Adolescents and Young Women in Global Women’s Health Policies: A Systematic Review

Introduction

Methods

Results

Overview of Included Policies

A total of 48 national and international policies, strategies, and guidelines published between the early 1990s and the 2020s were reviewed. These documents encompassed national health strategies from countries such as (Supplementary Table S1) Australia, Sri Lanka, Ghana, and Tanzania; reproductive health and financing reforms, including Ghana’s free delivery exemption, Nigeria’s Saving One Million Lives initiative, and Argentina’s harm-reduction abortion model; as well as clinical practice guidelines, such as the U.S. ACEP emergency care policy on early pregnancy. Rights- and equity-focused frameworks were also represented, for example, the comparative study on gender violence between Spain and Brazil, the World Health Organization’s guidance for refugee and migrant women, and Baltimore’s trauma-informed maternal health initiative. The dataset also included the Rwanda RMNCAH Strategic Plan (2018–2024), the Sierra Leone RMNCAH Policy (2017–2021), the Fiji Reproductive Health Policy, the Mongolia Reproductive Health Policy summary, and the Bhutan Reproductive Health Strategy, together demonstrating wide regional diversity. Collectively, these policies demonstrated a wide geographical spread across high-, middle-, and low-income contexts. Despite their diversity, they consistently highlighted the influence of global frameworks such as the Convention on the Elimination of All Forms of Discrimination Against Women (CEDAW, 1979) [24], the International Conference on Population and Development Programme of Action (1994) [25], the Beijing Platform for Action (1995) [26], and the Sustainable Development Goals (2015) [11]. These international agreements played a decisive role in shaping national agendas, with low- and middle-income countries frequently responding to donor-driven priorities, while high-income countries tended to embed equity, intersectionality, and rights-based approaches more explicitly.

Adolescents and young women, who were the central focus of this review, emerged as a group for whom there was a notable imbalance in policy attention. While nearly all policies acknowledged the importance of reproductive and maternal health, relatively few contained measures that explicitly addressed adolescents. When they were included, for instance, in Sri Lanka’s policies of 1998 and 2012 [27,28], Ghana’s 2014 reforms [29], Australia’s strategy for 2020–2030 [30], and the WHO’s guidance on migrant health [31], the framing of adolescents gradually shifted from viewing them primarily as vulnerable populations to recognizing them as rights-bearing agents. Nevertheless, significant implementation gaps persisted, and in many cases, adolescents remained only implicitly referenced within broader maternal health frameworks.

Table 1. Combined Thematic and Contextual Analysis.

Table 1. Combined Thematic and Contextual Analysis.

Theme	Contextual Evidence	Findings / Patterns	Implications for Adolescents & Young Women
Legal & Policy Frameworks	Spain’s Organic Law (2004) vs. Brazil’s Maria da Penha (2006); Tanzania’s donor-driven 1992 Population Policy; Australia’s 2020–2030 SDG-aligned strategy.	Shift from maternal/child focus to rights-based life-course policies; donor-driven adoption in LMICs often narrowed to fertility control.	Adolescents are acknowledged in some policies (Sri Lanka 1998, Ghana 2014, Australia 2020) but rarely operationalised into enforceable protections.
Financing & Coverage	Ghana’s free delivery exemptions showed both equity gains and collapse under debt; Nigeria’s Saving One Million Lives tied funding to performance; Buenos Aires decentralised safe abortion, cutting maternal mortality.	Fee removal and RBF increased utilisation, but donor dependence and hidden costs undermined sustainability.	Adolescents remain highly sensitive to transport costs, informal fees, and mistrust of facilities—often deterring them from early or preventive care.
Service Delivery & Workforce	Buenos Aires abortion decentralisation; Sri Lanka MCH life-course expansion; ACEP (U.S.) early pregnancy guideline modernisation.	Nurses/midwives central; decentralised services widened reach; continuity and adolescent confidentiality were weak.	Adolescents often faced stigma, lack of privacy, and inadequate youth-friendly training among providers, deterring service use.
Equity & Structural Determinants	WHO 2018 migrant guidance (refugee girls); Baltimore trauma-informed care (post–Freddie Gray); Australia equity focus (Indigenous, rural, LBTI).	Increasing recognition of violence, trauma, migration, and identity-based inequities, though stronger in HICs than LMICs.	Marginalised adolescents face compounded vulnerabilities (violence, poverty, migration). Few policies operationalised equity into targeted, youth-focused programmes.
Adolescent & Youth Health	Sri Lanka (1998, 2012), Ghana (2014), Australia (2020), and the WHO migrant guidance.	Youth-specific services are still rare, often framed as behavioural prevention.	Confidentiality gaps, provider stigma, and lack of youth participation undermine rights-based delivery; adolescents remain the least prioritised despite demographic significance.

Figure 2. PRISMA.

Figure 2. PRISMA.

Combined Contextual and Thematic Analysis

Policy Drivers and Global Influences

Global agreements played a pivotal role in shaping national women’s health agendas, with their influence visible across diverse economic and political contexts. High-income countries, such as Australia, have more readily integrated the Sustainable Development Goals (SDGs) and World Health Organization (WHO) frameworks into comprehensive national strategies that explicitly acknowledge equity, intersectionality, and rights-based approaches. By contrast, low- and middle-income countries, particularly in sub-Saharan Africa, were often constrained by donor-driven priorities and structural adjustment requirements. For example, Tanzania’s 1992 National Population Policy [32] was closely tied to International Monetary Fund and World Bank adjustment programs, which promoted fertility reduction as part of broader economic reform. Similarly, Ghana’s early free delivery exemptions in maternal health [33] reflected progressive intent but were introduced under conditions of financial pressure and lacked sustainable domestic ownership, leaving them vulnerable to policy failure.

While global frameworks such as CEDAW (1979), the International Conference on Population and Development Programme of Action (1994), the Beijing Platform for Action (1995), and the SDGs (2015) successfully prompted widespread policy adoption, their translation into practice revealed striking disparities. The extent to which adolescents and young women benefited from these frameworks was strongly conditioned by political will, resource allocation, and institutional capacity at the national level. In donor-dependent systems such as Nepal and Ghana [29,34], adolescents were rarely prioritized explicitly, often subsumed within broader maternal health agendas, and left without targeted interventions. In rights-oriented systems such as Sweden’s SRHR International Policy (2006) [35], adolescents were more visible as agents with entitlements, yet even in these contexts, their protection and participation were inconsistently implemented. This underscores the tension between international commitments and domestic realities: while global agreements provided important normative leverage, the realization of adolescent-responsive policies depended heavily on local ownership, sustainable financing, and the prioritization of equity in health governance.

Financing and Health System Capacity

Efforts to remove financial barriers to women’s health care have been central to policy reform, yet their outcomes reveal both opportunities and structural fragilities. In Ghana, maternal delivery exemptions [33] and subsequent reproductive health service standards demonstrated that abolishing user fees increased service utilization, particularly among poorer households, and offered measurable equity gains. Similarly, Nigeria’s Saving One Million Lives initiative [36] introduced an innovative results-based financing model, linking state-level disbursements to performance indicators such as skilled birth attendance, antenatal coverage, immunisation rates, and contraceptive uptake. In Latin America, Argentina’s adaptation of the Uruguayan harm-reduction model for abortion care [37] illustrated how decentralization and public funding of safe abortion services dramatically reduced abortion-related maternal mortality, achieving a two-thirds decline within four years. The Rwanda RMNCAH Strategic Plan (2018–2024) [38] built on progress in maternal and child health and explicitly positioned adolescent reproductive health within an agenda of equity, human rights, and universal health coverage.

Despite these advances, systemic constraints across low- and middle-income countries undermined the sustainability of financing reforms. In Ghana, unpredictable reimbursements and weak accountability mechanisms forced some facilities to reintroduce informal charges, eroding women’s trust in the policy and weakening its pro-poor orientation. In Nigeria, performance-based funding incentivized short-term gains but exposed deep inequities, as states with weaker administrative and health system capacity struggled to meet benchmarks, thereby exacerbating the country’s already acute geographic and socioeconomic disparities. Argentina’s decentralised model showed stronger institutionalisation, but its scalability remained dependent on political continuity and fiscal commitment.

For adolescents and young women, the limitations of financing reforms were particularly severe. Although the removal of user fees and the expansion of service packages increased theoretical access, hidden costs such as transportation, medicines, and informal payments remained prohibitive. These barriers disproportionately deterred younger women from seeking timely and preventive care, compounding risks of unsafe abortion, delayed antenatal attendance, and poor maternal outcomes. Financing reforms, therefore, highlight a recurring paradox: while they have the potential to reduce inequities and expand access, without stable domestic funding, robust institutional accountability, and adolescent-sensitive service design, they risk perpetuating the very exclusions they aim to address.

Service Delivery Models and Health Workforce

Across the policies reviewed, there was a clear trajectory from narrowly defined maternal–child health services toward more integrated and comprehensive reproductive health models. This evolution reflected the influence of global frameworks as well as domestic reforms that sought to broaden both the scope of care and the range of providers involved. In Argentina, for example, the adaptation of the Uruguayan harm-reduction model [37] demonstrated the potential of decentralization, with general practitioners and midwives in primary care facilities trained and authorized to deliver safe abortion and post-abortion services. This shift not only expanded access geographically but also embedded reproductive health care within community-level services, thereby reducing delays, stigma, and mortality. Sri Lanka’s maternal and child health policy [28] also exemplified integration, extending beyond maternal survival to include adolescent health, gender-based violence, nutrition, and non-communicable diseases within a life-course framework. In high-income contexts, clinical modernization was equally significant. The U.S. ACEP clinical policy for emergency departments [39] abandoned outdated reliance on discriminatory β-HCG thresholds in the evaluation of early pregnancy complications, instead recommending universal ultrasound for symptomatic women. This represented a major advance in patient safety, particularly for young women at risk of ectopic pregnancy, who historically faced delays in diagnosis and treatment. The Fiji Reproductive Health Policy [40] provided a life-course framework for reproductive health, emphasising primary care as the entry point and explicitly aligning with the Sustainable Development Goals. Similarly, the Mongolia Reproductive Health Policy [41] summary highlighted urban–rural inequities in access to sexual and reproductive health services.

Central to the effectiveness of these models was the health workforce, with nurses and midwives consistently identified as frontline actors in screening, counselling, and referral. In both Spain and Brazil [42], for instance, nurses played a pivotal role in responding to gender-based violence by identifying at-risk women and linking them with appropriate health and legal support. Similarly, in Ghana and Sri Lanka [28,29], midwives were crucial to implementing reproductive health strategies at community and facility levels. However, across diverse contexts, insufficient training, limited resources, and persistent provider stigma undermined the reach and quality of adolescent-friendly services. Young women often reported judgmental attitudes or breaches of confidentiality from providers, which created significant deterrents to accessing contraception, safe abortion, or care for gender-based violence.

Equity Considerations

Equity was a recurring theme across most policies, though the depth and scope of attention varied significantly by context. In high-income settings, such as Australia’s National Women’s Health Strategy 2020–2030 [30], the WHO’s technical guidance on refugee and migrant health [31], and Baltimore’s trauma-informed maternal health initiative [43], equity was framed through an explicit intersectional lens. These policies recognized the compounded disadvantages faced by Indigenous women, women in rural and remote areas, migrants and refugees, LBTI populations, and women living with disabilities, embedding these considerations as central to service planning. The Sierra Leone RMNCAH Policy (2017–2021) [44] directly responded to alarming maternal, child, and adolescent health indicators, making RMNCAH urgent national priorities. In middle- and low-income countries, by contrast, equity frameworks were more often anchored in poverty reduction, rural disadvantage, and alignment with donor priorities, reflecting the structural constraints of financing and governance.

Legal and rights-based approaches also revealed equity as a core determinant of health. Spain’s Organic Law 1/2004 and Brazil’s Maria da Penha Law (2006) [42] framed gender-based violence as both a public health crisis and a human rights violation, while Baltimore’s trauma-informed care initiative [43] situated maternal health within broader struggles against racial injustice, community violence, and structural trauma. These examples illustrate how health policy can move beyond biomedical framings to address the social conditions shaping women’s health across the life course.

Yet, despite progressive rhetoric, few policies have fully operationalized integration across sectors such as housing, education, employment, and social protection. As a result, equity considerations often remained aspirational rather than transformative. This gap was particularly evident for adolescents and young women from marginalized groups, including migrant girls, Indigenous youth, and those living in rural or remote areas. While their compounded risks were frequently acknowledged, policies rarely translated recognition into comprehensive action, leaving these groups disproportionately exposed to early pregnancy, unsafe abortion, gender-based violence, and poor access to services.

Adolescent and Young Women’s Health

Adolescents and young women were explicitly prioritized in only a limited number of policies, though where this occurred, it marked an important evolution in the framing of reproductive health. In Sri Lanka, the Population and Reproductive Health Policy (1998) and the Maternal and Child Health Policy (2012) [27,28] recognized adolescent sexual and reproductive health as a distinct concern, calling for youth-friendly services and life-skills education. Ghana’s Reproductive Health Service Policy and Standards (2014) [29] went further by establishing adolescent-friendly service corners and explicit standards for confidential and non-judgmental care. In high-income contexts, Australia’s National Women’s Health Strategy 2020–2030 [30] identified adolescence as a critical investment period, emphasizing mental health, sexual and reproductive health, and violence prevention as priorities with long-term implications for equity and wellbeing. Similarly, the WHO’s Technical Guidance on the Health of Refugee and Migrant Women [31] highlighted the disproportionate vulnerabilities of young migrant women, underscoring the intersection of age, gender, and migration status in shaping health risks.

The Bhutan Reproductive Health Strategy [45] explicitly recognised adolescent SRHR within a national development framework but noted resource and capacity constraints for full implementation. South Africa’s entries, including ‘Ten years of democracy in South Africa: Documenting transformation in reproductive health policy and status’ [46] and the ‘Strategic Plan for MNCWH and Nutrition’ [47], documented rights-based reforms and integrated maternal and adolescent commitments. The Kenya National Population Policy [48] addressed demographic change in relation to development while referencing adolescent needs. The Nepal National Reproductive Health Policy [34] shifted away from narrow demographic targets toward comprehensive services, including adolescent health. Bangladesh appeared in the thematic analysis of abortion access [49], where persistent financial and social barriers disproportionately affected young, unmarried women.

Despite these advances, the majority of policies in low- and middle-income countries framed adolescents primarily through moral or behavioral lenses, emphasizing the prevention of “early” pregnancies, responsible conduct, and family stability. This paternalistic framing often obscured adolescents’ status as rights-holders and reinforced barriers to care [18]. Confidentiality breaches, provider stigma, and restrictive social norms continued to deter young women from accessing contraception, safe abortion, and reproductive health services, undermining the stated policy goals [50]. Even where policies adopted progressive framings—viewing adolescence as a pivotal life stage that shapes long-term health trajectories—they frequently lacked the enforceable standards, resources, and system integration needed to translate rhetoric into reality [51].

As a result, adolescents and young women remained poorly served by fragmented and under-resourced systems. Policies that recognized their unique needs often did so at a discursive level, but implementation rarely addressed the structural determinants that constrain their autonomy and access.

Narrative Synthesis for Adolescents and Young Women

The data show that even though women’s health policy has been evolving globally from traditional frameworks that were focused on maternal survival to rights-based, equity-oriented ones, adolescents and young women continue to be a neglected majority in practice. When youth have a specific commitment, it is often inconsistent, symbolic, or rhetorical, with little or no financing, accountability, and skills building to support its application to impact [52,53]. The critical needs of adolescents’ access to confidential contraception and safe abortion care, prevention of violence, trauma-informed mental health care, and youth-driven service design are present, under varying degrees of frequency, in health system service delivery. Examples remain scarce, but important improvements in capacity and resilience among adolescents have occurred in places such as Ghana, where fundamentals of prevention, respect, and care are important [29]; Sri Lanka, considering mental health, guidance, and growth-prevention [27,28]; Buenos Aires, where working on prevention and care [37], and Australia where reduced barriers to equitable access [30]. The identified trends indicate improved adolescent outcomes linked to reduced unintended pregnancies, an increase in contraceptive uptake, and a reduction in maternal deaths, improved mental health indicators, and higher satisfaction rates with services. However, these solutions were more of an adaptation journey for those involved than a concrete outcome.

Adolescents are confronted with particular hazards from chronic conditions that are becoming more important and are rarely prioritized in policies. WHO’s Global Health Observatory (GHO) indicates that the burden of morbidity and disability during the adolescent lifecycle attributable to noncommunicable diseases (NCDs), especially mental health disorders, cancers, cardiovascular disease, diabetes, and chronic respiratory diseases, constitutes a significant and increasing proportion of morbidity and disability during the adolescent phase with the potential for multi-generational consequences [54]. An epidemiological fact sheet of the WHO identified that adolescents face several important health risks, injuries, violence between inter-personal partners, self-harm, pregnancy and childbirth, mental health disorders, and adolescent fertility rates estimated at 42 births per 1,000 girls aged 15–19 years in 2021 [55]. The combined impression of these chronic and acute health risks demands an urgent focus on the development of adolescent-centred policies that address immediate and potentially long-term health development trajectories.

Moreover, adolescents with chronic conditions face complicated realities: they have a strong clustering of health-risk behaviours, few protective factors, and concurrency of social vulnerabilities, including stigma, low school engagement, and family stress, all of which can undermine their health trajectory [56]. These intersections reinforce the need for policy frameworks that are both multisectoral and developmentally responsive.

Despite this strong evidence base, the reviewed policies show significant gaps. Although many countries have adopted adolescent-inclusive policies, they often remain siloed within the health sector, with limited engagement of education, social protection, or mental health systems. As the Lancet series underscores, “a multisectoral approach is essential” to effectively address structural determinants of adolescent health [57]. Moreover, implementation fidelity suffers as most frameworks lack comprehensive adolescent-specific indicators—scoping reviews show that even vital domains like service quality or system performance are seldom measured [58]. Combined with the widespread absence of economic evaluations—cost-effectiveness studies are rare in LMIC adolescent health programs [59], these findings highlight how adolescent health commitments often remain aspirational rather than operational.

This disparity underscores profound evidence gaps: the need to develop youth-sensitive monitoring systems, disaggregate data by age, sex, and context; consider chronic conditions; and include processes that allow adolescents to be active stakeholders, not just passive beneficiaries in the policy development process. Barring a significant investment in these areas, adolescents and young women remain at risk of being overlooked and left behind in global health policy development, even though they are shouldering substantial immediate and long-term health risks.

Figure 3. Global Distribution of Adolescent and Young Women’s Policies.

Figure 3. Global Distribution of Adolescent and Young Women’s Policies.

Discussion

Implications for Adolescents and Young Women

Adolescents and young women experience intersecting vulnerabilities—spanning sexual, reproductive, and mental health—that extend well beyond traditional maternal health concerns. Evidence from Sri Lanka illustrates how targeted rules and service adaptations, such as the establishment of Youth-Friendly Service centers (“Yowun Piyasa”), led to better alignment with adolescent needs—enabling access to condoms, emergency contraception, and pregnancy testing—while general, adult-oriented services faced shortcomings like poor confidentiality and low youth engagement [80,81]. In Australia, tailored community-based mental health initiatives, especially those offering integrated multidisciplinary care, have demonstrably improved mental health outcomes and psychosocial wellbeing among youth [82]. In contrast, policy approaches that frame adolescents primarily in moral or behavioral terms tend to miss the mark, perpetuating stigma, eroding care-seeking, and failing to address their lived realities.

Adolescents face a unique set of risk factors, including high rates of unintended pregnancy, unsafe abortion, gender-based and intimate partner violence, and high mental health burden. Chronic conditions depression, diabetes, and anaemia are common have relatively increased rates among adolescents, with lasting implications for health equity [55,83]. Social determinants such as poverty, rural residence, migration status, disability, and LBTI identity exacerbate these risks. Policies that addressed these factors with enforceable entitlements, dedicated financing, and youth participation achieved more durable improvements.

Below, we outline the four central features that shaped adolescent and young women’s health outcomes, with expanded explanations and recommendations for future policy design.

Table 2. Central features of Adolescent and Young Women’s Health outcomes.

Table 2. Central features of Adolescent and Young Women’s Health outcomes.

Feature	Explanation	Recommendations
Clear entitlements	Adolescents require explicit rights to free, confidential contraception, safe abortion, post-violence care, and mental health services. Without enforceable entitlements, services are inconsistently provided and easily deprioritized in budget cycles.	Legally codify adolescent entitlements in national regulations and provider contracts; include grievance redress mechanisms at the facility level; link facility accreditation to compliance with confidentiality and rights standards.
Youth-friendly service standards	Standards such as private counseling rooms, opt-out chaperone policies, adolescent-only clinic hours, and provider training for non-judgmental care directly improve care-seeking, confidentiality, and satisfaction.	Mainstream youth-friendly protocols into primary care; create national accreditation for adolescent-friendly facilities; include stigma reduction in continuing medical education.
Dedicated adolescent funding	In LMICs, adolescent programs are often diluted during budget execution, leaving young women dependent on under-resourced maternal health frameworks. Dedicated funding protects adolescent priorities from being absorbed into broader maternal programs.	Ring-fence funds for adolescent SRH services; introduce adolescent-specific performance indicators in financing contracts (e.g., % of adolescents accessing contraception or mental health services).
Youth participation in governance	Adolescents are often recipients but not co-creators of policy. Participatory mechanisms—youth councils, peer navigators, scorecards—ensure services reflect lived realities and strengthen accountability.	Institutionalize youth representation in health policy governance; provide funding for youth-led monitoring; expand peer-support models integrated into national systems.

Policies lacking one or more of these features showed only partial improvements: for instance, service utilisation increased, but continuity of care lagged; or stigma persisted despite expanded service menus. This highlights that rhetoric alone is insufficient; policies must be backed by legal enforceability, financial protection, system-level accountability, and youth voice.

Practice and Policy Implications

The findings of this review suggest that translating equity and rights commitments into tangible improvements for adolescents and young women requires a shift from aspirational policy language toward enforceable entitlements, backed by financing and measurable accountability. Ministries of health in both high- and low-income settings often publish comprehensive strategies that acknowledge adolescent needs, yet in the absence of regulatory mandates and budgetary allocations, these commitments remain rhetorical [53,107]. For example, Ghana’s experience with delivery fee exemptions underscores that policy intent alone cannot guarantee adolescent access when reimbursement systems falter and informal costs re-emerge [33]. Similarly, in Nigeria, results-based financing rewarded states with stronger health system capacity but widened inequities for adolescents in fragile regions, highlighting the risks of financing models that prioritize efficiency over equity [36].

In practice, this means that ministries must move beyond general commitments to “youth-friendly care” and instead codify adolescent entitlements within regulations, service contracts, and provider payment systems. Confidential access to contraception, safe abortion where legal, mental health first response, and care post-violence should not depend on the discretion of individual providers but should be enshrined as minimum service guarantees. These guarantees require clear age-specific targets and should be accompanied by provider training and supervision mechanisms that reinforce non-judgmental care [108,109].

For implementers, the priority lies in ensuring that frontline delivery systems reflect adolescent realities. Adolescents face unique barriers related to privacy, time, and stigma; thus, small but crucial adjustments such as designated clinic hours for youth, private counselling rooms, opt-out chaperone policies, and reliable contraceptive supplies can significantly influence care-seeking behaviours [50,110]. Experience from Argentina’s harm-reduction abortion model shows that when primary care services are funded and normalized for adolescents, outcomes improve rapidly and sustainably [37].

Development partners also have a role to play, but must avoid perpetuating donor-driven distortions. Too often, external funding emphasizes vertical, target-driven approaches that prioritize aggregate maternal outcomes while neglecting adolescent-specific indicators [111,112]. Instead, partners should support the development of national health information systems that routinely capture age-disaggregated data, invest in training curricula for adolescent-friendly services, and strengthen model clinics that can demonstrate best practice. Critically, financial support should be tied to accountability mechanisms that measure adolescent experience of care and equity across intersecting identities, rather than only service utilization numbers.

Figure 4. Barriers, Policy Actions, and Future Priorities for Adolescent and Young Women’s Health in Global Policies.

Figure 4. Barriers, Policy Actions, and Future Priorities for Adolescent and Young Women’s Health in Global Policies.

Conclusions

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