The World Health Organization (WHO) has issued its first update in 13 years to guidelines aimed at preventing adolescent pregnancies, identifying child marriage as a primary driver behind millions of early pregnancies that endanger girls’ lives and futures.

The document published Thursday by the UN health agency pinpoints uptake and access to safe contraception, barriers to girls’ right to education, child marriage laws and access to sexual and reproductive health services broadly as fundamental to reducing early pregnancies, which endanger adolescents around the world.

“Early pregnancies can have serious physical and psychological consequences for girls and young women, and often reflect fundamental inequalities that affect their ability to shape their relationships and their lives,” said Dr Pascale Allotey, Director of Sexual and Reproductive Health and Research at WHO.

The global crisis affects millions of girls, with devastating health consequences rippling across generations, particularly in regions torn by conflict and instability. Pregnancy and childbirth complications rank among the leading killers of girls aged 15-19 worldwide.

Over 21 million girls between 15 and 19 become pregnant annually in low and middle-income countries, the WHO review found. Half of those pregnancies are unintended, while 55% lead to abortions—often performed in unsafe conditions, carrying life-threatening risks.

Health dangers from pregnancy are intensified for mothers aged 10-19, who face significantly higher risks than women in their twenties, including dangerous high blood pressure conditions like eclampsia, post-childbirth uterine infections and systemic infections.

The health consequences extend to their infants as well. Babies born to adolescent mothers have higher rates of low birth weight, premature birth and serious neonatal conditions compared to those born to older mothers. 

“Adolescents who give birth face higher risks of maternal and infant mortality compared with older women, while early pregnancies can restrict adolescents’ choices, limiting their educational and economic prospects,” Allotey said. “These limitations often perpetuate cycles of poverty and inequality.”

“Tackling this issue means creating conditions where girls and young women can thrive—by ensuring they can stay in school, be protected from violence and coercion, access sexual and reproductive health services that uphold their rights, and have real choices about their futures,” Allotey added. 

Child brides: one every three seconds

An estimated 12 million girls marry before age 18 annually — approximately one every three seconds — according to Girls Not Brides, a coalition of over 14,000 international and human rights organizations. In low- and middle-income countries, nine out of ten adolescent births occur among girls married before turning 18.

“Early marriage denies girls their childhood and has severe consequences for their health,” said Dr Sheri Bastien, Scientist for Adolescent Sexual and Reproductive Health at WHO.

Though child marriage rates declined from 25% in 2010 to 19% in 2020, progress remains slow and is reversing in conflict zones. The prevalence has increased by 20% in Yemen and South Sudan amid ongoing conflicts.

About 650 million women alive today were married as children, with one in 20 girls worldwide wed before age 15.

The situation is most dire in fragile states, where Save the Children reported last year that a girl is married every 30 seconds. Global humanitarian crises from Sudan to Yemen, Gaza and Myanmar have only accelerated since that report, leaving millions of girls at heightened risk of dangerous pregnancies.

Child marriage not only leads to early pregnancies before girls’ bodies are fully developed, but also often restricts their access to adequate healthcare. Girls who marry before 15 are 50% more likely to experience intimate partner violence than those who marry later, creating additional health complications.

The issue forms part of a broader pattern of gender inequality. In regions where both female genital mutilation and child marriage are common practices, girls face compounded health risks. Countries including Sudan, Somaliland, Sierra Leone, Burkina Faso and Ethiopia report the highest rates of girls subjected to both practices.

Stark global divide in adolescent pregnancy crisis 

Progress region to region remains starkly uneven. Sub-Saharan Africa has far and away the highest prevalence of births to girls aged 15-19, with over six million occurring in 2021 alone, in addition to 332,000 births for girls between 10 and 14 years old. The best-performing region, Central Asia, saw just 68,000 adolescent births that same year.

This divide is also reflected in maternal death rates. Seventy percent of global maternal deaths in 2020 — over 200,000 — occurred in sub-Saharan Africa, where girls who reach age 15 face a one in 40 chance of dying from pregnancy-related complications in their lifetimes. In Chad, the country with the highest rate of maternal mortality, a 15-year-old girl has a one in 15 chance of dying of maternal causes.

Divides by income, culture and class can also occur within countries, undermining the representativeness of national-level statistics. The WHO cites examples of Zambia, where adolescent pregnancy rates vary from 14.9% in the capital region of Lusaka, to 42.5% in its Southern Province.

According to Save the Children’s 2024 Global Girlhood Report, the ten countries with the highest child marriage rates are either fragile or extremely fragile states. Eight of the top ten “fragility-child marriage hotspots” are in Africa, with Central African Republic, Chad, and South Sudan facing the most severe crises. In extremely fragile countries, almost 558,000 girls give birth before their 18th birthday, often without access to skilled birth attendants who could save their lives if complications arose. 

While worldwide adolescent birth rates have declined, the overall birth rate remains high. In 2021, an estimated 12.1 million girls aged 15–19 years and 499,000 girls aged 10–14 years gave birth globally, according to WHO.

“Ensuring that adolescents have the information, resources and support to exercise their sexual and reproductive health rights is not only a matter of health – it is a matter of justice,” concluded Allotey. “All adolescents need to be empowered to make choices that lead to healthier, more fulfilling lives.” 

Despite the heightened risks for girls worldwide, only 0.12% of all humanitarian funding between 2016 and 2018 was directed toward addressing gender-based violence, according to Save the Children.

Education as a shield

Among the WHO’s strongest recommendations is removing gender barriers to education, with evidence showing each additional year of secondary education reduces a girl’s likelihood of marrying as a child by six percentage points. 

Multiple randomized controlled trials from Kenya, India and Zimbabwe reviewed by WHO present strong evidence that that life skills curricula and support to remain in school effectively reduce child marriage rates.

“Quality education represents our strongest defense against early marriage and pregnancy,” WHO researchers noted in the guidelines. 

“These limitations often perpetuate cycles of poverty and inequality,” said Allotey. “In many parts of the world, adolescents – whether married or unmarried – lack access to the information and resources necessary to make informed decisions about their sexual and reproductive health. This leaves them vulnerable to early pregnancies and unprepared to navigate the physical, emotional and social changes that follow.”

While 50 million more girls enrolled in school between 2015 and 2023, completion rates for secondary education lag significantly behind primary education, with only 61% of girls finishing upper secondary school worldwide compared to 89% completing primary education.

Economic interventions also show promise according to the WHO guidelines. Programs focused on improving livelihood skills, financial literacy and economic autonomy demonstrated significant impact on reducing child marriage while increasing girls’ employment and control over resources.

“Education is critical to change the future for young girls, while empowering adolescents – both boys and girls – to understand consent, take charge of their health, and challenge the major gender inequalities that continue to drive high rates of child marriage and early pregnancy in many parts of the world,” Bastien said.

Beyond Legal Solutions

The WHO also conditionally recommends implementing laws restricting marriage before age 18, though with important caveats. Criminalizing child marriage can produce unintended consequences, potentially driving the practice underground, which can make reporting more difficult for the child brides who are victims of sexual assaults, the guidance suggests. 

The evidence reviewed by WHO on worldwide child marriage laws suggests that legal restrictions show inconsistent results in reducing marriage rates without addressing underlying social factors.

“Laws alone are insufficient without addressing root causes,” concludes the report, citing the need for comprehensive frameworks tackling gender inequality.

Both the UN Convention on the Elimination of All Forms of Discrimination Against Women and the Convention on the Rights of the Child call for eliminating harmful practices affecting children’s health, but organizations like Girls Not Brides warn that punitive approaches without corresponding social support can harm the very girls they aim to protect.

“Progress is uneven,” Allotay said. “We must sustain efforts to ensure that the most vulnerable groups of adolescent girls are not left behind.” 

Image Credits: The Hepatitis Fund.