Adolescent pregnancy has multiple consequences for the adolescent mother, including disruption to schooling, and for the baby, such as increased risk of mortality, morbidity, and undernutrition. Adolescent childbearing is underpinned by multiple social determinants, including inequities in access to sexual and reproductive health (SRH) services. Chile has experienced rapid and drastic declines in total fertility rate, from 5.5 children per woman in the early 1970s to approximately 1.6 children per woman in 2018, though the decline has been slower among adolescent girls. In 1995, adolescent sexual and reproductive health and rights (ASRHR) became a national priority, demonstrated by legal and policy reforms aimed at making access to services, particularly contraceptives (including condoms, oral contraceptives, and long-acting reversible contraception), universal, without economic and socio-legal barriers. Supportive policies were formulated, and a package of interventions delivered as part of a multifaceted approach to addressing the sexual, reproductive, mental, and nutritional health of adolescents.
ASRHR was prioritized through the establishment of institutions, such as the National Adolescent Health Program in the Ministry of Health and Ombudsman Office for Children, along with legal reforms which dealt with adolescents’ access to modern contraceptives, creating an enabling environment for adolescents to access services. The Chilean government strengthened accountability through young people’s participation in planning, implementing, monitoring, and evaluating policies and programs. Rather than establishing a parallel system, the approach made full use of existing health services. As part of the National Adolescent and Youth Health Policy 2008, the Ministry of Health created designated spaces within government health facilities, known as adolescent friendly spaces (AFS), to bolster adolescents’ access to SRHR services privately and confidentially, with financing from municipal governments to local level facilities.
AFS offer adolescents promotive, curative, and rehabilitative health services covering unintended pregnancy, sexually transmitted infections, mental health, and nutrition. From 2008–2020, the number of AFS increased from 54 to 348 across the country. The Chilean government addressed financial barriers through a universal health insurance program (FONASA), which allows children and adolescents (0–19 years) to access services in both private and public health facilities. The quality of the health workforce was addressed by building the competencies of providers to offer confidential and empathetic services to adolescents and young people. Health providers received extensive training on providing counselling and contraception services to adolescents. The Chilean Health Information Systems facilitates the timely use of age- and sex-disaggregated data with an additional layer for ethnicity and migration status, covering district, regional, and national levels. The National Survey of Children and Early Adolescents and the National Youth Survey provide insights for local level interventions.
The entire initiative was led, funded, and executed by the Ministry of Health, and resulted in significant improvements in SRH indicators for adolescents. From 2007–2017, the proportion of births to adolescents reduced by 51%. The fertility rate of adolescents aged 10–19 years declined from approximately 25/1000 in 2005 to 7.8/1000 in 2020. Contraceptive use at sexual debut increased by 30% between 2007 and 2018.
Several factors were instrumental in the outcomes achieved, including capitalizing on existing health service networks without setting up a separate system and leveraging windows of opportunity for change. Given the high rate of adolescent fertility in Chile, SRHR actors canvassed support for enabling laws and policies that liberalized and empowered health providers to offer contraceptives to adolescents aged 14 years and older – leadership and governance were crucial for this. Local government participation was crucial in translating national strategies to local priorities and providing critical resources for horizontal scale-up. However, challenges remain.
The coverage of AFS is not yet universal in Chile and there are outstanding medical barriers to contraceptive use for adolescents. AFS must be strengthened, focusing on rural and disadvantaged communities. Community support and partnerships need to be strengthened, inadequate parent-child communication and social norms around teen sexual behaviors persist. Intersectional disadvantages that drive teen pregnancy still exist and require multi-sectoral approaches to tackle, particularly to reach those left behind due to geographical and socioeconomic disparities. Many adolescents and young people do not have access to information and education and Chile must address the gap in counseling and educational interventions, supporting the use of evidence-based, medically accurate, and culturally and age-appropriate sexual health education.