Niren Ray MaharajIntroduction
It is estimated that adolescent girls in low- and middle-income countries (LMICs) have approximately 21 million pregnancies each year (1). Adolescent pregnancy, which occurs amongst adolescent girls aged between 10 and 19 years, is associated with various public health concerns and increased risks of maternal mortality, low birthweight, and other severe neonatal complications (2). They also have an unfavourable impact on the mental, physical, and social wellbeing of adolescents, and remain a leading cause of death among adolescent girls globally (2).
Although a decline in adolescent birth rates (ABR) has been observed globally, sub-Saharan Africa (SSA) continues to have twice the global average, with over 100 births per 1,000 women, in 2021 (3). The estimated actual number of births among 15–19-year-olds was 6 114 000 and 332 000 among younger adolescents aged 10–14 years in SSA in 2021 (3). Africa has a higher proportion of youth compared to any other continent; and adolescent pregnancy rates are therefore likely to increase further in countries in SSA (4). Adolescent pregnancies are therefore a significant health concern and have been recognised as a key objective in the United Nations Sustainable Development Goals (SDGs) (5). The contributing factors for high ABR in SSA are heterogenous and differ amongst countries in SSA. Existing data on the contributing factors for adolescent pregnancies in SSA emanate from country specific studies and collective data is limited. However, a few studies that combined data from single country studies on the determinants of adolescent pregnancy have been conducted (6–8). Collectively, these studies suggest that inter alia, socio economic status, lack of parental communication and support, early marriage, religion, and low educational status of adolescents are contributing factors.
Economic, sociocultural, and environmental factors
Poverty is generally considered as an indicator of the economic status of a country. Studies from Ghana (9), South Africa (10) and Tanzania (11) demonstrate the relationship between poverty and coerced sexual relations with older men, as a means for adolescents to meet their basic financial needs. Adolescent girls may also become pregnant intentionally to receive government support grants intended for teenage mothers, without considering the consequences of their actions (12). Nigeria, the country with the largest economy in Africa had an adolescent pregnancy rate of 106 adolescent births per 1,000 population in 2021 and shows an increasing trend (13). In South Africa (SA), which has the second largest economy in Africa, the ABR is also high (14). In SA, the lack of adequate reproductive health services and appropriate sexuality education are part of the composite etiology that contributes to increasing ABR's (15). Between 2017 and 2021, births among girls aged 10–14 years and 15–19 years increased in SA by 48.7% and 17.9% respectively, and are likely to increase (16). In contrast, in Burundi, which has the lowest gross domestic product per capita in Africa (17), the adolescent fertility rate (births per 1,000 women ages 15–19) was 58/1,000 compared with the total fertility rate of 5.5/1,000 women in that country (18). These comparisons suggest that the economic status of countries in Africa remains part of a composite etiology, which may also include power imbalances, gender-based violence, substance abuse, lack of access to termination of pregnancy services, negative attitudes of caregivers and inadequate reproductive health education.
It has also been suggested that lower levels of education may be associated with adolescent pregnancies. In Niger, Mali, and Chad, where the adolescent fertility rates are amongst the highest in the world, the expected years of schooling attained by girls between the ages of 4 and 17 is fewer than seven years (2). On the contrary, other studies suggest that higher levels of education are likely to be associated with a lower likelihood of having a first adolescent pregnancy, particularly in SSA (4, 7). Adolescents with higher levels of education are more likely to delay the onset of sexual relations and marriage; and are more informed about their rights, reproductive health, timing of marriage and pregnancy (19).
Child marriages are also implicated as a contributing cause for high ABR's in SSA, particularly in the Congo and Central Africa (20). The Congo has one of highest rates of child marriage globally, with one in three girls married before age 18, and 7% married before the age of 15 (20). Similarly, other studies have also shown an association between child marriage and adolescent pregnancy in African countries (21, 22). Most girls who experience child marriage have low levels of education, live in poor households and often in rural areas, increasing their odds of engaging in behaviours that put them at risk of pregnancy (23). Data also suggests the association of child marriages with first pregnancy among adolescent girls in SSA (6). Pregnancies in these marriages may occur because of pressure from partners or family members to start families earlier or to prove reproductive potential. In most sub-Saharan African countries, adolescent girls may face social pressure to marry and, once married, to have children (4). In parts of South Africa, cultural practices like “ukuthwala” also lead to adolescent pregnancies. This practice involves the arranged marriage of girls below the age 18 mostly to older men, without the bride's consent (24). This type of marriage is in violation of the country's national law, as well as regional and international instruments to which this country is a party (24).
Individual factors
Individual perceptions about abstinence from sexual intercourse, early sexual debut, and negative perceptions about contraceptive usage among adolescents may contribute to adolescent pregnancies. Sexual coercion, low or incorrect use of contraceptives, and low self-esteem have also been suggested as contributing factors (6–8). Other personal factors may include stigma, fear of negative attitudes from parents and elders in the community and discrimination by healthcare providers. It has been suggested that healthcare providers may not appreciate the fears of adolescents regarding contraception or reproductive health issues, and adolescents themselves may not appreciate comprehensive sexuality education (10). Adolescents may also perceive contraceptive usage as a reserve for married couples, thereby contributing to low contraceptive uptake and resultant pregnancies (10). Additionally, a lack of awareness, misconceptions and poor knowledge about the range and use of contraceptive methods exists amongst some adolescents (25). Alternatively, some adolescents may desire pregnancy despite a suitable knowledge and available access to contraception. Career plans may also be affected, and poorly educated, unemployed and grant dependent youngsters pose an economic burden on the fiscus in the long term.
Health related factors
Teenagers may also face challenges in accessing reproductive health care in their communities. In some rural areas, the sparsity of clinics, long distances, and lack of transport may present barriers to access to reproductive health services. Judgemental attitudes of staff, particularly to teenagers seeking contraception or termination of pregnancy services should be avoided. Poor staff attitudes at termination of pregnancy clinics, may drive teenagers to seek “back street” terminations, with potential morbidity and even mortality.
The Covid epidemic may have exacerbated the problem further, with resultant school closures and access to contraception and healthcare services being unavailable or restricted during this period. A lock down of recreational, sporting, and other youth activities that keep youngsters occupied may also be a contributing factor. During the Covid period, secondary school girls in rural western Kenya were more likely to be sexually active, less likely to report their first sexual encounter, and reported increased hours of non-school-related work (26). Higher rates of teenage pregnancies were also seen in SA in the past 2 years, possibly in relation to the Covid 19 pandemic (27).
Unprotected sex, either consensual or resulting from sexual co-ercion and exploitation, predisposes young girls to contracting sexually transmitted infections and HIV. Evidence shows that adolescent girls and young women have the highest rate of acquisition of HIV currently (28). Most teenage pregnancies are unplanned and often concealed, and not only have a disruptive effect on the schooling trajectory of children, but are also associated with complicated pregnancies, difficult labour, challenges with breastfeeding and issues with the ongoing healthcare of the baby.
Mapping the way forward
Bold steps need to be taken and concerted efforts must be made to turn the tide of this trend. There should be a consolidation of efforts from various state and non-state actors to achieve a reduction in ABR's in SSA and globally. Data from South Asia, Middle East and North Africa indicates that ABR's dropped by between 75% and 80% by 2019 and continues to show a consistent decline (2). Activities that have proven to be effective in reducing adolescent pregnancy include the implementation of sexual and reproductive health policies, educational and vocational programs, empowerment initiatives, training activities, school retention programs and behaviour change campaigns (29).
Lessons can also be learnt from other countries which have had some success in reducing their ABR. In the Dominican Republic, a soft skills and vocational youth training program was shown to reduce the probability of teenage pregnancy by about 20% after implementation (30). In Mexico, the National Strategy for the Prevention of Adolescent Pregnancy (ENAPEA), a multisectoral approach is currently in the process of implementation to curb this phenomenon (31). In Northern Ireland live births from mothers aged 19 and younger dropped in 2020, largely due to progressive improvements in access to contraception and sexual education (32), and in the US the overall birth rate among 15- to 19-year-old girls dropped to half of what it had been in 2008 following various initiatives (33).
Similarly, many countries in SSA have developed and implemented national policies and programmes aimed at dealing with adolescent sexual and reproductive health (ASRH), including adolescent pregnancy (34).
In Ghana, the adolescent fertility rate declined steadily, and the country has also made progress in decreasing the rates of child marriage and school dropouts of girls (2). One of the key national policies for reducing adolescent pregnancy in Ghana is their Adolescent Health Service Policy and Strategy, which focuses on mainstreaming ASRH information, and gender-sensitive and responsive health services (35). These national policies coexist with programmes which are developed and implemented by both governmental and non-governmental organisations (36). In South Africa, the Department of Basic Education (DBE) has announced their implementation of comprehensive sexuality education (CSE) program in schools, which aims to empower young people with age-appropriate information about the cognitive, emotional, physical and social aspects of sexuality (37).
In Uganda, the Ministry of Education published revised guidelines for the prevention and management of teenage pregnancy in school settings, providing a policy to clarify the role of schools in adolescent pregnancies (38). At least 30 African Union countries now have laws, policies, and strategies in place that protect the rights of pregnant students and adolescent mothers to education (39).
Support grants are seen by some as a double edge sword in preventing teenage pregnancies. Perceptions that some recipients do not utilise the grant in the best interest of their children exist, and therefore need close monitoring by authorities. An alternate approach exists in Columbia, where a conditional cash transfer (CCT) program allows adolescent girls to receive a subsidy if they attended school, complete their school year, and enrol in the following year. This initiative was also effective in reducing pregnancy among adolescents across all grades included in the program (40).
A paradigm shift is required in the behaviour and attitude amongst teenagers themselves, supported by collective efforts from parents, teachers, healthcare providers and policy makers. Policymakers and community organisations should work in unison to develop and promote adolescent sexual and reproductive health policies and programmes, and emphasis should also be placed on human rights issues and gender empowerment programmes. The attitude of healthcare workers should be supportive rather than judgemental, and separate facilities should be considered for adolescent reproductive health services. Policy development, implementation strategies and quality assurance programmes are necessary to reduce adolescent pregnancies and meet the objectives of the United Nations Sustainable Development Goals (SDGs) (5).
Author contributions
The author confirms being the sole contributor of this work and has approved it for publication.
Conflict of interest
The author declares that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.
Publisher's note
All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.
References
1. World Health Organisation. Adolescent pregnancies. Available from: https://www.who.int/news-room/fact-sheets/detail/adolescent-pregnancy (Updated September 15, 2022; Accessed October 18, 2022).
2. World Bank. The social and educational consequences of adolescent childbearing. Available from: https://genderdata.worldbank.org/data-stories/adolescent-fertility (Updated February 25, 2022; Accessed September 30, 2022).
3. United Nations, Department of Economic and Social Affairs, Population Division. World population prospects. Available from: https://population.un.org/wpp/Download/Standard/Fertility (Updated 2022; Accessed October 18, 2022).
4. Ahinkorah BO, Kang M, Perry L, Brooks F, Hayen A. Prevalence of first adolescent pregnancy and its associated factors in sub-Saharan Africa: a multi-country analysis. PLoS One. (2021) 16(2):e0246308. doi: 10.1371/journal.pone.0246308
5. Inter-Agency and Expert Group in Sustainable Development Goal Indicators. Final list of proposed sustainable development goal indicators. Available from: https://sustainabledevelopment.un.org/content/documents/11803Official-List-of-Proposed-SDG-Indicators.pdf (Updated 2016; Accessed October 20, 2022).
6. Kassa GM, Arowojolu AO, Odukogbe AA, Yalew AW. Prevalence and determinants of adolescent pregnancy in Africa: a systematic review and meta-analysis. Reprod Health. (2018) 15(1):1–17. doi: 10.1186/s12978-018-0640-2
7. Yakubu I, Salisu WJ. Determinants of adolescent pregnancy in sub-Saharan Africa: a systematic review. Reprod Health. (2018) 15(1):1–15. doi: 10.1186/s12978-018-0460-4
8. Gunawardena N, Fantaye AW, Yaya S. Predictors of pregnancy among young people in sub-Saharan Africa: a systematic review and narrative synthesis. BMJ Global Health. (2019) 4(3):e001499. doi: 10.1136/bmjgh-2019-001499
9. Krugu JK, Mevissen FE, Prinsen A, Ruiter RA. Who's that girl? a qualitative analysis of adolescent girls’ views on factors associated with teenage pregnancies in Bolgatanga, Ghana. Reprod Health. (2016) 13:39. doi: 10.1186/s12978-016-0161-9
10. Wood L, Hendricks F. A participatory action research approach to developing youth-friendly strategies for the prevention of teenage pregnancy. Educ Action Res. (2017) 25(1):103–18. doi: 10.1080/09650792.2016.1169198
11. Silberschmidt M, Rasch V. Adolescent girls, illegal abortions and “sugar-daddies” in Dar es salaam: vulnerable victims and active social agents. Soc Sci Med. (2001) 52(12):1815–26. doi: 10.1016/S0277-9536(00)00299-9
12. Lambani MN. Poverty the cause of teenage pregnancy in Thulamela municipality. JSSA. (2015) 6(2):171–6. doi: 10.1080/09766634.2015.11885656
13. Africa Check. Factsheet: understanding Nigeria’s teenage pregnancy burden. Available from: https://africacheck.org/fact-checks/factsheets/factsheet-understanding-nigerias-teenage-pregnancy-burden (Updated June 21, 2021; Accessed September 27, 2021).
14. Kamer L. African countries with the highest Gross Domestic Product (GDP) in 2021. Statista. Available from: https://www.statista.com/statistics/1120999/gdp-of-african-countries-by-country (Updated May 17, 2021; Accessed October 2, 2022).
15. Ncwane N. Experts unpack causes of teenage pregnancy. IOL. Available from: https://www.iol.co.za/pretoria-news/news/experts-unpack-causes-of-teenage-pregnancy (Updated September 01, 2021; Accessed October 02, 2022).
16. Barron P, Subedar H, Letsoko M, Makua M, Pillay Y. Teenage births and pregnancies in South Africa, 2017–2021 - a reflection of a troubled country: analysis of public sector data. SAMJ. (2022) 112(4):252–8. doi: 10.7196/SAMJ.2022.v112i4.16327
17. World Population Review. Poorest countries in Africa. Available from: https://worldpopulationreview.com › country-rankings (Updated 2022; Accessed October 20, 2022).
18. Unicef. Adolescent investment case Burundi-Estimating the impacts of social sector investments for adolescents. Available from: https://www.unicef.org/esa/media/6111/file/UNICEF_Burundi-Adolescent_Investment_Case-2020-English.pdf (Updated December 2019; Accessed September 23, 2022).
19. Poudel S, Upadhaya N, Khatri RB, Ghimire PR. Trends and factors associated with pregnancies among adolescent women in Nepal: pooled analysis of Nepal demographic and health surveys (2006, 2011 and 2016). PloS One. (2018) 13(8):e0202107. doi: 10.1371/journal.pone.0202107
20. UNICEF. Child marriage. Available from: https://data.unicef.org/topic/child-protection/child-marriage (Updated May 22, 2020; Accessed October 19, 2022).
21. Yaya S, Odusina EK, Bishwajit G. Prevalence of child marriage and its impact on fertility outcomes in 34 sub-Saharan African countries. BMC Int Health Hum Rights. (2019) 19(1):33. doi: 10.1186/s12914-019-0219-1
22. de Groot R, Kuunyem MY, Palermo T. Child marriage and associated outcomes in northern Ghana: a cross-sectional study. BMC Public Health. (2018) 18(1):1–12. doi: 10.1186/s12889-018-5166-6
25. Boamah EA, Asante KP, Mahama E, Manu G, Ayipah EK, Adeniji E, et al. Use of contraceptives among adolescents in kintampo, Ghana: a cross-sectional study. J Open Access J Contracept. (2014) 5:7–15. doi: 10.2147/OAJC.S56485
26. Zulaika G, Bulbarelli M, Nyothach E, van Eijk A, Mason L, Eunice Fwaya E, et al. Impact of COVID-19 lockdowns on adolescent pregnancy and school dropout among secondary schoolgirls in Kenya. BMJ Global Health. (2022) 7:e007666. doi: 10.1136/bmjgh-2021-007666
27. Kim J. Teenage pregnancy during COVID-19 in South Africa: a double pandemic. Available from: https://www.samrc.ac.za/news/teenage-pregnancy-during-covid-19-south-africa-double-pandemic (Updated October 21, 2021; Accessed October 20, 2022).
28. Govender K, Beckett S, Reddy T, Cowden RG, Cawood C, Khanyile D, et al. Association of HIV intervention uptake with HIV prevalence in adolescent girls and young women in South Africa. JAMA Netw Open. (2022) 5(4):e228640. doi: 10.1001/jamanetworkopen.2022.8640
29. Cadena K, Hernandez PB, Inchauste G. Preventing teenage pregnancy: a priority for the well-being of women in Mexico. Available from: https://www. https://blogs.worldbank.org/latinamerica/preventing-teenage-pregnancy-priority-well-being-women-mexico (Updated April 13, 2022; Accessed October 19, 2022).
30. Novella R, Ripani L. Are you (not) expecting? The unforeseen benefits of job training on teenage pregnancy. IZA J Labor Develop. (2016) 5:19. doi: 10.1186/s40175-016-0065-7
31. ENAPEA. Government of Mexico (2019). Available from: https://enapea.segob.gob.mx/es/ENAPEA (Accessed Oct 22, 2022).
32. BBC News. Why are there fewer teenager mothers in Northern Ireland? (2021). Available from: https://www.bbc.com/news/uk-northern-ireland-59001641.
33. Martin JA, Brady E, Hamilton BE, Osterman M. Births in the United States, (2018). NCHS Data Brief; vol 3462019 Centers for Disease Control and Prevention. Available from: https://www.cdc.gov/chs/data/databriefs/db346-h.pdf (Accessed Oct 2, 2022).
34. Ahinkorah BO, Kang M, Perry L. Prevention of adolescent pregnancy in anglophone sub-Saharan Africa: a scoping review of national policies. Int J Health Policy Manag. (2020) 11:726–39. doi: 10.34172/IJHPM.2020.185
35. Republic of Ghana. Adolescent health service policy and strategy 2016-2020. Accra: Ghana: The Republic of Ghana (2016).
36. Awuni A. NGO rolls out project to combat teenage pregnancy in upper East. Accra, Ghana, (2016). Available from: https://citifmonline. com/2016/04/ngo-rolls-out-project-to-combat-alarming-teenagepregnancy-in-ue/.
37. Department of Basic Education. Sexuality education lesson plans (2021). Available from: https://www.education.gov.za/Home/ComprehensiveSexualityEducation.aspx (Accessed Oct 17, 2022).
38. Ministry of Education and Sports. Revised guidelines for the prevention and management of teenage pregnancy in Uganda (2020). Available from: https://www.ungei.org/sites/default/files/2021-02/Revised-Guidelines.
39. Human Rights Watch. Africa: Rights progress for pregnant students. Available from: https://www.hrw.org/news/2021/09/29/africa-rights-progress-pregnant-students (Accessed on 20 Oct, 2022).
Keywords: adolescents, sexually transmitted infections, HIV, contraception, pregnancy
Citation: Maharaj NR (2022) Adolescent pregnancy in sub-Saharan Africa – a cause for concern. Front. Reprod. Health 4:984303. doi: 10.3389/frph.2022.984303
Received: 1 July 2022; Accepted: 15 November 2022;
Published: 2 December 2022.
Edited by:
Samanta Tresha Lalla-Edward, Ezintsha, a division of the Wits Health Consortium, South AfricaReviewed by:
Nomathemba Chandiwana, University of the Witwatersrand, South Africa© 2022 Maharaj. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.
*Correspondence: Niren Ray Maharaj obgyn80@gmail.com
Specialty Section: This article was submitted to HIV and STIs, a section of the journal Frontiers in Reproductive Health