FIGIJ Advocacy Statement: The Need for Safe Abortion Access for Adolescents

Malaysian Translation: Penggugurannaag (Translated in Malay, N. Azurah, AOSPAG, 2024)

Introduction and purpose: demographics of Global Abortion Access for Adolescents
WHO estimated in 2019 that adolescents aged 15–19 years in low- and middle-income countries (LMICs) had an estimated 21 million pregnancies each year, of which approximately 50% were unintended. In many countries unsafe abortion is the leading cause of death in women (maternal mortality and also contributing to morbidity). In global crises, such as war or pandemics (i.e. COVID-19 or Ebola virus), girls are particularly vulnerable to sexual abuse, often resulting in unintended pregnancies and/or early marriage. Even in high income countries, access to abortion is not distributed equitably, with low-income communities having less access to abortion services.

Access to safe and legal abortion is an important, essential component of healthcare, especially for adolescents who have a higher percentage of unintended pregnancies and higher maternal morbidity and mortality, a worldwide public health problem.

In some countries abortion is completely restricted for all women. Restrictive regulations on abortions specifically targeting adolescents, even in countries where abortion is legal, include waiting periods, requirement for parental notification and/or consent, and restriction on travel across borders for accessing abortion services. FIGIJ supports the WHO 2022 Abortion Care Guidelines recommendation for decriminalization of abortion services.

Restricting abortion for adolescents leads to:

• Increased risk of distress and shame in adolescents who seek abortion services.
• Lack of robust systems for objective data collection and analysis about numbers of girls seeking abortions leading to knowledge gaps in sexual and reproductive medicine.

• Rise in maternal morbidity and mortality in vulnerable adolescents.
• Loss of trust in healthcare systems.
• Seeking of abortion services through unsafe channels
• Missed opportunities to access patients to prevent subsequent unintended pregnancy.

Restricting abortion leads to negative effects for healthcare providers, including:

• Reconsideration or refusal of evidence-based safe abortion services according to international guidelines.
• Fear of legal consequences of providing abortion health services.

Safe versus unsafe abortions: A matter of access

Both medical and surgical abortions are a crucial part of healthcare and performed in the clinical setting are safer than pregnancy, with the risk of death in childbirth greater than 10-fold more than with abortion. The risk of complications from legal abortion performed by a provider is extremely low, and contrary to myths does not affect future fertility or increase risk of cancer.

Historically, globally 45% of abortions occurred outside the healthcare setting and the majority in low and middle income countries (LMIC). Many women and girls with unintended pregnancies face barriers to attaining safe, timely, affordable, geographically reachable, respectful and non-discriminatory abortion care, so as a consequence they often resort to home remedies and unskilled providers to obtain an abortion resulting in unsafe abortion practices. Data show that restriction access to abortion does not prevent people from seeking abortion, it simply makes it more deadly. In order to access safe abortion young women need to face and manage stigma, lack of confidentiality and overcome significant systemic, social and cultural barriers. The need for parental consent, providers’ bias and the mere recognition of young people as sexual beings prevent youth from accessing sexual and reproductive health services they need and deserve.

Echoing the WHO, FIGIJ supports broad access for medical abortion for all adolescents as it is safe, private, cost-effective and limits the need for transportation for clinic visits.

FIGIJ advocates for the full spectrum of comprehensive reproductive care for adolescents including contraception, emergency contraception, sexual education and abortion services.

This includes:

• Providing women and girls with comprehensive sexuality education, accurate family planning and contraception information and services, and access to quality abortion care.
• Providing appropriate method mix for abortion (self-managed abortion, medical and surgical abortion) to all patients based on values and preferences of women and girls and the available resources.
• Training health professionals to provide safe and quality abortion care services with an appropriate understanding and interpretation of the laws and policies that regulate this practice.
• Staffing of health professionals offering abortion care within reach of patients.
• Supporting and protecting health professionals and patients against stigmatization.
• Recognition that pregnancy can occur due to violence and/or coercion and would necessitate appropriate safeguarding measures.

Postabortion care should include full contraceptive access, reproductive health counseling as well as nonjudgmental mental health support. Please see FIGIJ advocacy states “LARC’s access to prevent teenage pregnancy“ and “Mental health in children and adolescents from a PAG perspective “.

Conclusion

Human rights – including sexual and reproductive – should be respected, protected, and promoted by professional societies. Progressive legislation decriminalizing abortion upholds adolescent’s sexual and reproductive health.

Call for action

● FIGIJ supports access for adolescents to comprehensive sexuality and reproductive health education and the full range of contraceptive options, including emergency contraception to reduce unplanned pregnancy.

● FIGIJ supports legal and safe access to the full range of abortion services as a part of comprehensive medical care.

● FIGIJ supports a full decriminalization of abortion as recommended by the WHO.

● FIGIJ supports removing abortion restrictions specifically aimed at adolescents including third party authorization and/or parental notification and parental consent laws.

@ 2023
Mariela Orti, Argentina
Evelien Roos, the Netherlands
Anastasia Vatopoulou , Greece
Michalina Drejza, Poland/United Kingdom Clara Di Nunzio, Argentina
Judith Simms-Cendan, USA

FIGIJ Statement Adolescent: A call to minimize the risk of adolescent pregnancy through education and contraceptive access

Malaysian Translation: Kehamilan Remajanaag (Translated in Malay, N. Azurah, AOSPAG, 2024)

Introduction

Adolescent pregnancy, according to the World Health Organization (WHO) is pregnancy occurring in women under the age of 20 years. When a girl becomes pregnant during adolescence, her present and future changes radically. Adolescent pregnancy is a serious health risk relevant to all social classes, all economic levels and all cultures, yet profoundly affects adolescents living in low and middle income countries (LMICs). Every year, an estimated 21 million girls aged 15–19 years living in LMICs become pregnant, approximately 12 million girls between 15-19 years give birth. Just under 1 million girls under the age of 15 years give birth every year in LMICs. Pregnancy and childbirth among early adolescents in particular results in serious harm to the health of the affected dyad. Even for the older adolescent, girls aged 15 to 19 years, it is the second leading cause of maternal mortality globally.

Risk factors for Adolescents Becoming Pregnant

Adolescents who have low self esteem, a lower level of education and socioeconomic status (poverty), who lack family or social support and who live in communities without any institutional social support are especially vulnerable to becoming pregnant at a young age. Many girls experience considerable pressure to marry and become mothers while they are still children themselves, and this varies by culture and region. As a result, child marriage is a main contributing factor for adolescent pregnancy. The United Nations and WHO have estimated that 9 out of 10 births to girls between 15-19 years occur within marriage. Child marriage, according to UNICEF, affects girls disproportionately,and increases the personal risk of violence, exploitation, abuse, and adolescent pregnancy.

Adolescent Pregnancy Affects the Health and Welfare of Both Mother and Child

As gynecologists who care for adolescents, FIGIJ members recognize that girls especially below the age of 15 have much higher rates of maternal morbidity and mortality than older women as their body is not physically ready for the physiologic effects of pregnancy. Adverse maternal outcomes of pregnancy in this age group include obstructed labor, obstetric fistula, placental abruption, hypertensive (preeclampsia/eclampsia) and hemorrhagic complications, infection, and even death. Perinatal complications affecting the baby include prematurity, low birth weight and fetal death in utero. Pregnant teens with no support from their family are at risk of not accessing prenatal care and higher rates of depression and anxiety. While some adolescents see a rise in social standing and increased access to medical care, for many others the impact is much more adverse including denial of education, social ostracism, susceptibility to intimate partner violence, and economic hardship for her and her offspring.

Adolescent Pregnancy Prevention Requires Broad Efforts

Prevention of adolescent pregnancy requires comprehensive sexual health education and accessibility of services. Adolescents who may want to avoid pregnancies may not be able to do so due to knowledge gaps and misconceptions on where to obtain contraceptive methods and how to use them. Age-appropriate reproductive health education has been found to be effective. Targeting at-risk adolescents and providing individualized care were also effective. Improvement in health care and psychosocial support to pregnant adolescents prevents adverse outcomes for both the mother and the neonate. Governments must improve literacy of girls, improve legislation with regard to banning child marriage and addressing sexual violence and make laws to prioritize national support adolescent pregnancy.

Adolescents face barriers to accessing contraception including restrictive laws and policies regarding provision of contraceptive based on age or marital status, health worker bias and/or lack of willingness to acknowledge adolescents’ sexual health needs, and adolescents’ own inability to access contraceptives because of knowledge, transportation, and financial constraints. Effective interventions are available to prevent adolescent pregnancy and mitigate the effect of pregnancy on the young. However, many intervention programs do not include married girls, nor very young adolescents aged 10-14 years. Providing support especially to socioeconomically disadvantaged communities to keep the children in school and to provide access to health services is key to decreasing the incidence of adolescent pregnancies. Adolescents who become pregnant should be free from stigmatization and be permitted to continue their education. Programs caring for adolescents during their pregnancy and postpartum should support their emotional, medical and educational needs in a positive way, avoiding blame and shaming of young mothers.

Conclusions

FIGIJ calls for a holistic approach to respond to this problem (see Figure 1 below). Preventing adolescent pregnancies requires analysis of unique factors that place the child at risk. Family and community resources should be mobilized with both policy and material support of national governments and other influential sectors worldwide to recognize this burden and to reduce its impact on adolescent health.

Call for action

• FIGIJ supports comprehensive sexual and reproductive health education.
• FIGIJ advocates for access to youth-friendly health services including affordable and safe contraception, such as emergency contraception and LARCs. See FIGIJ Statement: A Call to Increase Access to LARC’s for Prevention of Adolescent Pregnancy.
• FIGIJ supports development of comprehensive programs from communities and institutions for both prenatal and postpartum care, education and socioeconomic support to optimize adolescent health and wellbeing during and after pregnancy.

© 2022
Angela Aguilar, Philippines Anastasia Vatopoulou, Greece Evelien Roos, the Netherlands

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Malaysian Translation: Panggilan untuk Meningkatkan Akses kepada LARC untuk Pencegahan Kehamilan Remaja  (Translated in Malay, N. Azurah, AOSPAG, 2024)

Introduction

Long Acting Reversible Contraception (LARCs) methods, methods which have more than a year of duration of efficacy, include copper intrauterine devices (IUDs), levonorgestrel IUD ́s and etonogestrel subdermal implants. These are highly effective and safe for use in adolescents and should be offered as first-line contraception. There is no evidence showing an increased risk of complications when using IUDs/implants in adolescents. Additionally, hormonal LARCs have numerous noncontraceptive benefits including reduction of menstrual pain and bleeding.

Adolescent pregnancy rates have declined in the past decade for a combination of reasons, including the increased access to and use of LARCs, but adolescent pregnancy remains disproportionately prevalent in women with low socioeconomic status (SES) compared to those with higher SES in high and middle income countries. (See the FIGIJ Preventing the Risks of Adolescent Pregnancy Statement). With postpartum LARCs use, the rate of repeat adolescent pregnancy decreases and the time interval to subsequent pregnancy increases. Despite the strong encouragement for their use, LARCs are not yet the most chosen methods due to various barriers including education of patients, families and providers as well as accessibility and affordability of these methods.

Improving education, access and use of LARCs

Dispelling Misconceptions of Providers and Patients

A misconception that IUD use increases the risk of pelvic inflammatory disease and impairs future fertility limits its uptake globally. An abundance of data with the levonorgestrel and copper IUDs confirms when placed according to guidelines infection risk is not increased. Adolescents who are at high risk for sexually transmitted infections should be screened either prior to or at the time insertion and treated if needed. Dual method of contraception use including condoms with LARCs or short acting contraception (SARC) such as oral contraceptives is recommended universally for adolescents and prevents sexually transmitted infections in at risk youth.

According to the UN Report on Contraceptive Use by Method in 2019, LARCS are used 13 times more by married than unmarried women (IUD 151 v 8 million, Implant 18 v 5 million). Both the WHO and the US-CDC-MEC state that IUD use in nulliparous adolescents under the age of 20 has benefits that outweigh the risks.

Misconceptions amongst parents and adolescents include that IUDs are not highly efficient at preventing pregnancy, and that they are not safe methods in younger women. Social media is filled with videos and posts regarding pain with IUD insertion, IUD expulsion and other complications, yet it is known that these complications are rare. These very compelling personal statements do not represent the general experience and safety; they induce fear and create negative perceptions about these methods. Improving education about the benefits of LARCS, as well as accurate information about the complications, should be provided widely on platforms most accessible to the young patients who need this information.

Improving access and affordability

Globally, there remains a lack of skilled providers in IUD and implant insertion and removal. Providing training opportunities for midwives, birth attendants and others who provide women’s health care will improve their skills and increase their capacity to provide care. Supplies of LARCs to underserved and rural areas should be increased concurrently with training of providers

The up-front costs of IUDs and implants, while expensive compared to SARCs, are actually economical because of their long duration of use and the higher comparable efficacy in prevention of pregnancy. This makes them a cost effective choice for countries and insurance carriers, but unless there is support at the individual level, barriers will remain for patients unable to afford the upfront cost.

Same day insertion will increase accessibility to patients who may be unable to return for multiple provider visits, either because of family, education or job responsibilities, or due to cost of travel.
As long as pregnancy can be excluded, a LARC method can be placed at any time during the menstrual cycle. The copper IUD can also be used as an emergency contraceptive method.

Globally there are widespread cultural or religious beliefs that act as barriers to LARC, including fear that increasing teen contraception will increase sexual promiscuity among adolescents. Establishing dialogues with communities regarding adolescent sexuality and safe relationships, while maintaining respect for cultural norms is important for developing trusting relationships between providers, patients and families.

Conclusion

Removing barriers of access to and correcting misperceptions about LARCs is cost effective, is safe and can reduce adolescent pregnancy and its medical and psychosocial sequela.

Call for action

• FIGIJ advocates for broad education on LARCs for reproductive health providers and the public.
• Providers, professional societies as well as governments are encouraged to provide factual information on LARCS and other forms of contraception through social media platforms to adolescents.
• FIGIJ endorses free provision of contraception, including LARCS for adolescents and encourages both government and the insurance industry to support this initiative.

© 2022
Mariela Orti, Argentina
Angela Aguilar, Philippines
Judy Simms-Cedan, United States of America Clara Di Nunzio, Argentina

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Introduction/purpose

The global prevalence of eating disorders (EDs) has doubled in the last decade from 3.5% to 7.8%, and 40% of these disorders are seen in those aged between 15-19 years. Amongst adolescents an ED is one of the most common chronic illnesses. EDs can have significant consequences, leading to impaired physical health, quality of life, and disruption of psychosocial functioning of adolescent patients and their families. They are, however, treatable conditions, and early recognition enables better outcomes. This statement focuses on the gynecologic consequences of EDs that result in under- and overnutrition.

The most common EDs are anorexia nervosa (AN), bulimia nervosa (BN) and binge eating disorder (BED). EDs are not the result of an individual’s choice but rather a result of interaction between genetic and environmental factors at critical time points in development. Adolescents, particularly girls, are increasingly conscious of their body and this has a bearing on their diet. Transgender youths are vulnerable to EDs resulting from having a body image that is not compatible with their gender identity, with an up to 2-4 fold increased prevalence of these disorders compared to cis-gendered youths. In the adolescent gynaecology setting, EDs may present with weight loss, menstrual disturbances, unexplained growth or pubertal delay, restrictive or abnormal eating behaviours, over exercising or recurrent vomiting. Although formal diagnosis and treatment of EDs are outside the scope of practice for pediatric and adolescent gynecologists, it is critical that providers are comfortable in recognising and screening for EDs thereby enabling referral for appropriate treatment giving the opportunity for better health outcomes. Treatment of EDs should be individually tailored and requires a holistic approach including counselors, patients and their families.

Anorexia Nervosa (AN)

AN may present with low weight, self-induced starvation and an intense fear of gaining weight. The underlying cause is weight or shape concerns and a distorted view of body image. Its prevalence peaks between 13 and 14 years of age. Diagnosis can be difficult as the patient may feel their behavior is not abnormal. AN affects all organs and systems and results in severe medical complications due to malnutrition and purging behaviors. Amenorrhoea is a pivotal feature of AN due to hypothalamic dysfunction. In adolescents presenting with hypothalamic amenorrhoea, early onset AN should be considered and is suggested by other symptoms such as obvious weight loss, cold intolerance, bloating, constipation or diarrhoea, fatigue, fainting, easy bruising, hair loss and dry skin. There is no longer a BMI cut off required to make a diagnosis of AN. This ED is associated with multiple psychiatric comorbidities. AN has the highest mortality rate of all psychiatric disorders at 5-6%, with one in five of these deaths due to suicide. When the condition is suspected a multi-disciplinary approach including a mental health provider with expertise in EDs should be adopted. Inpatient care is advised when severe bradycardia, hypotension, orthostasis, and/or electrolyte imbalance occur.

Menstrual function recovery is usually delayed after adolescents reach a healthy weight. Bone density may however be severely affected by AN. In the setting of significantly low bone density, replacement with the short-term use of combined hormonal therapy may protect bone health. The addition of calcium and vitamin D might further optimize bone health.

Restricted eating may also occur in athletes and contribute to Relative Energy Deficiency in Sports (RED-S). Recognised by the International Olympic Committee, and other international sports associations, the condition can be triggered by weight requirements for certain sports (for example wrestling) or expected body habitus of certain athletes, such as figure skaters. Often presenting with amenorrhea, RED-S can affect athletic performance and increase risk of stress fractures. In addition to medical providers, coaches and parents should be aware of RED-S in young athletes.

Bulimia Nervosa (BN) and Binge Eating Disorder (BED)

BN and BED are characterized by recurrent episodes of over eating. BN is defined by extreme compensatory behaviors designed to control weight such as induced vomiting. BED is associated with recurrent episodes of binge eating but with fewer compensatory behaviors than in BN. Obesity is prevalent in all cases as are other metabolic disorders, however both can be diagnosed at any weight.

Self induced vomiting has been associated with three times the rate of irregular menses. BN can also lead to menstrual irregularity even when controlling for factors of PCOS and obesity. Laxative abuse may lead to melanosis and secondary hyperaldosteronism. BN and BED may be associated with high risk sexual behaviours, decreased self-respect and psychiatric comorbidities. The primary aim of laboratory workup is to exclude medical conditions that may have contributed to the presenting symptoms of malnutrition. PAGs should be able to recognise red flags for BN or BED in history and examination. It is important the adolescent is evaluated alone and shaming of behaviors avoided. Psychiatrists and a dietician should be involved in these cases.

Social Media

There have been concerns for decades about the media’s impact on adolescents’ body image and resulting EDs. This has only been further amplified with the advent of social media and online influencers. Social media is used to share information and it has become a significant tool for influencing others. It places huge value on the perfect body and appearance which may impact EDs in a number of ways. The solution for this is to use social media in a positive aspirational way to promote self confidence and respect, and a body positive attitude.

Call for action

1. Providers should be trained to evaluate for eating disorders in adolescents presenting for gynecology care.
2. National medical societies should encourage social media to promote a variety of body images, encourage exercise and support healthy eating habits.
3. Providers, schools and social media should promote education strategies about normal body changes during puberty.
4. Medical providers, coaches and parents should be trained to recognize RED-S in young athletes and refer them for treatment to avoid long-term health consequences.

© 2022
Emily Gelson, United Kingdom Anastasia Vatopoulou, Greece

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Purpose

Malaysian Translation: Vaksinasi HPV Dos Tunggal (Translated in Malay, N. Azurah, AOSPAG, 2024)

The International Federation of Pediatric Adolescent Gynecology (FIGIJ) supports the initiation of single-dose human papilloma virus (HPV) vaccination programs, especially in low- and middle- income countries (LMICs) where they can have the greatest impact. A recent review by Gallant et al in the Journal of Pediatric Adolescent Gynecology provides ample evidence for support of this strategy, highlights of which are emphasized in this advocacy statement.

Background

Cervical cancer is the world’s fourth cancer type among women after breast, colorectal and lung cancer. It affects more than half a million women annually, and it caused 311,000 deaths in 2018. 84% of invasive cervical cancer cases occurs in LMICs, and low-income nations bear 88% of this type of cancer’s mortality rate.

90% cervical cancer is caused by high risk HPV, and that 80% of women are infected with HPV at some point in their lifetime. Persistence of HPV infection and development of cervical dysplasia are the greatest risk factors for cervical cancer.HPV vaccination and cervical dysplasia screening programs are the major public health strategies to prevent cervical cancer in the general population. HPV vaccination is safe and effective, and would have the greatest impact in prevention of cervical cancer in resource-poor countries where screening is unaffordable or unavailable, treatment options are limited, and morbidity and mortality remain high.

Current Global HPV vaccination coverage

While 80%of high income countries have implemented HPV vaccine programs, only 41% of LMIC have vaccination programs, resulting in 15% global HPV vaccination coverage.

Reflecting the implementation of HPV vaccination programs in HIC, by 2014, 32% of females aged 10-20 had received the full course of the HPV vaccine, while 41% had received at least one dose. In contrast, in Latin America, 19% of females aged 10-20 had received the full course of the vaccine, and 22% had received at least one dose. A large majority of the female population worldwide, but concentrated in Africa and Asia, have still not been vaccinated. This means that the most vulnerable populations, which would benefit most from vaccination, remain unprotected.

Evidence for Single-Dose HPV Vaccination Efficacy

Current WHO guidelines recommend a 2-dose vaccination for girls between age 9-14 years, ideally prior to onset of sexual activity and exposure to HPV. HPV vaccines are known to be highly immunogenic, and the earlier they are given the higher immune response is achieved. In fact, several studies are now assessing the level of protection against cervical cancer from a single dose. Observational studies carried out in the last decade have shown that a single dose of the HPV vaccine can achieve a good level of protective antibodies for at least 7-10 years. The Costa Rica Vaccine Trial (CVT), the Papilloma Trial against Cancer in Young Adults (PATRICIA) and a large Indian research project conducted by Sankaranarayanan et. al. suggest that a single dose of the vaccine provides long-lasting protection against infections with HPV 16 and 18. In their review, Gallant et al cited 8 large multinational, multiethnic long-term studies, including those mentioned, which demonstrate observational data that single doses of HPV vaccination provides at least 7-10 years of prevention against persistent HPV and cervical dysplasia.

Equity in HPV vaccination

The COVID pandemic and COVID vaccine implementation has highlighted global disparitiesinvaccination. Throughcost-effectivestrategies,thesignificantburdenof HPV-related disease can be reduced in LMICs. School-based single dose HPV vaccination, done when girls are aged 9-14 years would provide optimal coverage especially in poorer countries, where continuation through secondary education is lower for girls. Sexual assault and abuse of girls is unfortunately a global issue, and HPV vaccination may help prevent cervical cancer as a sequela in this very vulnerable group. Single-dose vaccination will increase the vaccine dose availability, supply of which has been noted to be low at the moment. Finally, single dose vaccination will facilitate vaccine access and affordability for LMIC.

Call for action

1. Increased availability of HPV vaccination globally, including LMICs.

2. Where possible, WHO guidelines recommending 2-dose vaccination for age 9-14 year olds should be followed.

3. Consideration of global endorsement of single-dose HPV vaccination, especially for LMICs where access is currently limited.

Copyright FIGIJ 2021

Judith Simms-Cendan, MD, United States Clara Di Nunzio, MD, Argentina Anastasia Vatapoulou, MD, Greece

Introduction / Purpose

Malaysian Translation: Pemakanan dan Kesihatan Reproduktif pada Kanak-kanak dan Remaja (Translated in Malay, N. Azurah, AOSPAG, 2024)

While nutrition is important during the whole life span, for children and adolescents adequate nutrition is of utmost importance for growth and development. During adolescence, the nutritional needs are the greatest. These nutritional needs relate to the fact that adolescents gain up to 50% of their adult weight, more than 20% of their adult height, and 50% of their adult skeletal mass during this period.

In low and middle income countries (LMIC) each year nearly 6 million deaths among children under-five years of age are associated with malnutrition. The world’s adolescent population, about 19% of the total population, faces serious nutritional challenges not only affecting their growth and development but also their health and livelihood as adults.

The World Health Organization (WHO) identified the main nutritional problems affecting adolescent populations worldwide, they include:

• undernutrition in terms of stunting and severe underweight, with subsequent catch-up growth leading to obesity,
• perpetuation of intergenerational undernutrition through intrauterine growth retardation of the fetus in undernourished pregnant adolescent girls;
• iron deficiency and anemia, exacerbated by the onset menstruation
• deficiencies in vitamin and mineral intake necessary for physical and mental health, especially of vitamin A, iodine, calcium, folate, zinc and other micronutrients;
• obesity, especially due to intake of high calorie, low nutrient foods and sedentary behavior.

Worldwide, the prevalence of being overweight has increased, however the prevalence of being underweight has remained the same in recent decades. As a result, the global distribution of BMI has widened. However, it remains important to realize that the global burden of being moderately or severely underweight is still

higher than that of being overweight. This Statement focuses on the gynecological consequences of over- and undernutrition. For undernutrition due to eating disorders, see FIGIJ Statement Eating disorders.

Undernutrition

The global prevalence of being underweight among children and adolescents is 8.4% for girls. It is important to understand that undernutrition goes along with poverty, but also with family structure. Gender bias in child care, which often puts females at a greater disadvantage in terms of nutrition, means that female children may be served last in disadvantaged families.

The prevalence of being moderately and severely underweight is highest in South Asia. While the lowest mean BMIs for children (aged 5–9 years) are found in East Africa and the lowest mean BMIs in adolescence in South Asia.

The consequences of chronic malnutrition, in early infancy and childhood mainly and to a lesser extent inadequate nutrition in adolescence, can potentially retard growth and sexual maturation. When using maximum growth spurt or menarche as an indicator, the onset of puberty can be delayed in malnourished girls by an average of two years. In addition, the delayed growth and maturation in girls attributed by malnutrition further increases the risks associated with adolescent pregnancy, as biological age lags behind chronological age, for example leading to increased maternal morbidity. Adolescent pregnancy exposes both the stunted or undernourished mother and her child to adverse health and socioeconomic consequences. Decreased bone mineralization occurs when puberty is delayed and there is inadequate energy availability for bone development. Low iron intakes alone do not fully account for the high prevalence of anemia. A 12% menorrhagia rate was found among menstruating girls aged less than 20. Heavy menstrual bleeding was suspected to be an important contributor to the high rate of anemia (40%, see also FIGIJ Statement Menstrual Health).

Overnutrition

A massive global epidemic of obesity is emerging in children and adolescents. Globally, the prevalence of obesity has risen from <1% in 1975 to more than 5% in girls. Obesity has increased in all regions of the world, with the largest proportional increase in southern Africa. At the moment, 10% of school children have obesity in (high income countries) HIC.

Obesity, and poor metabolic profile in adolescence are associated with non-communicable diseases, e.g. hypertension and diabetes mellitus, and mortality later in life. Obesity is increasing globally in LMIC undergoing a nutrition transition from food insecurity and undernutrition problems, to overnutrition with high caloric low-nutritional value food..

Obesity may be brought about by poor nutritional choices of adolescents (poverty, access to healthy food, education (school/families)). In high-income countries overnutrition can focus more on life-style interventions, whereas for LMIC access to healthy food and education are more important.

We, as healthcare providers, should be concerned about adolescent overnutrition because we are already observing the impact and it’s gynecologic consequences amongst our patients. Childhood obesity leads to earlier pubertal onset which can put the child at risk of sexual abuse.

Overnutrition leads to cycle disturbances like, oligomenorrhea and amenorrhea. As a consequence of obesity, there is an increased risk of developing PCOS, fertility disorders, and increasing the risk of endometrial cancer later on in life.

Closing remarks

• Adolescence is a vulnerable period and provides a window of opportunity for nutrition education and prevention of non-communicable disease
• When a patient with early puberty, delayed puberty, or cycle disturbance comes to the office, nutrition status should be assessed.
• Adolescents are usually open to new ideas and many habits acquired during adolescence will last a lifetime. With increasing age, adolescents’ personal choices and preferences gain priority over eating habits acquired in the family, and have progressively more control over what they eat, when and where. For these reasons, adolescents are an ideal target for nutrition education.

Call for action

1. All healthcare providers should screen nutritional health status in the adolescent population in order to prevent negative reproductive health consequences of nutritional problems.
2. Legislation for adolescent nutrition programs (IEC, screening, program intervention) and support for healthy school-based meals.
3. Stakeholders (national gynecologic societies, (social) media, schools,families) should advocate for healthy evidence-based nutritional policies in schools, cafeterias and clinics.
4. FIGIJ supports and endorses the WHO and UNICEF statements for proper adolescent nutrition.

©2022, second version

Angela Aguilar, Philippines

Mariela Orti, Argentina

Evelien Roos, the Netherlands

Download: FIGIJ Statement Nutrition gynaecological consequences