experienced coerced sex prior to the first wave and 13% did so between waves [see article]. In cross-sectional and prospective analyses examining the influence of household composition and wealth, family process variables, school enrollment and relationship experience, only ever having had a boyfriend was independently associated with having experienced coerced sex. The authors conclude that although strategies designed to increase parental behavior control or to improve skills for managing conflict in parent-adolescent relationships may offer some protection against sexual coercion, strategies aimed at influencing behaviors within romantic relationships may be more promising.

According to population-based data from nearly 3,400 couples in northern India, 24% of husbands had had premarital sex with a woman other than his wife, 7% had had extramarital sex in the previous year and 6% had had STI symptoms during that period [see article]. Using structural equation modeling, Alpna Agrawal and colleagues found that wives who reported higher levels of autonomy were less likely than those with lower levels to have a husband who had had extramarital sex in the last year (direct association) or one who had had STI symptoms in the past year (indirect association). Moreover, husbands who endorsed more inequitable gender attitudes were more likely than those who did not to report having had premarital sex with someone other than their spouse, which in turn was associated with having had extramarital sex and STI symptoms in the previous year. According to the authors, their findings support making gender issues a standard component of HIV prevention programs.

Also in This Issue

In a Comment, Karen Hardee and colleagues examine what constitutes coercion in family planning policy and program management—which they define as actions or factors that compromise individual autonomy, agency or liberty related to contraceptive use or reproductive decision making through force, violence, intimidation or manipulation—and identify practices that are either violations (coercion is clearly occurring or is very likely to occur) or red flags (potential for coercion exists). The authors contend that examining allegations of coercion will aid in the development of safeguards to reduce the incidence of coercion, help protect or redeem programs that are falsely accused of coercion, and help ensure that programs provide voluntary family planning services that respect, protect and fulfill human rights.

The Editors