systematic review of adolescent pregnancy

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Int J Environ Res Public Health

The Effects of Pregnancy: A Systematic Review of Adolescent Pregnancy in Ghana, Liberia, and Nigeria

Augustine lambonmung.

1 Faculty of Public Health, Thammasat University, Pathum Thani 12120, Thailand

2 Tamale Teaching Hospital, Ministry of Health, Tamale P.O. Box TL 16, Ghana

Charity Asantewaa Acheampong

3 Princess Marie Louise (PML) Children Hospital, Ghana Health Service, Accra P.O. Box GP 122, Ghana

Uma Langkulsen

Associated data.

Not applicable.

There is a high incidence of adolescent pregnancy in West Africa. The objective of this study is to highlight the health impacts of adolescent pregnancy through a systematic review. A search was conducted in the electronic databases of Google, Google Scholar, SCOPUS, EBSCO, CINAHL, Web of Science, African Journals Online (AJOL), and the Demographic Health Surveys (DHS) Program. The study found anemia, complications of pregnancy, obstetric and gynecological risks, unsafe abortions, and psychological effects to adversely impact the health of adolescent girls in Ghana, Liberia, and Nigeria. Pregnancy could be deleterious to the health and well-being of adolescent girls in various forms. In addition, adolescent pregnancy could expose adolescent girls to gender-based violence, exclusions, and inequities, be detrimental to upholding women’s sexual and reproductive health rights, and could also have implications for Sustainable Development Goal 3. Targeted interventions to prevent pregnancy in young women and mitigate these effects by stakeholders are encouraged.

1. Introduction

The adolescence (10–19) years are a transitional period between childhood and adulthood [ 1 ]. There are about 1.2 billion adolescents globally with over 50% of them from Asia. Sub-Saharan Africa has the largest proportion of their general population [ 2 ]. For this group of young people to grow and make meaningful contributions to society, their fundamental human rights must be ensured and they must be well-educated. The provision of jobs, inclusiveness, and important issues relating to their health should effectively be dealt with [ 3 ]. Adolescents are faced with myriad health challenges with an increased risk depending on which part of the world they find themselves in [ 4 ]. Sexual and reproductive health and rights among adolescents have been an ongoing global health concern given the fact that they are regarded as critical for the progress of society.

The issue of adolescent health as a global health challenge is due to the complexity of meeting sexual and reproductive health needs and the provision of antenatal care (ANC) services to adolescents. It requires a multi-sectoral and collaborative approach to prevent of unwanted pregnancies and alleviate the negative consequences of adolescent pregnancy [ 5 ]. The World Health Organization (WHO) issued 18 guidelines in 2011 seeking to prevent adolescent pregnancies and improve reproductive health in Low- and Middle-Income Countries (LMICs) [ 6 ]. In spite of this and other local interventions, pregnancies among young girls in LMICs are unacceptably high. According to the World Health Organization (WHO), about 21 million girls (15–19) years become mothers and a further 2 million younger than 15 years old give birth annually across the world, with most of them occurring in LMICs, specifically countries in South Asia and Sub-Saharan Africa. Further, three million pregnancies are unsafely terminated which can negatively impact the health of these girls [ 7 ]. Adolescent pregnancy in West Africa, as in other regions of the developing world, is among the highest in the world [ 8 ]. The rate of adolescent pregnancy in the sub-region has been persistently high, with a prevalence of about 25% spanning a period of two decades (1992–2011) [ 9 ]. An adolescent birth rate of 115 per 1000 births in West Africa in recent times is considered the highest of any sub-region globally [ 2 ]. Moreover, pregnancy at a tender age could adversely affect young girls diversely. Pregnant adolescent girls in LMICs are impacted by pregnancy in many facets of their lives, particularly in health, employment, education, and to some extent, family members later in life [ 10 ]. Though there is a decline in mortality and morbidity of children and adolescents globally (from 1990–2015), it is sadly observed that maternal and reproductive health-related issues are significantly contributing to the disease burden of adolescent girls in LMICs [ 4 ]. Three broad determining factors for adolescent pregnancy contributing significantly to this chronic public health concern were identified as socio-cultural, environmental and economic, and individual and health services [ 11 ]. This global health challenge, which has adverse consequences for birth outcomes and poverty eradication and can transverse generations [ 12 ], remains high in West Africa. Issues such as poverty, weak health systems, gender inequality, and some cultural practices, such as early marriages, are implicated in adolescent pregnancy [ 8 ]. The highly restrictive abortion regimes in most countries in the region with their clandestine abortion practices further injure the health of adolescent girls [ 13 ]. The health impacts of pregnancy on adolescent girls in Ghana, Liberia, and Nigeria in West Africa have been examined by a few studies. The three countries purposively selected are English-speaking countries since publications in the English language only were considered for the study. They are representative of the similarities in the region with regard to politics, low socioeconomic development, and geography, as well as demographic backgrounds. Liberia is a country emerging from a devastating civil war and has a very high rate of child marriage, a low level of educated girls, and a high incidence of adolescent pregnancy in Sub-Saharan Africa. Nigeria, the most populated nation in West Africa, is considered one of the countries with the highest rate of adolescent pregnancy and a low level of educated girls globally [ 14 ]. Ghana has been stable politically and economically among its peers in the sub-region. With about 11% of their respective populations being adolescent girls (10–19) years, they have high adolescent birth rates. Ghana, with 78 per 1000 girls (15–19) years, is among the lowest in the West Africa region, followed by Nigeria with 106 and Liberia with 128, which is considered among the highest worldwide [ 2 ].

Highlighting how pregnancy is defiling the health of adolescent girls in these countries in West Africa through a systematic review could help in adopting more pragmatic approaches to check unplanned pregnancies, especially in younger adolescents, and institute measures to improve adolescent maternal health outcomes to further reduce maternal mortality in line with the Millennium Development Goals (MDGs) to help achieve the Sustainable Development Goals (SDG 3). SDG 3 and targets 3.1 and 3.7, which are closely linked to the objectives of this review, seek to reduce the maternal mortality ratio and ensure wider coverage of sexual and reproductive health care services, respectively [ 15 ]. The study would also be beneficial in recognizing the need for the fulfillment of sexual and reproductive health, and the rights of women, especially safe abortion care services without undue legal restrictions. This study intends to bring together the maternal health impacts of adolescent pregnancy in the context of West Africa with a focus on Ghana, Liberia, and Nigeria.

2. Materials and Methods

2.1. study design and search strategy.

The design for the study is a systematic review. A review protocol was developed and registered in PROSPERO (CRD42021289636). Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) 2020 guidelines [ 16 ] were adhered to. Google, Google Scholar, SCOPUS, EBSCO, CINAHL, Web of Science, African Journals Online (AJOL), and the Demographic and Health Surveys (DHS) Program were searched in November 2021 using the following terms: adolescent pregnancy, adolescent birth, and teenage pregnancy. Search terms such as outcomes, risks, impacts, effects, consequences, and associated factors were also used.

2.2. Selection Criteria

A broad search framework was constructed and implemented for a thorough online search of applicable studies. The inclusion criteria applied for the purposes of gathering literature for the review were publications and articles published from the year 2016, post-Millennium Development Goals (MDGs), to 2021 were considered. Abstracts were screened, and a full text was retrieved and assessed for eligibility. Publications that discussed adolescent pregnancies in the selected countries were reviewed. Reports and publications by organizations (governmental and non-governmental bodies) on the impacts of adolescent pregnancy in the selected West African nations were evaluated for inclusion. Publications in the English language relating to the search terms relevant for the review and analyzed the effects of pregnancy in adolescent women between the ages of 10–19 years, determined to be useful for the review, were used. Publications were excluded from the review if they lacked relevant data on pregnant adolescents aged 10–19 years. Studies on adolescent pregnancy conducted outside of the region were not considered for the review.

2.3. Data Extraction and Quality Assessment

The Joanna Briggs appraisal tool was independently used by two reviewers to ascertain their quality for inclusion or exclusion. The tool is a checklist made up of a set of eleven questions [ 17 ]. Where there was a disagreement or due to inadequate information, the full text of the disputed abstract was obtained, and a third reviewer mediated following a discussion on the issue for a consensus to be reached. Studies that reported different outcomes from the same study sample were excluded for the likelihood of publication bias. The latest and final reports of the relevant Demographic and Health Surveys were included. For a possible publication bias, some articles were excluded from the final synthesis of the review [ 18 , 19 , 20 ].

2.4. Data Synthesis

A narrative synthesis was chosen to carefully select the clearest reported outcomes that were directly relevant to the review question and were grouped under common themes suitable to the objective of the study. The narrative synthesis complied with the recommended criteria in the performance of a rigorous synthesis without meta-analysis (SWiM) [ 21 ]. This provides a clear guide for reporting on the evaluation of studies using alternative synthesis approaches to a meta-analysis of effect estimates. It allowed for the extracted data to be summarized, structured, and described independently of the reviewers, and a consensus formed over disputed results. The effects of pregnancy on girls were combined and homogenously grouped as anemia, complications of pregnancy and obstetric and gynecological effects, unsafe abortions, psychological effects based on conceptual appropriateness, methods employed, and how unbiased they were in terms of designing, conducting, and analyzing the studies.

The 28 studies included in the review were conducted in Ghana, Liberia, and Nigeria in the West African sub-region, and were used after they were blindly reviewed by two independent reviewers and a third reviewer whenever there was no consensus between independent reviewers. Figure 1 illustrates the screening steps for inclusion and exclusion. Three studies that reported different outcomes from the same study were excluded from the final synthesis of results for possible publication bias.

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PRISMA flowchart of search results.

3.1. Characteristics of Included Studies

As shown in Table 1 , most of the studies used were qualitative, cross-sectional studies, and surveys (five each). Three of the surveys were demographic and health surveys (final reports) and two were national surveys. There were three retrospective studies. Two of the studies used descriptive, prospective, and longitudinal designs. One of the two longitudinal studies used Adolescent Birth Outcomes, Ghana (ANBOG). There was one randomized control trial, exploratory, observational, and mixed study design (qualitative and quantitative) studies each for the reviews.

Characteristics of included studies.

Participants in the studies used had at least a sample size of 17 [ 22 ] and the highest sample size was 26,055 [ 23 ]. These studies were carried out in both rural and urban settings, and were institution-based and community-based. A total of 47,479 adolescent girls eligible for the studies were pregnant either during or before the studies were undertaken. Their ages ranged from 11 years (youngest) to 24 years (oldest) and included educated and non-educated, and married and unmarried. Some key informants comprising parents, teachers, adolescent mothers and partners, and health care providers participated in some of the qualitative studies used, providing useful and relevant information on how pregnancy impacts the health of adolescent girls.

It is worthy of note that none of the studies included in this review included studies on vulnerable adolescent groups, such as the disabled or those living with non-communicable diseases (NCDs) or victims of pandemics, such as HIV/AIDS or Ebola, which have devastated the sub-region. There was no study found to have investigated COVID-19-positive pregnant adolescent girls in the selected countries in West Africa. Detailed characteristics of all included studies are summarized in Table 1 .

As summarized in Table 2 , this review found four main themes on how pregnancy affects the health and well-being of adolescent girls in West Africa. They are anemia, complications of pregnancy, obstetric and gynecological effects, unsafe abortions, and psychological effects.

Main effects of adolescent pregnancy.

3.2. Anaemia

Anemia as determined by the six studies is a common complication that occurs among pregnant adolescents in these countries. Higher anemia among adolescents [ 24 ], iron deficiency anemia common among pregnant teenagers [ 25 ], the presence of morbidity in the form of anemia [ 26 ], and adolescent expectant mothers more likely to be anemic [ 27 ] were the findings under this theme.

3.3. Pregnancy-Related Complications and Obstetric and Gynecological Effects

The various unpleasant health effects during pregnancy in adolescent girls, categorized as complications of pregnancy, and obstetric and gynecological effects, are immature pelvic structures of pregnant teenagers that could cause cephalo-pelvic disproportion which could injure pelvic structures, thereby causing postpartum bleeding [ 44 ], hypertensive disorders of pregnancy and obstructed labor among teenagers [ 24 ], the likelihood of fistula experience and postpartum hemorrhage [ 43 ], and cesarean sections as a result of the mother’s medical conditions [ 14 ].

3.4. Unsafe Abortions

Abortions under unsafe circumstances were found to be a common health hazard for teenage mothers largely due to the illegality of abortion in the sub-region. Most abortions by adolescents were unsafely terminated [ 45 ], more adolescents indulged in unsafe abortions [ 32 ], abortions by adolescents were performed under unsafe circumstances [ 29 ], methods for abortions were obtained from non-formal providers [ 35 ], and crude methods such as insertion of objects into the vagina, a heavy message and the drinking of a herbal concoction were used [ 34 ].

3.5. Psychological Effects

The mental health and psychological effects related impact of adolescent pregnancy findings reported by the studies are sadness and an unhappy mood [ 37 ], moderate to severe depression, and major psychosocial effects due to pregnancy [ 28 , 31 ], such as feelings of fear, anger, shyness, and being miserable [ 30 ] were described. Findings of pregnancy-related stress [ 24 ], suicidal thoughts, ideations and feelings of rejection [ 33 ], fear, self-condemnation, guilt [ 22 ], and poorer coping ability and attitude toward pregnancy [ 41 ] were also found through this review. Lastly, three of the studies included in the review measured other outcomes different from the themes above. They reported not encouraging eating habits of pregnant adolescent women [ 27 ] and experiences of physical violence by pregnant adolescent girls [ 23 , 39 ].

4. Discussion

This systematic review was conducted to identify the adolescent maternal health impacts of pregnancy in three West African states. It found pregnant adolescent mothers to be anemic; they overly become exposed to pregnancy-related complications, they suffer from obstetric and gynecological effects, and they indulge in unsafe abortions, as well face pregnancy-related psychosocial stresses. These deleterious adverse health outcomes could have implications for women’s sexual and reproductive health and rights, as well as the attainment of SDG 3. All the studies that reported these deleterious medical effects that accompany adolescent pregnancy were conducted recently (post-MGDs), which is consistent with a study on the global burden of diseases that found adverse adolescent maternal outcomes as a substantial burden of adolescent morbidity and mortality in the Global South [ 4 ]. This review reported the health impacts of adolescent pregnancy from studies published in the last six years preceding this review, about six years into the start of the SDGs, and also in an era (twenty-first century) where the advancement in medical care is complemented by sophisticated information communication technology (ICT) driving the quality and efficacy of health care, bringing about an increment in quality and longer life span since the turn of the century [ 10 ]. However, over 70% of women of reproductive age face restrictive abortion laws in West Africa, where about 85% of abortions are performed in an unsafe manner [ 13 ]. The emergence and diffusion of Islam and Christianity together with traditional African religious beliefs in these countries make it challenging for the implementation of such scientific interventions, such as abortion care [ 46 ]. Some attitudes of healthcare providers influenced by religion, access and stigma, and victimization discourage women from patronizing the limited available safe abortion care services [ 47 ]. This forces many adolescent girls in the region to be in need of such services, as found through this study to engage in deadly abortion practices, where over 90% of the countries have prohibitive abortion rules [ 13 ]. Unsurprisingly, maternal mortality and morbidity indices in the selected countries are worrying [ 48 ]. These findings by this study are consistent with [ 49 ] stating that adolescent women are categorized within a special risk group of expectant mothers and routine antenatal care might not be enough to avert complications. What perhaps is not clear is the association of inadequate dietary intake, unhealthy eating habits, and intimate partner violence with adolescent pregnancy since only a couple of studies reported these outcomes. Young maternal age is found to be at an increased health risk during pregnancy [ 44 ]. Risks of complications and injuries such as obstetric fistulas, abortions, and even death could be a consequence of pregnancy in young women (10–19) [ 12 ]. The adverse health outcomes emanating from adolescent pregnancy are considered a public health hazard contributing significantly to maternal and child morbidity and mortality, and have been reported widely [ 8 ]. The health effects, as stated above, could manifest from the period of conception and may last a lifetime.

As has been revealed through this study, pregnancy could severely and adversely impact the health of girls in West Africa. One such adverse health outcome is anemia. Pregnancy during this period can contribute substantially to making them anemic without effective interventions. Anemia during pregnancy is due to physiological changes resulting in hemodilution and the increased requirements of iron [ 50 ]. A cross-sectional retrospective quantitative study found 68.9% of parturient adolescents to be anemic [ 51 ]. Cognitive performance is thought to be affected by anemia, in particular iron deficiency anemia. Iron deficiency anemia is a common phenomenon in adolescent pregnancy and iron treatment is required for a positive maternal outcome [ 52 ]. Anemic pregnant adolescents are found to have a postpartum hemorrhage, preeclampsia, and heart failure. The underlying factors for these adverse maternal outcomes are adolescent pregnancy itself [ 53 ], thus emphasizing the need to deal with the root cause which is adolescent pregnancy. Pregnancy-related complications, and obstetric and gynecological effects are also known to cause various degrees of harm to the health of adolescents. Pregnancy-induced hypertension and cesarean sections are commonly associated with adolescent pregnancy [ 54 ]. This is considered not only risky for adolescent childbearing but a risk factor for later pregnancies as well [ 45 ]. The development of obstetric fistulas among adolescent mothers accounted for up to 86% of treated cases with the majority of them from Sub-Saharan Africa in a clinical review study [ 55 ].

Another serious health impact is mental state disturbances. Postpartum depression in adolescent mothers has been reported [ 56 ]. In a systematic review in Sub-Saharan Africa and globally of adolescent girls and young women’s psychosocial experiences post-abortion, the prevalence of shame and abandonment was reportedly experienced by adolescents of all ages [ 57 ]. This population subgroup at this critical developmental stage is noted for its fragility in terms of mental health stability [ 56 ] and, therefore, pregnancy should be avoided if undesired, especially among the younger adolescents who are less than fifteen years old and who are known to suffer gravely to prevent it from becoming a precursor to mental health disorders. Reduced uptake and the use of contraception and reproductive health-related services among adolescents is a painful reality. The goal of SDG 3, target 3.7, for wider coverage of sexual and reproductive healthcare services for adolescents, truly deserves some more attention as contraception usage is regarded as the surest way of preventing unintended pregnancy in this population sub-group [ 32 ]. This is even more so as low coverage and patronage of this essential service is noted as a major determining factor in the incidence of adolescent pregnancy [ 11 ]. Restrictions on reproductive services to adolescents could be infringing on international conventions that are seeking to abolish all forms of discrimination, inequalities, and abusive practices against women [ 58 ]. International treaties such as The Convention on the Elimination of All Forms of Discrimination Against Women (CEDAW) and The African Charter on the Human and Peoples’ Rights and Rights of Women of Africa (Maputo Protocol) are some specific treaties adopted to ensure the protection of women’s sexual and reproductive rights. CEDAW, also referred to as the international bill of rights of women, calls on countries to guarantee adolescents access to reproductive health services and family planning. Similarly, the Maputo Protocol aims to guarantee sexual and reproductive health including safe abortion care (Article 14). Early marriages (under 18 years) which contribute to adolescent pregnancy are discouraged by the protocol. It further calls upon duty bearers in Article 14 to ensure a woman’s right to health, including respecting and promoting their sexual and reproductive health [ 59 ]. This suggests that much more needs to be performed to promote the uptake and usage of contraception by adolescents. Key to the expansion of coverage and uptake of contraception is education and information dissemination. Adopting and comprehensively implementing the WHO’s guidelines on adolescent sexual and reproductive health and rights [ 6 ] can help push the wheels of progress to attain the above target 3.7 of SDG 3, as sexual and reproductive health and right is a critical tool for fulfilling developmental goals [ 58 ]. Ensuring universal coverage of sexual and reproductive healthcare, as far as the adolescent girl population in these countries and to a large extend West Africa is concerned, could help build their capacity to take charge of their sexual live and significantly consolidate gains in the realization of SDG 3 [ 60 ]. HRBA to sexual reproductive health services and rights could promote increased access and uptake in women, particularly adolescents [ 58 ].

The study has some strengths and limitations. The study identified adverse adolescent maternal outcomes attributable to pregnancy in Ghana, Liberia, and Nigeria in West Africa through a comprehensive search and the religious application of the PRISMA 2020 guidelines [ 16 ]. The inclusion of DHS improves the quality of the review as it provides reliable and timely information on population and health in developing countries. However, the main sources of data were scientific databases and DHS; therefore, there is a possibility of missing out on some studies during the search process as they might not have published their findings in journals in these databases as adolescent pregnancy is a multidisciplinary topic. Some included studies had small sample sizes. Only studies in the English language published from 2016 to 2021 were used for this study. Contrary to the initial plan, meta-analyses are not performed as a result of a lack of reported statistically estimated effect sizes by most of the studies, thus making the study lack statistical power. In addition, there are no studies from all the West African countries which could limit this review’s generalization.

5. Conclusions

In conclusion, the review identified anemia, complications of pregnancy, obstetric and gynecological effects, unsafe abortions, and mental health-related effects as negatively impacting the health and well-being of adolescent girls which could substantially contribute to maternal and child morbidity and mortality. As women suffer these ailments, and some sadly lose their lives rather prematurely through pregnancy as a result of restrictions on sexual and reproductive health and rights and safe abortion care which might be required exclusively by women, could suggest the need to prioritize HRBA to sexual and reproductive health issues in Ghana, Liberia, and Nigeria in West Africa. This unfortunate situation seems to infringe on their rights to health and ripples to hinder their full participation, and could expose adolescent girls to gender-based violence (GBV), exclusions, and inequities. Sexual reproductive health and rights services for adolescents should be scaled up across these countries and the entirety of the sub-region to help accelerate the attainment of SDG 3. Women’s rights to exclusive services, such as safe abortion care, should be regarded as a safe scientific intervention to promote health and well-being and, therefore, legal instruments, religion, and culture should not be used to discourage the provision and accessibility of such services.

Funding Statement

There was no funding source for this study.

Author Contributions

Conceptualization, A.L. and U.L.; methodology, A.L. and U.L.; validation, A.L. and C.A.A.; formal analysis, A.L. and C.A.A.; data curation, A.L. and C.A.A.; writing original draft preparation, A.L.; review and editing, A.L., C.A.A., and U.L.; supervision, U.L. All authors have read and agreed to the published version of the manuscript.

Institutional Review Board Statement

This study was approved by the Human Research Ethics Committee of Thammasat University (Science), Thailand (HREC-TUSc) (COE No. 020/2564).

Informed Consent Statement

Data availability statement, conflicts of interest.

The authors declare no conflict of interest.

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Prevalence and determinants of adolescent pregnancy in Africa: a systematic review and Meta-analysis

Reproductive Health volume 15 , Article number: 195 ( 2018 ) Cite this article

Metrics details

Adolescence is the period between 10 and 19 years with peculiar physical, social, psychological and reproductive health characteristics. Rates of adolescent pregnancy are increasing in developing countries, with higher occurrences of adverse maternal and perinatal outcomes. The few studies conducted on adolescent pregnancy in Africa present inconsistent and inconclusive findings on the distribution of the problems. Also, there was no meta-analysis study conducted in this area in Africa. Therefore, this systematic review and meta-analysis were conducted to estimate the prevalence and sociodemographic determinant factors of adolescent pregnancy using the available published and unpublished studies carried out in African countries. Also, subgroup analysis was conducted by different demographic, geopolitical and administrative regions.

This study used a systematic review and meta-analysis of published and unpublished studies in Africa. Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guideline was strictly followed. All studies in MEDLINE, PubMed, Cochrane Library, EMBASE, Google Scholar, CINAHL, and African Journals Online databases were searched using relevant search terms. Data were extracted using the Joanna Briggs Institute tool for prevalence studies. STATA 14 software was used to perform the meta-analysis. The heterogeneity and publication bias was assessed using the I 2 statistics and Egger’s test, respectively. Forest plots were used to present the pooled prevalence and odds ratio (OR) with 95% confidence interval (CI) of meta-analysis using the random effect model.

This review included 52 studies, 254,350 study participants. A total of 24 countries from East, West, Central, North and Southern African sub-regions were included. The overall pooled prevalence of adolescent pregnancy in Africa was 18.8% (95%CI: 16.7, 20.9) and 19.3% (95%CI, 16.9, 21.6) in the Sub-Saharan African region. The prevalence was highest in East Africa (21.5%) and lowest in Northern Africa (9.2%). Factors associated with adolescent pregnancy include rural residence (OR: 2.04), ever married (OR: 20.67), not attending school (OR: 2.49), no maternal education (OR: 1.88), no father’s education (OR: 1.65), and lack of parent to adolescent communication on sexual and reproductive health (SRH) issues (OR: 2.88).

Conclusions

Overall, nearly one-fifth of adolescents become pregnant in Africa. Several sociodemographic factors like residence, marital status, educational status of adolescents, their mother’s and father’s, and parent to adolescent SRH communication were associated with adolescent pregnancy. Interventions that target these factors are important in reducing adolescent pregnancy.

Peer Review reports

Plain English summary

Adolescent pregnancy is defined as the occurrence of pregnancy in girls aged 10 to 19. Adolescent pregnancy has become a major public health problem, particularly in Africa. Consequently, the region is known for the high rate of maternal and child morbidity and mortality. Since recent times, several governmental and non-governmental organization in some African countries focused on reducing the adolescent pregnancy rate, although a very slow progress was made. Several published and unpublished studies conducted on the prevalence of adolescent pregnancy in Africa are available. However, these studies present inconsistent and inconclusive findings and little is known about the overall epidemiology of adolescent pregnancy in the continent. This study, therefore, was conducted to estimate the prevalence and sociodemographic factors associated with adolescent pregnancy in Africa using published and unpublished studies. This study included a total of 52 studies from 24 African countries. Accordingly, almost one-fifth (18.8%) adolescent get pregnant in Africa. A higher prevalence was observed in East African sub-region (21.5%). Adolescents from rural areas, ever married, whose mother or father were not educated, and had no parent to child communication on SRH issues were more likely to start childbearing at a younger age. Therefore, African countries and other non-governmental organizations need to address these factors and the multifaceted sexual and reproductive health needs of adolescents. Programs aimed at improving the contraceptive use, prevention of unintended pregnancy, prevention of early marriage and risk behavior reduction can reduce the high rate of adolescent pregnancy in Africa.

Globally, around 1 in 6 people are adolescents aged 10 to 19 years old [ 1 ]. Adolescent pregnancy is defined as the occurrence of pregnancy in girls aged 10–19 [ 2 ]. Almost one-tenth of all births are to women below 20 years old, and more than 90% of such births occur in developing countries [ 1 , 3 ]. The declining age at menarche and better nutrition and healthier lifestyles of younger generations are the main factors for high rate of adolescent pregnancy globally [ 4 ]. World Health Organization (WHO) 2014 report showed that the global adolescent birth rate was 49 per 1000 girls aged 15 to 19 years old [ 5 ].

Adolescent pregnancy is a major public health problem, particularly in Africa [ 6 ]. It is associated with high maternal and child morbidity and mortality and affects the socio-economic development of a country [ 1 , 5 , 7 ]. It is linked to an increased risk of adverse pregnancy and childbirth outcomes compared to older women [ 6 ]. More than 70,000 adolescent girls die every year because of these complications mainly in developing countries [ 3 ]. Most maternal and child morbidity and mortality are related to hypertensive disorders of pregnancy, infections, low birth weight, and preterm delivery [ 2 ].

Pregnancy among adolescent women has implications on the educational opportunity, population growth and ill-health of women. For this reason, prevention of child marriage and reduction of adolescent pregnancy has long been the focus of attention by several governmental and non-governmental organizations [ 8 ]. Moreover, the reduction in the adolescent pregnancy birth rate since 1990 has resulted in the decline of maternal mortality rate among teenagers especially in developed nations [ 1 ]. Several studies have shown that the high level of maternal and perinatal morbidity and mortality can be reduced by lowering the high rate of adolescent pregnancy in developing countries [ 6 , 9 , 10 ]. Consequently, reducing the high rate of adolescent pregnancy and maternal mortality is considered as the key Sustainable Development Goals (SDG),target 3.1 and 3.7 [ 11 ].

Even though the identification of the distribution of adolescent pregnancy is important in designing proper interventions to reduce the problem, the small sample sizes and a limited number of available studies were the challenges in identifying the magnitude of the problem in Africa. There is also the absence of the distribution of the problem in different geopolitical and administrative areas. Additionally, the available studies which assessed the factors associated with adolescent pregnancy in Africa showed inconsistent findings [ 12 , 13 , 14 , 15 , 16 , 17 , 18 , 19 , 20 , 21 , 22 , 23 , 24 , 25 ]. Therefore, this review used the evidence of these studies and summarized the pooled estimates using a meta-analysis. There was one previous systematic review [ 26 ] conducted to assess the determinants of adolescent pregnancy in Sub-Saharan African countries. However, it included the sociocultural, economic and environmental factors which affect adolescent pregnancy, and didn’t use meta-analysis methods to pool the prevalence and determinants of adolescent pregnancy. The current study, therefore, used both systematic and meta-analysis methods to estimate the pooled prevalence and sociodemographic determinants of adolescent pregnancy in Africa. This study further examined the prevalence of adolescent pregnancy by different study characteristics like sub-regions of Africa, study design and type, publication year, and study quality score. The findings of this study will help to design strategies aimed at reducing adolescent pregnancy and monitor the progress of programs aimed at achieving the adolescent pregnancy rate and maternal mortality reduction targets of SDG.

Study design and search strategy

A systematic review and meta-analysis of published and unpublished studies were conducted to assess the pooled prevalence and associated factors of adolescent pregnancy in Africa. Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines [ 27 ] were strictly followed in doing this review. The databases used to search for studies were: MEDLINE, PUBMED, Cochrane Library, EMBASE, Google Scholar, CINAHL, and African Journals Online (AJOL). All search terms for “ Adolescent pregnancy OR teen pregnancy OR teenage pregnancy OR young maternal age AND Africa ” were used separately and in combination using the Boolean operators like “OR” or “AND”. Also, terms like “ determinant factors OR determinant variables OR associated factors” were used in combination with the above search terms. The search was also made by combining the above search terms with the name of all countries included in Africa.

Study selection and eligibility criteria

All available studies conducted between 1990 to September 2018 were included in this review. All prospective and retrospective cohort studies, cross-sectional studies, case control and Demographic and Health Survey (DHS) reports of African countries were included in this review. For the latter, only the recent DHS final reports published in the English language were extracted from the official website of the DHS program [ 28 ]. The references of the selected articles were also screened to retrieve any additional articles which could be incorporated in this review. However, studies conducted among the non-adolescent population or on male adolescents (teenage fatherhood), or those not reporting the outcome of interest, and review articles were excluded.

Definition of adolescent pregnancy

The DHS reports measured teenage pregnancy as “ Percentage of women aged 15-19 who have given birth or are pregnant with their first child ” [ 29 , 30 , 31 , 32 , 33 , 34 , 35 , 36 , 37 , 38 , 39 , 40 , 41 , 42 , 43 , 44 , 45 , 46 ]. Prevalence of adolescent pregnancy can also be measured as the percentage of pregnant adolescent women from all women who attended health institutions for delivery services [ 47 , 48 , 49 , 50 , 51 , 52 , 53 , 54 , 55 , 56 , 57 ] or antenatal care services [ 58 , 59 ] during a specific period of time. Therefore, this review included all studies which used either of the above- definitions.

Several sociodemographic related factors which affect adolescent pregnancy were included. These factors include residence (rural vs urban), marital status (ever married vs never married), educational status of an adolescent girl (not attended vs attended), educational status of mother (not attended vs attended) and educational status of the father (not attended and attended). Adolescent girls who were currently married or divorced or previously married or living together were categorized as ever married. Also, for the educational status of adolescents and their family, primary, secondary or tertiary educational levels were grouped as attended and those who have never been admitted to school were grouped as not attended. In addition, parent to adolescent communication on sexual and reproductive health (SRH) issues was also included.

Quality assessment and data extraction

Articles were screened using their titles, abstracts, and full paper reviews prior to including in the meta-analysis. The Joanna Briggs Institute (JBI) critical appraisal checklist [ 60 ] was used to assess the quality of included studies. The tool contains information on sample representativeness of the target population, participant recruitment, adequacy of the sample size, detailed description of the study subjects and study setting, sufficient coverage of the data analysis, objective criteria in the measurement of the outcome variable and identification of subpopulation, reliability, appropriate statistical analysis, and identification of confounding variables. The quality scores of included studies were assessed and presented using the mean scores to designate as high or low-quality.

The JBI tool for prevalence studies [ 61 ] was used as a guideline for data extraction from the finally selected articles. The data extraction tool contains information on the author and year of the study, title, year study was conducted and year of publication, study area and country, sub-region, study design and type, study population, age range of adolescent participants, sample size, response rate, the outcome measured, and prevalence rate of adolescent pregnancy. Information regarding the publication status was also collected. Additionally, for the factors, a separate data extraction tool was prepared. The tool contains information on author’s name, year of publication, number of pregnant adolescents and total adolescents by residence, marital status, adolescent’s and their family educational status, and parent to adolescent communication on SRH issues was collected.

Heterogeneity and publication Bias

The heterogeneity test of included studies was assessed by using the I 2 statistics. The p -value for I 2 statistics less than 0.05 was used to determine the presence of heterogeneity. Low, moderate and high heterogeneity was assigned to I 2 test statistics results of 25, 50, and 75% respectively [ 62 ]. The publication bias was assessed using the Egger regression asymmetry test [ 63 , 64 ]. For meta-analysis results which showed the presence of publication bias (Egger test = p < 0.05), the Duval and Tweedie nonparametric trim and fill analysis using the random effect analysis was conducted to account for publication bias [ 65 ].

Statistical methods and analysis

Data were entered into Microsoft Excel and the meta-analysis was conducted using STATA 14 software. Forest plots were used to show the magnitude of adolescent pregnancy in Africa. Due to its help in minimizing the heterogeneity of included studies, the random effect model of analysis was used as a method of meta-analysis [ 62 ].

Subgroup analyses were also conducted by different study characteristics such as sub-regions of Africa (East, South, West, Central and Northern Africa), study design (cross-sectional or retrospective study), study type (community based or institution based), type of the document (DHS report or research article), publication status (published or unpublished), publication year (before 2015 or after 2015) and study quality score (low or high score). Moreover, the meta - analysis regression was conducted to identify the sources of heterogeneity among studies [ 66 ]. It was conducted using the following study-level covariates: sample size, publication year, study quality score, sub-region, and publication status of included studies. The different factors associated with adolescent pregnancy were presented using odds ratios (ORs) with 95% confidence interval (CI).

Study selection

This systematic review and meta-analysis included published and unpublished studies conducted on adolescent pregnancy in Africa. A total of 1889 records were retrieved through electronic database searching. From these, 334 duplicated records were excluded, and from 1555 articles screened using their titles and abstracts, 1450 were excluded. One hundred five full-text articles were assessed for eligibility. From these, 53 full-text articles were excluded for prior criteria, and a total of 52 studies were included in the final quantitative synthesis (Fig. 1 ).

Flow diagram of the included studies for the systematic review and meta-analysis of prevalence and determinants of adolescent pregnancy in Africa

Characteristics of included studies

Twenty-four African countries were represented in this review. From all, 18 (34.6%) of the studies were from West Africa [ 17 , 19 , 20 , 22 , 33 , 35 , 36 , 37 , 39 , 48 , 51 , 52 , 53 , 54 , 58 , 59 , 67 , 68 ], 19 (36.5%) were from East African countries [ 12 , 13 , 15 , 16 , 18 , 21 , 23 , 24 , 29 , 30 , 32 , 38 , 40 , 42 , 44 , 45 , 46 , 69 , 70 ], 7 (13.5%) from Central Africa [ 25 , 47 , 49 , 50 , 56 , 57 , 71 ], 6 (11.5%) from Southern Africa [ 31 , 34 , 43 , 67 , 72 , 73 ] and 2 (3.8%) were from only one Northern African country (Egypt) [ 41 , 55 ]. Almost all, 50 of the included studies were from Sub-Saharan African countries. The majority, 49 of the studies were published while only 3 studies were unpublished [ 16 , 25 , 50 ] (Table 1 ).

Forty one (78.8%) of the included studies were cross-sectional studies [ 12 , 15 , 16 , 17 , 18 , 19 , 20 , 21 , 22 , 23 , 24 , 25 , 29 , 30 , 31 , 32 , 33 , 34 , 35 , 36 , 37 , 38 , 39 , 40 , 41 , 42 , 43 , 44 , 45 , 46 , 54 , 57 , 58 , 59 , 67 , 68 , 69 , 70 , 72 , 73 ], of which 18 studies were most recent DHS survey reports [ 29 , 30 , 31 , 32 , 33 , 34 , 35 , 36 , 37 , 38 , 39 , 40 , 41 , 42 , 43 , 44 , 45 , 46 ]. Ten (22.7%) were retrospective studies [ 47 , 48 , 49 , 50 , 51 , 52 , 53 , 55 , 56 , 71 ] and one study [ 13 ] was case-control. Almost two thirds, 31 of the articles assessed the percentage of adolescent girls who begun childbearing, while 16 of the studies assessed the percentage of current pregnancy. Also, thirty two of the studies were community based [ 13 , 16 , 17 , 19 , 20 , 21 , 22 , 23 , 25 , 29 , 30 , 31 , 32 , 33 , 34 , 35 , 36 , 37 , 38 , 39 , 40 , 41 , 42 , 43 , 44 , 45 , 46 , 67 , 68 , 70 , 73 ], while 19 were institution-based studies [ 12 , 15 , 18 , 47 , 48 , 49 , 50 , 51 , 52 , 53 , 54 , 55 , 56 , 57 , 58 , 59 , 69 , 71 , 72 ]. The sample size of the included studies ranged from a minimum of 106 in a study conducted in Nigeria (59) to maximum of 57,787 in a study conducted in Cameroon [ 56 ]. Overall, this review included a total of 254,350 study participants (Table 1 ). The study quality score of included studies ranged from 6 to 10, with the mean study quality score ( + standard deviation) of 8.48 + 1.57.

A meta-regression analysis was conducted since there was statistically significant heterogeneity, I-square test statistics less than 0.05. The purpose of the analysis was to identify the source of heterogeneity so that correct interpretation of the findings is made. However, the meta-regression analysis found no significant variable which can explain the heterogeneity. There was no statistically significant study level covariate: sample size, publication year, study quality score, sub-region, and publication status of included studies. Therefore, the heterogeneity can be explained by other factors not included in this review. (Table 2 ).

Prevalence of adolescent pregnancy in Africa

The pooled prevalence adolescent pregnancy ranged from 1.62 to 51%, both in Nigeria [ 53 , 59 ] (Fig. 2 ) . The prevalence was highest, 21.5% (95%CI: 17.3, 25.7) in the East African sub-region , followed by 20.4% (95%CI: 18.9, 21.7) in Southern Africa, 17.7% (95%CI: 14.1, 21.4) in West Africa, 15.8 (95%CI: 10.3, 21.3) in Central Africa, and the lowest was in Northern Africa, 9.2% (95%CI: 5.8, 12.5). Similarly, the pooled prevalence of adolescent pregnancy in Sub-Saharan African countries was 19.3% (95%CI: 16.9, 21.6). Overall, the pooled prevalence of adolescent pregnancy in Africa was 18.8% (95%CI: 16.7, 20.9) (Table 3 ). A significant heterogeneity of included studies in the meta-analysis was observed, I 2 = 99.7%, p < 0.001. The Egger’s regression asymmetry test also showed significant publication bias, p -value < 0.001. After adjustment, the final pooled prevalence of adolescent pregnancy in Africa after the trim and fill analysis was 18.8% (95%CI: 16.7, 20.9) (Fig. 3 ).

Distribution of pooled prevalence of adolescent pregnancy in 24 African countries, 2003 to 2018

Prevalence of adolescent pregnancy in Africa, 2003 to 2018

A higher (21.3%) prevalence of adolescent pregnancy was observed among studies conducted using the cross-sectional design compared to 10.1% in retrospective studies. Similarly, the prevalence using community-based studies was 20.9% (95%CI: 18.2, 23.7) and it was 15.2% (95%CI: 12.5, 17.9) using the institution-based studies. The result of the eighteen DHS reports showed a pooled prevalence of adolescent pregnancy of 20.9% (95%CI: 17.4, 24.3). Also, using the high-quality score studies, the prevalence of adolescent pregnancy in Africa was 20.8% (95%CI: 17.3, 24.4) and it was 16.3% (95%CI: 13.6, 18.9) for low quality score studies. The prevalence of adolescent pregnancy prior to the end of the Millennium Development Goals (MDGs) period (2003 to 2015 in the current review) was 18.2% (95%CI: 15.9, 20.5), which rose to 20.5% (95%CI: 15.1, 25.9) during the post MDG (2016 to 2018) (Table 3 ).

Factors associated with adolescent pregnancy

Sociodemographic characteristics.

The sociodemographic factors included in this analysis were the place of residence, marital status and educational status of adolescent girls. A separate analysis was conducted for each variable. A total of 8 articles [ 13 , 16 , 17 , 20 , 21 , 22 , 23 , 25 ] were included to determine the association of place of residence and adolescent pregnancy. Five of the included studies [ 16 , 17 , 20 , 23 , 25 ] found significant association while the rest three articles [ 13 , 21 , 22 ] showed non-significant association between residence and adolescent pregnancy. The final pooled meta-analysis showed that adolescents who reside in rural areas were two times more likely to be pregnant than adolescent girls who live in urban areas, OR = 2.04 (95%CI = 1.3, 3.18). Additionally, A total of 8 articles [ 12 , 13 , 16 , 18 , 19 , 21 , 22 , 25 ] were included to assess the association of marital status and adolescent pregnancy. The pooled meta-analysis showed that ever married adolescents were more than twenty times more likely to start childbearing during adolescence age than adolescents who were never married, OR = 20.67(95%CI = 11.56, 36.96) (Fig. 4 ).

Forest plot of odds ratio for the association of selected sociodemographic characteristics and adolescent pregnancy in Africa

Similarly, ten articles [ 15 , 16 , 18 , 19 , 20 , 21 , 22 , 23 , 24 , 25 ] were also included to determine the association of educational status of adolescent girls and experience of pregnancy. From this, five articles [ 16 , 18 , 20 , 23 , 25 ] found higher pregnancy rate among adolescents who had no education, while one article found the opposite [ 15 ]. The rest four researches [ 19 , 21 , 22 , 24 ] showed non-significant association. However, the final pooled meta-analysis using data from the ten articles found that adolescent girls who are not attending school are more than two times more likely to start childbearing than those who are in school, OR = 2.49 (95%CI = 1.58, 3.92) (Fig. 4 ).

Family educational characteristics A total of five research articles [ 12 , 13 , 14 , 19 , 24 ] were included to assess the association of mother’s educational status and adolescent pregnancy. From this, two studies [ 14 , 24 ] found significant association and the rest three articles [ 12 , 13 , 19 ] found no association. However, the final pooled meta-analysis showed that adolescents with mother’s educational status of not educated were almost two times more likely to start childbearing during adolescence period than their counterparts, OR = 1.88 (95%CI = 1.29, 2.73) (Fig. 5 ).

Forest plot of odds ratio for the association of family educational characteristics and adolescent pregnancy in Africa

Four articles [ 13 , 14 , 19 , 24 ] were also included to determine the association of father’s educational status and adolescent pregnancy. Even though all included studies independently had non-significant association, the pooled meta-analysis showed statistically significant association. Adolescents with father’s educational status of not educated were 1.65 times more likely to start childbearing than those whose father were educated, OR = 1.65 (95%CI = 1.14, 2.38) (Fig. 5 ).

Parent to adolescent communication on SRH issues

Three research articles [ 12 , 13 , 14 ] were included to assess the association between parent to adolescent communication on SRH and adolescent pregnancy. The final pooled meta-analysis showed that adolescents who had no open discussion or communication on SRH issues with their parents were almost three times more likely to start childbearing, OR = 2.88 (95% = 2.12, 3.91) (Fig. 6 ).

Forest plot of the odds ratio for the association of lack of sexual and reproductive health communication between adolescents and parents and adolescent pregnancy in Africa

This systematic review and meta-analysis was conducted to estimate the prevalence and determinants of adolescent pregnancy in Africa using the available published and unpublished studies. Adolescent pregnancy is considered a risk factor for adverse maternal and neonatal outcomes [ 2 ]. A WHO report showed that pregnancy and childbirth complications are the second commonest causes of death among adolescent girls [ 5 ].

This study found a higher prevalence of adolescent pregnancy in Africa compared to other low- and middle-income countries (LMIC). The pooled prevalence of adolescent pregnancy in Sub-Saharan African countries was 19.3%, higher than the overall prevalence of adolescent pregnancy in Africa (18.8%). This finding is much higher compared to 6.4% (× 3) in Latin America, 4.5% (× 4) in Southeastern Asia and 0.7% (× 26) in Eastern Asia [ 74 ]. The inaccessibility of contraceptive services, the unfavorable attitude of the community towards the adolescent contraceptive use, poor knowledge of adolescents of the SRH) issues and widespread sexual violence in developing countries are some of the reasons for the higher prevalence of adolescent pregnancy in Africa [ 75 ]. In addition, the prevalence of unmet need for contraceptives among adolescents in Sub-Saharan African countries is high, resulting in a high rate of unwanted pregnancy in the region [ 76 ]. Also, half of the adolescent pregnancy occurring among 15 to 19 years old girls in developing countries are unintended [ 77 ]. Improvement of the knowledge of adolescents towards the SRH issues, increasing the contraceptive access and use among young people, and reducing child marriage is important to prevent adolescent pregnancy and reduce its poor maternal and neonatal outcomes [ 75 ].

Variations in the rate of adolescent pregnancy were observed in different sub-regions of Africa, the highest in East Africa (21.5%) and lowest in Northern Africa (9.2%). Sociocultural, environmental and economic factors, resulting in differences in the access to the already inadequate adolescent sexual and reproductive health services can be mentioned as possible reasons for the observed disparities. These factors are also mentioned as reasons for a high level of adolescent pregnancy in Sub Saharan Africa [ 26 , 78 ] . Evidence also showed that adolescent pregnancy is more likely to occur in poor countries and communities with poor education and employment opportunities [ 79 ].

Despite several progresses made by the governmental and non-governmental organizations, the global rate of adolescent pregnancy and birth rate is still high [ 80 ]. This study also showed an increasing level of adolescent pregnancy in Africa in the years 2016 to 2018 (20.5%) than studies conducted before 2015 (18.2%). This could be related to a higher detection rate in the recent years because diagnosis of pregnancy is earlier and surer and more rural areas are accessing these tests more than before. Researchers are penetrating the rural areas more, in more coordinated and multidisciplinary fashion [ 13 , 16 , 17 , 20 , 21 , 22 , 23 , 25 ]. Moreover, the United Nations Population Fund (UNFPA) report on adolescent pregnancy also showed that the percentage of adolescent pregnancies will increase globally by 2030, particularly in the Sub Saharan African countries [ 80 ]. The increasing number of the adolescent population in the continent can be mentioned as a reason for the high rate of adolescent pregnancy [ 80 ]. This calls for efforts to address the sexual and reproductive health needs of adolescent girls to achieve the SDG targets on reduction of maternal mortality.

The increasing prevalence of adolescent pregnancy in Africa is one of the reasons for the high rate of maternal and child morbidity and mortality on the continent. Moreover, 99 % of maternal deaths of women aged 15 to 19 years occur in LMIC, particularly in Sub Saharan African countries [ 81 ]. Adolescent pregnancy is also a major contributor to an intergenerational cycle of poverty and poor health outcomes. Therefore, emphasis should be given to the prevention of adolescent pregnancy through improvement of contraceptive access, adolescent-friendly health services, and sexuality education [ 75 ]. Studies found that educational programs aimed at reducing sexual risk behaviors and prevention of pregnancy among young people can effectively reduce the pregnancy rates among teenagers [ 82 ]. Also, programs aimed at abstinence-centered sexuality education are also effective in preventing adolescent pregnancy [ 83 ].

This review also assessed the association of selected variables with adolescent pregnancy. Adolescents who live in rural areas were more likely to start childbearing than adolescents in urban areas. This could be because of the lack of educational opportunities, poverty and limited access to SRH services in ssrural than urban areas [ 84 , 85 ]. A systematic review of studies to assess factors associated with adolescent pregnancy in LMIC also found similar findings [ 78 ]. This calls the design of health services specifically designed for rural adolescents. Future researchers should also address the gap of studies on the needs of adolescent girls and possible interventions needed to reduce adolescent pregnancy in rural areas.

The current study also found that adolescents who were ever married were more likely to start childbearing than those who were never married. Even though several national and international laws forbid early marriage, the practice is still common in many countries, particularly in African countries [ 86 ]. A recent world bank report showed investment in reducing child marriage can result in substantial reduction in population growth, and improves child health and even reduces the economic cost [ 87 , 88 ]. Furthermore, early marriage is associated with several SRH complications. For example, problems like sexually transmitted diseases, complications during childbirth, including obstetric fistula are common among adolescent who are married before their eighteenth birthday [ 89 ]. Early marriage also exposes to high fertility and lower school attainment among adolescent girls [ 84 ]. Despite this, Sub-Saharan Africa is known for the highest proportion of adolescent girls who are married. For instance, more than one fourth (28%) of female adolescents aged 15 to 19 in West and Central Africa and 26.6% in Sub-Saharan Africa were currently married in 2010 [ 84 ].

The findings of this study and available evidence suggest that investment in ending child marriage is important not only to reduce adolescent pregnancy and related complications, but also to improve the economic development of a country. Therefore, adherence to the available legal frameworks against child marriage will help countries to achieve the national and international targets. Moreover, law enforcement to protect the sexual and reproductive health and human rights of adolescent girls is essential to end child marriage and adolescent pregnancy [ 84 ].

This study also found that adolescents who are not attending school are more likely to get pregnant or start childbearing than those who are in school. This may be related to the empowerment of adolescents attending school with the necessary skills to prevent pregnancy. Adolescents who are out of school are denied access to comprehensive sexuality education and skills needed to negotiate sexuality and reproductive options and prevent pregnancy. This could also justify the high rate of adolescent pregnancy in sub Saharan African countries. Because, the UNFPA report showed that almost one third of adolescents in Sub-Saharan Africa are out of school [ 84 ]. Furthermore, educated women are better informed of their basic SRH rights and are able to make better decisions to protect their health. Similar findings were found in LMIC [ 78 ]. Similarly, this review found that adolescent with educated parents, either father or mother, were less likely to start childbearing during young age than those with no parent education.

Age appropriate sexual health education is important for adolescent to develop safe sexual and reproductive health and to prevent adolescent pregnancy [ 90 ]. This review also found that adolescents who had discussions with their parents are less likely to start childbearing than those who had no discussion. Open discussion about sexuality among children and parents in homes is important to prevent adolescent pregnancy [ 91 ]. Moreover, previous studies have shown that risk reduction education programs and parental support are effective in reducing adolescent pregnancy [ 92 , 93 ], lower risk behaviors, and improve healthy sexual decision making including consistent and correct use of condoms [ 94 ]. This finding suggests the importance of design of programs which facilitate parent to child communication on sexuality issues, especially in resource limited areas where access to SRH information is very limited. But, there still exists a controversy about the extent of effect of parents on sexual health decisions of adolescents [ 95 ].

The factors affecting adolescent pregnancy are not limited to sociodemographic characteristics. Factors like employment attainment [ 23 ], lower economic status [ 13 ], living arrangement, the sex of the household head [ 17 ], history of maternal teenage pregnancy [ 13 ], knowledge toward SRH issues, family planning use [ 18 ], presence or absence of sexuality education in schools, and substance use [ 12 ] also affects adolescent pregnancy.

This review has certain strengths and limitations. It included a large number of published and unpublished studies conducted in Africa. The PRISMA guideline was strictly followed in all steps of the systematic review and meta-analysis. Also, the most recent DHS reports of African countries were retrieved from the official DHS program website [ 28 ]. The inclusion of population-based studies (DHS surveys) improves the generalizability of the findings since they used validated tools to measure the outcome variable. But, prevalence data collected in the clinic-based studies may have introduced bias since the population in these studies may not represent the general population. On the other hand, the fact that self-performed abortions are becoming common, especially when performed early, make it difficult to determine the true prevalence of adolescent pregnancy. Abortifacients like misoprostol tablets are poorly restricted in many African countries [ 96 ]. Additionally, only studies published in the English language were included. Also, due to the absence of articles from some of them, this study didn’t include all African countries. The quality assessment also showed evidence of poor quality, and this may affect the findings. However, we conducted proper subgroup analysis by the quality of included studies. Additionally, most of the articles included in this review assessed the sociodemographic characteristics as the main factor and there were limited studies which presented the association of other variables like social, economic andSRH issues with adolescent pregnancy. For this reason, this review mainly included those studies which presented the selected sociodemographic factors discussed above. Future review studies which elucidate the association of adolescent pregnancy with other factors like social and economic factors, substance use, peer pressure, knowledge regarding SRH issues including family planning are important. Also, this review didn’t include qualitative studies on the reasons for adolescent pregnancy. Other behavioral, environmental and health care system variables that affect adolescent pregnancy were also not addressed, and this ispossible future research area.

Almost one-fifth of adolescent girls in Africa gets pregnant. Wide differences in rates were observed across the different sub-regions of Africa, the highest being in the Eastern African region. Countries should work towards preventing adolescent pregnancy through school and community-based family life education that promotes abstinence and safe sexual practice. Better access to contraceptive information and the use of contraceptive methods by adolescent girls to avoid unwanted pregnancy should be encouraged. Special focus should be given to the diverse sexual and reproductive health needs of adolescents by policymakers, population planners, researchers and healthcare workers.

This review also found different sociodemogaphic factors associated with adolescent pregnancy. Adolescents from rural residence, ever married, not educated, no mother’s education, no father’s education, and lack of parent to child communication on SRH issues were more likely to start childbearing. Future intervention programs for prevention of adolescent pregnancy need to target the identified factors. Moreover, further large-scale review studies are also needed to investigate environmental, behavioral and other social, economic and family related factors associated with adolescent pregnancy and thereby to plan and effect interventions. Experimental studies aimed at reducing unwanted pregnancy among adolescent girls in resource-limited settings are also recommended.

Abbreviations

Confidence Interval

Demographic and Health Survey

Low- and Middle-Income Countries

Millennium Development Goal

Sustainable Development Goal

Sexual and Reproductive Health

World Health Organization

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Acknowledgments

We would like to acknowledge the African Union Commission (AU) for funding this study and the University of Ibadan (UI) for hosting the program. We would also like to acknowledge the teaching and non-teaching staff of Pan African University Life and Earth Science Institute (PAULESI), UI, Nigeria and to all authors of studies included in this review.

Competing of interests

The authors declared that they have no competing interests.

This study was sponsored by the Pan African University (PAU), a continental initiative of the African Union Commission (AU), Addis Ababa, Ethiopia, as part of the Ph.D. program in Reproductive Health Sciences.

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Getachew Mullu Kassa

Department of Obstetrics and Gynaecology, College of Medicine, University College Hospital, University of Ibadan, Ibadan, Nigeria

A. O. Arowojolu & A. A. Odukogbe

School of Public Health, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia

Alemayehu Worku Yalew

College of Health Sciences, Debre Markos University, P.O.BOX: 269, Debre Markos, Ethiopia

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GMK was involved in the conceptualization, design, selection of articles, study quality assessment, data extraction, statistical analysis and writing the first draft of the manuscript. AOA, AAO, and AWY were variously involved in the conceptualization, statistical analysis and editing of the manuscript. All authors approved the final version of the manuscript.

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Kassa, G.M., Arowojolu, A.O., Odukogbe, A.A. et al. Prevalence and determinants of adolescent pregnancy in Africa: a systematic review and Meta-analysis. Reprod Health 15 , 195 (2018). https://doi.org/10.1186/s12978-018-0640-2

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Teenage pregnancy and social disadvantage: systematic review integrating controlled trials and qualitative studies

Objectives To determine the impact on teenage pregnancy of interventions that address the social disadvantage associated with early parenthood and to assess the appropriateness of such interventions for young people in the United Kingdom.

Design Systematic review, including a statistical meta-analysis of controlled trials on interventions for early parenthood and a thematic synthesis of qualitative studies that investigated the views on early parenthood of young people living in the UK.

Data sources 12 electronic bibliographic databases, five key journals, reference lists of relevant studies, study authors, and experts in the field.

Review methods Two independent reviewers assessed the methodological quality of studies and abstracted data.

Results Ten controlled trials and five qualitative studies were included. Controlled trials evaluated either early childhood interventions or youth development programmes. The overall pooled effect size showed that teenage pregnancy rates were 39% lower among individuals receiving an intervention than in those receiving standard practice or no intervention (relative risk 0.61; 95% confidence interval 0.48 to 0.77). Three main themes associated with early parenthood emerged from the qualitative studies: dislike of school; poor material circumstances and unhappy childhood; and low expectations for the future. Comparison of these factors related to teenage pregnancy with the content of the programmes used in the controlled trials indicated that both early childhood interventions and youth development programmes are appropriate strategies for reducing unintended teenage pregnancies. The programmes aim to promote engagement with school through learning support, ameliorate unhappy childhood through guidance and social support, and raise aspirations through career development and work experience. However, none of these approaches directly tackles all the societal, community, and family level factors that influence young people’s routes to early parenthood.

Conclusions A small but reliable evidence base supports the effectiveness and appropriateness of early childhood interventions and youth development programmes for reducing unintended teenage pregnancy. Combining the findings from both controlled trials and qualitative studies provides a strong evidence base for informing effective public policy.

Introduction

Countries such as the United Kingdom and the United States have high teenage pregnancy rates relative to other countries. 1 2 3 Although teenage pregnancy can be a positive experience, particularly in the later teenage years, 4 5 it is associated with a wide range of subsequent adverse health and social outcomes. 6 7 These associations remain after adjusting for pre-existing social, economic, and health problems. 8 Despite the establishment of a national teenage pregnancy strategy in 1999, 9 teenage birth rates in the UK are the highest in western Europe 10 and conceptions among girls under 16 years of age in England and Wales have increased since 2006. 11

Recent research evidence shows that traditional approaches to reducing teenage pregnancy rates—such as sex education and better sexual health services—are not effective on their own. 12 13 This evidence has generated increased interest in the effects of interventions that target the social disadvantage associated with early pregnancy and parenthood. 14 15 16 17 18 19 Social disadvantage refers to a range of social and economic difficulties an individual can face—such as unemployment, poverty, and discrimination—and is distributed unequally on the basis of sociodemographic characteristics such as ethnicity, socioeconomic position, educational level, and place of residence. 20 21

The objectives of this study were to determine on the basis of evidence in qualitative and quantitative research the impact on teenage conceptions of interventions that address the social disadvantage associated with early parenthood and to assess the appropriateness of such interventions for young people in the UK.

We undertook a three part systematic review of the research evidence on social disadvantage and pregnancy in young people by using an innovative method we developed previously for integrating qualitative and quantitative research. 22 23 The first part of the review focused on quantitative controlled trials and was designed to assess the impact on teenage conceptions of interventions that address the social determinants of teenage pregnancy. The second part focused on qualitative research and examined intervention need and appropriateness on the basis of the perspectives and experiences of young people. In the third part of the review, we integrated the two sets of findings to assess the extent to which existing evaluated interventions do in fact address the social disadvantage associated with early pregnancy and parenthood as determined by the needs and concerns of young people.

The inclusion of qualitative research in systematic reviews facilitates the incorporation of “real life” experiences into evidence based policy making. 24 An ability to unpack the worldview of participants at a particular time and location has been highlighted as a key strength of qualitative research. 25 26 Although we included trials conducted in any country, we drew only on qualitative studies conducted in the UK to help assess the applicability of interventions to reduce teenage pregnancy within this country in particular.

Search strategy

Our literature searches covered seven major databases and five specialist registers (table 1 ⇓ ). Highly sensitive topic based search strategies were designed for each database. We did not use study type search filters and identified controlled trials and qualitative studies using the same strategy.

Major databases and specialist registers searched

View inline

We included randomised and non-randomised controlled trials that evaluated interventions designed to target social disadvantage and that reported teenage conceptions or births as an outcome measure. The inclusion of trials was not restricted according to language, publication date, or country. We included any qualitative study published between 1994 and 2004 that focused on teenage pregnancy and social disadvantage among young people aged less than 20 years old living in the UK.

Relevant interventions were those that aimed to improve young people’s life opportunities and financial circumstances; for example, through educational or income support. Relevant interventions could be targeted at children, young people, or their families. Controlled trials of sex education or sexual health services and qualitative studies focusing solely on attitudes to and knowledge of sexual health or sex education were excluded.

We hand searched American Journal of Public Health (from January 1999 to January 2004), Journal of Adolescent Health (from January 1999 to February 2004), Journal of Adolescence (from February 1999 to April 2004), and Perspectives on Sexual and Reproductive Health (from issue 1, 1999, to issue 1, 2004). We also reviewed the reference lists of all studies that met our inclusion criteria and contacted experts in the field who suggested further studies to pursue.

Quality assessment

We assessed the extent to which controlled trials had minimised bias and error in their findings by using a set of criteria developed in previous health promotion reviews. 27 28 29 “Sound” trials were those that reported data on each outcome measure indicated in the study aims; used a control or comparison group equivalent to the intervention group on relevant sociodemographic measures (or, in cases with non-equivalent groups, adjusted for differences in the analysis); provided pre-intervention data for all individuals in each group; and provided post-intervention data for all individuals in each group.

The criteria we used to assess the methodological quality of the qualitative studies were built on those suggested in the literature on qualitative research. 26 30 31 32 33 Each study was assessed according to 12 criteria designed to aid judgment on the extent to which study findings were an accurate representation of young people’s perspectives and experiences (box). A final assessment sorted studies into one of three categories on the basis of quality: high quality (those meeting 10 or more criteria), medium quality (those meeting between seven and nine criteria), and low quality (those meeting fewer than seven criteria).

Criteria used to assess the quality of qualitative studies

Quality of reporting.

Were the aims and objectives clearly reported?

Was there an adequate description of the context in which the research was carried out?

Was there an adequate description of the sample and the methods by which the sample was identified and recruited?

Was there an adequate description of the methods used to collect data?

Was there an adequate description of the methods used to analyse data?

Use of strategies to increase reliability and validity

Were there attempts to establish the reliability of the data collection tools (for example, by use of interview topic guides)?

Were there attempts to establish the validity of the data collection tools (for example, with pilot interviews)?

Were there attempts to establish the reliability of the data analysis methods (for example, by use of independent coders)?

Were there attempts to establish the validity of data analysis methods (for example, by searching for negative cases)?

Extent to which study findings reflected young people’s perspectives and experiences

Did the study use appropriate data collection methods for helping young people to express their views?

Did the study use appropriate methods for ensuring the data analysis was grounded in the views of young people?

Did the study actively involve young people in its design and conduct?

Data extraction

We used a standardised tool to extract from “sound” controlled trials information on the development and content of the intervention evaluated, the population involved, and the trial design and methods. 34 Data to calculate effect sizes for pregnancy and birth rates were identified from study reports and via contact with study authors if data were incomplete or not in an appropriate form.

Data on the development, design, methods, and the populations involved were extracted from the qualitative studies in a standardised way by using an established tool designed for a broad range of study types. 35 The findings of the qualitative studies were identified within the “findings” or “results” sections of study reports and exported verbatim into NVivo (version 2; QSR, Victoria, Australia), a qualitative data analysis software package.

Data synthesis

The data synthesis was conducted in three stages according to the model described by Thomas and colleagues. 22 Firstly, we used statistical meta-analysis techniques to assess the effectiveness of the interventions in the controlled trials. Chi square statistical tests were used to test for heterogeneity (“Q statistic”) between controlled trials; when there was no significant heterogeneity, we combined effect sizes in a random effects statistical meta-analysis using Evidence for Policy and Practice Information Centre reviewer software. 36 Relative risk (RR) was used to calculate both individual study and combined effect sizes. Our procedures for meta-analysis followed standard practice in the field 37 38 39 and were similar to those used in previous reviews by the Evidence for Policy and Practice Information Centre. 29 40

Secondly, we conducted a thematic synthesis of the findings from the qualitative studies, 41 42 following established principles developed for the analysis of qualitative data. 25 43 44 Study findings were coded line by line to characterise the content of each line or sentence (for example, “frustration with rules and regulations at school,” “expectations for the future”). Codes were compared and contrasted, refined, and grouped into higher order themes (for example, “dislike of school”). The review team then drew out the implications for appropriate interventions suggested by each theme.

Thirdly, we constructed a methodological and conceptual matrix to integrate the findings of the two syntheses. The potential implications of young people’s views for interventions to prevent teenage pregnancy were laid out alongside the content and findings of the soundly evaluated interventions.

Screening of full reports against inclusion criteria, quality assessment, data extraction, and data synthesis were all carried out by pairs of reviewers working independently at first and then together. Initial screening of titles and abstracts was done by single reviewers after a period of double screening to ensure consistency across reviewers.

Study characteristics and quality

Ten controlled trials w1-w10 and five qualitative studies w11-w15 met our inclusion criteria. Six controlled trials were judged to be of sufficient methodological quality to provide reliable evidence about the impact of interventions on teenage pregnancy rates. w1-w3 w6 w7 w9 All these trials were conducted in the US and targeted disadvantaged groups of children and young people (tables 2 ⇓ and 3 ⇓ ).

Characteristics of the six “sound” trials

Characteristics of the interventions in the six “sound” trials

Each of the methodologically sound controlled trials evaluated one of two intervention types: ( a ) an early childhood intervention, or ( b ) a youth development programme. Three studies evaluated early childhood interventions that aimed to promote cognitive and social development through preschool education, parent training, and social skills training. w2 w3 w7 Two of these studies—the Perry Preschool Program w2 and the Abecedarian Project w3 —evaluated the long term effects of preschool education and parenting support interventions; the third—the Seattle Social Development Project—evaluated the long term effects of a school based social skills development intervention for children and their parents. w7

A further three studies evaluated youth development programmes that aimed to promote self esteem, positive aspirations, and a sense of purpose through vocational, educational, volunteering, and life skills work. w1 w6 w10 Two of these studies—Teen Outreach w1 and the Quantum Opportunities Program w6 —evaluated after school programmes based on the principle of “serve and learn,” in which community service is combined with student learning and educational support; the third—the Children’s Aid Society Carrera-Model Program—evaluated a comprehensive academic and social development intervention delivered in youth centres, which included work experience, careers advice, academic support, sex education, arts workshops, sports, and other activities. w10

In each trial, the control group received no intervention or standard education. The four controlled trials that were deemed not to be of sufficient quality also evaluated youth development programmes in the US. w4 w5 w8 w9 All five qualitative studies were judged to be of medium or high quality. w11-w15 These studies included participants from a range of areas throughout the UK and used individual interviews, focus groups, and self completion questionnaires to collect data (table 4 ⇓ ). Four studies focused on, or included, the views of young parents, w11 w12 w14 w15 but only two of these studies included the views of young fathers as well as young mothers. w14 w15

Characteristics of the four high and medium quality qualitative studies

Quantitative studies of the effects of interventions on teenage pregnancy rates

Of the six controlled trials deemed to be of sufficient methodological quality, four measured pregnancy rates reported by young women, w1 w2 w7 w10 three measured partner pregnancy rates reported by young men, w1 w7 w10 and two measured birth rates reported by young men and young women separately w3 or together. w6 The four controlled trials measuring pregnancy rates reported by young women or young men w1 w2 w7 w10 were included in two random effects meta-analyses: one that assessed the effects of interventions on teenage pregnancies reported by young women and a second that measured the effects of interventions on teenage pregnancies reported by young men. The findings of the two controlled trials that measured birth rates w3 w6 were not subject to meta-analysis, but their findings are summarised after each meta-analysis. Tests revealed no statistical heterogeneity between the studies, suggesting that it would be appropriate to pool the effect sizes. However, effect sizes for youth development interventions and early childhood education interventions were pooled separately in recognition of the differences between these two types of intervention.

The pooled effect size from the first meta-analysis showed that early childhood interventions and youth development programmes reduced teenage pregnancy rates among young women (RR 0.61, 95% CI 0.48 to 0.77; fig 1 ⇓ ). The effect of an early childhood intervention on birth rates reported by young women was similar in the study by Campbell and colleagues w3 (0.56, 0.42 to 0.75).

Fig 1 Forest plot showing the effect of youth development programmes and early childhood interventions on pregnancy rates reported by young women

The effect of these interventions on pregnancies reported by young men is less clear (fig 2 ⇓ ). The pooled effect size from the second meta-analysis showed that young men who had received an early childhood or youth development intervention reported fewer partner pregnancies than those who had not, but this result was not statistically significant (RR 0.59, 95% CI 0.34 to 1.02).

Fig 2 Forest plot showing the effect of youth development programmes and early childhood interventions on pregnancy rates reported by young men

Hahn and colleagues w6 evaluated a youth development programme and measured birth rates reported by both young women and young men. The intervention reduced the birth rate by 36%, although this result was of borderline statistical significance (RR 0.64, 95% CI 0.40 to 1.03).

Qualitative studies of the views and experiences of young people

Three major themes relating to teenage pregnancy emerged from the findings of the five qualitative studies: dislike of school; poor material circumstances and unhappy childhood; and low expectations and aspirations for the future (fig 3 ⇓ ).

Fig 3 Thematic analysis of young people’s views on the role of education; training; employment and careers; and financial circumstances in teenage pregnancy

Dislike of school was a key aspect of young parents’ accounts of their lives before becoming parents and of young people identified as “at risk” of becoming teenage parents (for example, “Still be at school? I’d rather have a baby than that. I just didn’t like school, it was hard, it was horrible” w14 ). The reasons young people gave for disliking school varied (fig 3). Some related to the subject matter taught in school, which was seen as boring or irrelevant, especially for young women who had difficult or unhappy home lives and caring responsibilities (for example, “what on earth is this going to do for me?” w15 ). Other reasons related to insufficient or inappropriate support when falling behind with school work or experiencing bullying by teachers and peers (for example, “I got bullied so I just stopped going” w12 ). Some young people were frustrated with the inflexibility of “institutional life,” with all its rules and regulations (for example, “You can’t sit with your friends, which I found the best way of learning” w11 ).

Young parents reported unhappiness, rather than poverty in itself, as the most significant aspect of their childhood experiences that related to becoming a parent, although unhappiness went hand in hand with adversity and material disadvantage in their accounts. Common experiences included family conflict and breakdown, sometimes caused by violence, which could lead to living in care (fig 3). Young fathers reported violent fathers and a lack of suitable role models. Young parents noted how they had to “grow up faster” in order to survive, and also reported a lack of confidence, low self esteem, and high anxiety levels. w11 Some young women saw having a baby at an early age as a way to change their circumstances and ameliorate the effects of adversity. It is important to note, however, that not all the teenage mothers who participated in these studies had grown up unhappy or experienced personal adversity. Regardless of circumstances, some women had wanted to have a baby when they were young and looked forward to still being young when their children were older.

There were differences in the expectations and aspirations of young people who had, or wanted to have, a baby early in life and young people who had or wanted to have a baby later in life. For example, mothers who had children when they were teenagers wanted to leave school as soon as possible and get a job. In contrast, those who became pregnant later in life expected to go to university and travel. Both young mothers and young fathers believed that few opportunities were open to them apart from poorly paid, temporary work in jobs that they disliked (for example, “There are so many jobs out there that I didn’t even know existed . . . I probably could have done something but I just didn’t even think of these high paid jobs I could have done” w14 ). Young mothers described how having a baby was a more attractive option than entering the workforce, further education, or training. Young men’s lack of ambition was compounded by the low expectations their parents and peers held for them. Young people who wanted children later in life had long term plans and a more positive outlook for the future, and they described how participating in out of school activities such as sports, music, and arts improved their self esteem and motivation.

Do current interventions address the needs and concerns reported by young people?

The themes in our synthesis of qualitative studies suggest areas that should be addressed in preventive interventions, but measures to target these areas have not all been soundly evaluated for their effect on teenage pregnancy rates (table 5 ⇓ ).

Comparison of themes arising from studies of young people’s views with interventions assessed in “sound” trials

Youth development programmes and early childhood interventions both go some way to addressing young people’s dislike of school. Two of the three youth development programmes in the controlled trials we reviewed included components designed to promote young people’s academic achievement, such as tutoring and homework assistance, w6 w10 whereas the third aimed to improve young people’s interpersonal skills so they could develop good relationships with their peers and others. w1 One early childhood intervention both taught children conflict resolution skills and trained parents to create a home environment supportive of learning. w7 We did not find any research that had tested the impact on teenage pregnancy rates of interventions designed to change the school culture and environment, such as antibullying strategies, teacher training, or involving young people in making decisions about what happens in the school.

All the youth development programmes aimed to prevent teenage pregnancy by broadening young people’s expectations and aspirations for the future. These programmes offered young people work experience in their local communities, careers advice, group work to stimulate active reflection, and discussion of future careers and employment opportunities. Two of the three soundly evaluated youth development programmes also provided out of school sports or arts activities. w6 w10

Summary of principal findings

This review sought to improve our understanding of the link between social disadvantage and teenage pregnancy by integrating evidence from qualitative studies and quantitative trials.

The evidence from the six controlled trials we looked at showed that early childhood interventions and youth development programmes can significantly lower teenage pregnancy rates. Both types of intervention target the social determinants of early parenthood but are very different in content and timing. Preschool education and support appear to exert a long term positive influence on the risk of teenage pregnancy, as well as on other outcomes associated with social and economic disadvantage such as unemployment and criminal behaviour. 45 Programmes of social support, educational support, and skills training delivered to young people have a much more immediate impact.

Our review of five qualitative studies of young people in the UK indicated that happiness, enjoying school, and positive expectations for the future can all help to delay early parenthood. Young people who have grown up unhappy, in poor material circumstances, do not enjoy school, and are despondent about their future may be more likely to take risks when having sex or to choose to have a baby.

The findings of our review are especially important in the light of evidence that sex education and sexual health services are not on their own effective strategies for encouraging teenagers to defer parenthood 12 ; they need to be complemented by early childhood and youth development interventions that tackle social disadvantage. 13 18 46 Early childhood interventions and youth development programmes provide enhanced educational and social support in the early years of life and engage young people in developing career aspirations, respectively, thus addressing some of the key themes identified within our qualitative synthesis. However, important gaps exist in the evidence on how effectively current interventions address these themes (table 5). Structural and systemic issues such as housing, employment opportunities, community networks, bullying, and domestic violence were all important issues in young people’s accounts, but these factors have yet to be addressed in appropriate interventions and evaluated as wider determinants of teenage pregnancy.

Comparison with other studies

Our review adds to a growing body of research identifying factors that may explain the association between social disadvantage and teenage pregnancy. Dislike of school, an unhappy childhood, and a lack of opportunities for jobs and education have all emerged as explanatory factors in large scale national and international epidemiological analyses. 3 9 17 18 47 48 49 Dislike of school appears to have an independent effect on the risk of teenage pregnancy. 49 Our analysis of qualitative research provides additional insight into how factors that increase the risk of teenage pregnancy may operate. For example, a dislike of school was frequently the result of bullying, frustration with rules and regulations, lack of curriculum relevance, boredom, and inadequate support.

As well as developing and testing interventions to modify these antecedents, future research on teenage pregnancy and social disadvantage needs to consider strategies that counter the stigmatisation and discrimination faced by young parents. Some of the social exclusion experienced by young parents is the result of negative societal reaction. However, there is evidence to suggest that teenage parenting can under certain circumstances be a route to social inclusion rather than exclusion. 50

Like many other systematic reviews in health promotion and public health, we found few trials conducted in the UK. 27 29 40 This raises questions about the generalisability of the trial evidence. Our inclusion of qualitative evidence permitted us to examine the appropriateness of interventions evaluated in US trials from the perspective of young people in the UK. The appropriateness of interventions is an important aspect of generalisability to consider. 51 Our inclusion of qualitative evidence does not, however, replace the need for further trials in the UK and elsewhere to address the impact of interventions designed to ameliorate the wider determinants of teenage pregnancy.

A recent study carried out in England evaluated the effects of the Young People’s Development Programme—an intensive, multicomponent youth development intervention based on the Children’s Aid Society Carrera Model Program. w10 52 In contrast to the findings of this review, the quasi-experimental study found that young women in the intervention group were more likely to report pregnancy than those in the comparison group. This finding may be the result of the potentially stigmatising effect of targeting and labelling young people as “high risk” or of introducing participants to other “high risk” young people in alternative educational settings. In comparison with the Young People’s Development Programme, the youth development programmes evaluated by the controlled trials in our review used after school programmes or interventions delivered in community settings rather than the approach of keeping young people out of mainstream schools and working with them in alternative educational settings. This difference in approach may explain the difference in the findings of the two studies and highlights the need to evaluate a revised youth development programme in the UK.

Strengths and limitations of the study

The strengths of our review include the comprehensiveness of our searches, the exclusion of methodologically weak studies, the rigorous synthesis methods used, and the inclusion of qualitative research alongside controlled trials to establish not only “what works” but also appropriate and promising intervention strategies on the basis of young people’s views on the factors associated with teenage pregnancy. Including only studies that evaluated interventions relative to control conditions over the same period of time avoids missing temporal differences between groups. Such changes include the relaxing of abortion laws and the increasing acceptability of abortion over time, which may affect self reported pregnancy rates.

The small numbers of studies we found are a limitation of the available body of research, as is the dominance of controlled trials conducted in the US (although this is a common feature of many health promotion and public health reviews). Our search strategies would have under-represented non-English language studies. As with any systematic review, we cannot be certain that we identified all relevant studies; in particular we may not have identified all unpublished studies, which are more likely to report negative findings than are published studies. We are only aware of one relevant study published since the searches for this review were carried out: the evaluation of the Young People’s Development Programme. 52 Whether this study would meet the quality criteria for our review is unclear, but it should be considered in any update.

Conclusion and policy implications

This review provides a small but reliable evidence base that early childhood interventions and youth development programmes are effective and appropriate strategies for reducing unintended teenage pregnancy rates. Our findings on the effects of early childhood interventions highlight the importance of investing in early care and support in order to reduce the socioeconomic disadvantage associated with teenage pregnancy later in life. 53 Both the early childhood interventions and the youth development programmes combined structural level and individual levels components, which is in line with many current recommendations in health promotion and public health. 54 55 A policy move to invest in youth programmes should complement rather than replace high quality sex education and contraceptive services, and should aim to improve enjoyment of school, raise expectations and ambitions for the future, and provide young people with relevant social support and skills.

What is already known on this topic

Evidence suggests that sex education and better sexual health services do not reduce teenage pregnancy rates

A number of controlled trials have tested the effects of interventions that target the social disadvantage associated with early pregnancy and parenthood, and a number of qualitative studies have considered young people’s views of the factors associated with teenage pregnancy

No systematic review has brought these quantitative trials and qualitative studies together to determine intervention effectiveness and appropriateness

What this study adds

Early childhood interventions and youth development programmes that combine individual level and structural level measures to tackle social disadvantage can lower teenage pregnancy rates

Such interventions are likely to be appropriate for children and young people in the UK because they improve enjoyment of school, raise expectations and ambitions for the future, and ameliorate the effect of an unhappy childhood in poor material circumstances

A policy move to invest in interventions that target social disadvantage should complement rather than replace high quality sex education and contraceptive services

Cite this as: BMJ 2009;339:b4254

Contributors: AH, AO, and GB designed the study and obtained funding. AH, AO, and GB wrote the review protocol. AF, GB, and AH conducted the searches, screened titles and full papers, assessed study quality, extracted data, and undertook the statistical and qualitative syntheses. All authors contributed to the drafting of the paper and approved the final submitted version. AH, AO, and GB are the guarantors. All authors had full access to all the data in the study, including statistical reports and tables, and can take responsibility for the integrity of the data and the accuracy of the data analysis.

Funding: The review was funded by the Department of Health. AH was funded by a senior level research scientist in evidence synthesis award from the Department of Health. The researchers operated independently from the funders and the views expressed in this paper are those of the authors and not necessarily those of the Department of Health.

Competing interests: None declared.

Data sharing: Technical appendix available at http://eppi.ioe.ac.uk/cms/Default.aspx?tabid=674 .

This is an open-access article distributed under the terms of the Creative Commons Attribution Non-commercial License, which permits use, distribution, and reproduction in any medium, provided the original work is properly cited, the use is non commercial and is otherwise in compliance with the license. See: http://creativecommons.org/licenses/by-nc/2.0/ and http://creativecommons.org/licenses/by-nc/2.0/legalcode .

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Adolescent Research Review volume 2 , pages 113–129 ( 2017 ) Cite this article

Metrics details

Previous research on teenage pregnancy suggests that there are distinct profiles of pregnancy intent among adolescents, reflecting differences in young people’s understanding and endorsement of the concept of pregnancy intendedness. Little is known about adolescents’ subjective perceptions of pregnancy intent. This systematic literature review comprehensively examines qualitative studies of intended teenage pregnancy. Several online databases were searched for publications on attitudes towards adolescents’ pregnancy intentions. Following a systematic selection process, findings from included studies were analyzed and integrated using thematic synthesis. Six dominant themes emerged: pregnancy desire, negative and positive perceptions of pregnancy, ambivalence and fatalism, other people’s views, and common characteristics of adolescent mothers. The themes are discussed in the context of current knowledge on adolescent reproductive health.

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Introduction

Every year, approximately 16 million females aged 15–19 years and about one million females younger than 15 years old give birth worldwide (WHO 2014 ). Although most of these births occur in low- and middle-income countries, adolescent pregnancy remains a critical public health concern in developed countries (UNICEF 2013 ). From a public health perspective, adolescent pregnancy has a high-risk profile as the impact of multiple factors, including medical complications, lower educational level and long-term socio-economic consequences that confer increased risk of lifespan vulnerabilities to both mother and child. In addition, the perception of early childbearing as socially undesirable (McCarthy et al. 2014 ) contributes to the perception of adolescent pregnancy as a negative phenomenon (Pinzon and Jones 2012 ). However, there is a lack of understanding of how adolescents themselves understand adolescent pregnancy. Understanding the adolescent perspective on pregnancy could generate new insights into how policy makers as well as health and social care providers respond to the challenges of adolescent pregnancy.

There are different reasons for adolescents to become pregnant. Evidence suggests that the majority of teenage pregnancies are unplanned and undesired (e.g., Clear et al. 2012 ). Consequently, most studies focus on developing strategies for preventing teenage pregnancy. However, not all adolescents view their pregnancies as unintended. Recent research has begun to distinguish between different teenage pregnancy intentions profiles—in particular dividing along dimensions of intent, e.g., intended or planned, unintended, and ambiguous (Jaccard et al. 2003 ; Speizer et al. 2004 ).

Planned (as distinct from unplanned) pregnancy in youth has been given relatively little attention in previous publications (Cater and Coleman 2006 ). Indeed, estimates of the degree of pregnancy intendedness among adolescents differ across samples. In a sample of USA females aged 14–17 years (Bartz et al. 2007 ), almost 6 % of participants reported that they were currently trying to get pregnant, whereas in another sample of urban USA females approximately 12 % of 15 to 19-year-olds declared plans to conceive at the time of the study (Kavanaugh and Schwarz 2009 ). In the United Kingdom, Teenage Pregnancy Strategy Evaluation (British Market Research Bureau International 2005 ) estimated that up to 10 % of teenage pregnancies had been planned.

Although a substantial body of research examines adult perceptions of teenage pregnancy, relatively few studies have explored adolescents’ perspectives (Herrman 2008 ). A number of quantitative studies examined pregnancy attitudes and intentions among young people, identifying common characteristics associated with positive attitudes toward early childbearing (e.g., Lau et al. 2014 ). Most of the published evidence in this group of adolescents concerns attitudes toward termination (Cater and Coleman 2006 ). Two narrative literature reviews have examined qualitative studies of teenage pregnancy in general, and identified evidence of positive perceptions of childbearing and a degree of planning among adolescent mothers. A meta-synthesis of studies investigating experiences of teenage mothers of children aged 3 months–3 years by Clemmens ( 2003 ) identified five themes including an observation that young motherhood, despite bringing hardship, provides a stabilizing influence and can positively transform an adolescent’s life. In a descriptive review of teenage pregnancy and motherhood, Spear and Lock ( 2003 ) reported that some adolescents recollect their pregnancies as being planned. As it has been suggested that pregnancy attitudes and intendedness may influence occurrence and outcomes of adolescent pregnancies (Phipps and Nunes 2012 ), gaining insight into young people’s attitudes toward it may improve understanding of the phenomena related to early childbearing. Consequently, the literature suggests that there is a lack of clarity over what is unique to adolescents perceptions and experiences of pregnancy, both in comparison to adult pregnancies, and in how we contextualize adolescent intended pregnancy in relation to adolescence development as a whole.

The above narrative reviews notwithstanding, there are no systematic literature reviews of how young people conceptualize intentional adolescent pregnancy. In particular, there is a paucity of qualitative examination of pregnancy perceptions (Rosengard et al. 2006 ). This is unfortunate, as examinations of qualitative research methods are acceptable approaches for investigating adolescents lifestyles and behaviors (Rich and Ginsburg 1999 ) and can be “especially appropriate for exploring issues about which little is known or written” (Burns 1999 , p. 495).

Understanding young people’s perceptions of the benefits and disadvantages of young parenthood is crucial for supporting adolescents in making better-informed decisions regarding their reproduction and leading them to safer and healthier futures (Rosengard et al. 2006 ). Improved understanding of pregnancy intent may also aid in designing more effective, appropriate and acceptable strategies for public health interventions. Cater and Coleman ( 2006 , p. 6) argue that there is “a need for new materials/resources for professionals in order that they can work effectively with young people who have planned their pregnancy”. In this respect, a qualitative approach highlighting the subjective impression of adolescents provides an important stakeholder perspective in identifying the individual needs of this group.

The Current Review

The current review aimed to synthesize and critically evaluate published qualitative literature regarding intended adolescent pregnancy. The focus of the review is on non-medical aspects of teenage pregnancies and births, particularly adolescent females views on the subject. Review of the qualitative literature was chosen as an appropriate way to represent the subjective views of young women. Unintended pregnancy, males expectations, abortion, and concerns relating exclusively to sexual health such as contraception use and Sexually Transmitted Infections were considered to be outside the scope of the present review and were not examined. The primary research objective was to identify and evaluate the major themes emerging from the studies. A secondary aim was to identify methodological sources of bias in the qualitative literature.

Design of Review

Interpretive synthesis (IS) was utilized as the conceptual framework for the review. This approach, initially defined by Noblit and Hare ( 1988 ) and refined by Dixon-Woods et al. ( 2005 ), is grounded in the data reported from primary studies and assists the researcher to avoid specifying concepts and theories in advance of qualitative synthesis. An IS framework was chosen as the most adequate for reviewing the literature on a subject interweaving various scientific domains which has not been previously explored systematically (Dixon-Woods et al. 2005 ).

The current systematic review was conducted in three stages:

Systematic search of qualitative studies reporting on intended teenage pregnancy

Data extraction and critical appraisal of the studies included in the review

Synthesis of the data

Systematic Search

The following databases were searched between 24 April and 14 June 2015 to identify eligible articles: Ovid MEDLINE (1946–June 2015), PsycINFO (1806–June 2015), Embase (1974–June 2015), The Joanna Briggs Institute Evidence Based Practice Database (1996–June 2015), ASSIA (1987–June 2015) and CINAHL Plus (1937–June 2015). The final search terms consisted of three main categories: attitudes, age group, and the phenomenon under investigation. The first group incorporated words capturing psychological aspects of the research question: the attitudes, beliefs and perceptions of young people regarding teenage pregnancy (including intentions to become pregnant or remain non-pregnant). The second category pertained to the age group of participants studied in the review. The last group indicated the phenomenon studied: terms such as planned, wanted, intended or intentional combined with pregnancy, motherhood or childbearing were searched for. Boolean search operators were utilized to connect key terms. Truncation was used where appropriate. The extended search strategy is detailed in Appendix A of supplementary material.

Inclusion and Exclusion Criteria

Studies were included if they met following criteria:

Qualitative design

At least 50 % of the studied sample included adolescents aged 10–19 years old

Study aims included examining thoughts, beliefs and attitudes regarding intended pregnancy in adolescents (actual or potential)

English language

Peer-reviewed article

Studies were excluded if they focused solely on:

Contraception use (other than discussing pregnancy intention as a reason for contraceptive failure)

Medical aspects of pregnancies or births

Pregnancy or Sexually Transmitted Infections (STI) prevention interventions

Male participants

Unintended adolescent pregnancy

Reproductive behaviors in adolescents with HIV or diabetes

Abortion and its consequences

Study Selection

The results of the search strategy are illustrated in Fig. 1 . Records were identified through database searching. In addition, 30 additional records identified through screening of reference lists. Articles were screened via title screening, abstract screening and full-text articles assessment. Study selection was based on the above inclusion and exclusion criteria. Where there was a query on whether the article met the inclusion criteria, the full-text was retrieved and evaluated by a second reviewer. Final decisions on eligibility were made through consensus discussion. Eight articles were discussed this way, four of which were ultimately included and four excluded.

PRISMA flowchart of search and paper extraction

Data Extraction

Data from the articles were extracted using a bespoke proforma, incorporating elements from previous similar systematic reviews (e.g., Valderas et al. 2012 ). Bibliographic information, study characteristics, methods, main findings (including identified themes) and the interpretations of the authors (including recommendations) were collected. With regard to data from individual studies, where possible, relevant information was gathered using direct quotations from participants or authors interpretations in order to preserve the original meaning. In cases where only part of the findings of a study regarded pregnancy intentions among adolescents, the component which was assessed as irrelevant (i.e. directly corresponded to the exclusion criteria) was documented and reasons for excluding it from further synthesis were given. This ensured data collected was relevant to the subject of the review without unnecessarily excluding whole studies. For example, the study “Factors influencing teenage mothers participation in unprotected sex” by Burns ( 1999 ) generated six themes, yet only the ones related to pregnancy desire were extracted for the synthesis.

Critical Appraisal

Qualitative research is a heterogeneous field encompassing a diversity of methods (Willig 2013 ). Correspondingly, there are no unified protocols for quality assessment of qualitative studies (Dixon-Woods and Fitzpatrick 2001 ). The Critical Appraisal Skills Programme (CASP, Hawker et al. 2002 ) tool was chosen to appraise the quality of the studies included in the synthesis and to ensure consistency. The tool consists of nine questions with which studies are scored as “good”, “fair”, “poor” or “very poor” on a range of criteria (Appendix B of supplementary material). Given the high degree of methodological variation across included studies, the rigor in documentation of study procedures was closely appraised as a key component of competent qualitative research (Willig 2013 ). The researcher assessed all studies and 25 % of them were checked by an independent rater to ensure the reliability of the quality measures, with a substantial level of agreement.

Data Synthesis

Data-driven thematic analysis was chosen as the most effective method for synthesizing diverse types of evidence (Dixon-Woods et al. ( 2005 ). This was also the most appropriate approach to integrate descriptive data, given the relevant lack of data on subjective appraisals of teenage pregnancy intent in the existing literature. Lack of clarity regarding standardized procedures involved in the process of thematic analysis is often perceived as the central limitation of this form of analysis (Braun and Clarke 2006 ). This obstacle was addressed by applying guidelines for thematic synthesis of qualitative research (Thomas and Harden 2008 ).

The extracted data were repeatedly re-read to identify patterns. Each sentence (including both direct quotations and researchers descriptions of collected data) was analyzed and relevant content coded. Codes were collated and grouped according to their meaning. When appropriate, new codes were created to name groups of initial codes. A network of interlinked items was analyzed and reorganized, and emerging overarching families of codes were labeled as individual themes. Extracted data was independently assessed by the second author, and the final set or themes was established through consensus agreement between authors. In the last stage of the synthesis the author supplemented an interpretation of patterns identified across studies, reflecting the differences in designs and contexts of each study.

Study Designs

The systematic search identified 18 published articles, reporting findings from 14 cohorts. Key characteristics are detailed in Table 1 . All studies were published between 1995 and 2013. The majority of the studies were based in the USA (10 out of 14 cohorts), two in Australia and two in the UK. All studies employed a qualitative design, although three reported mixed method designs combining qualitative and quantitative methods (Kendall et al. 2005 ; Rosengard et al. 2006 ; Schwartz et al. 2010 ). All studies were cross-sectional with the exception of one cohort that was examined two times over an interval of 4 years (Smith Battle 1995 , 1998 ). Data from two cohorts (five articles in total) describe findings from cross-sectional cohorts incorporating analyses of subsets of each cohort. Data collection methods comprised focus groups (four cohorts), observation combined with interviews (two cohorts), questionnaires combined with other methods (one cohort) and various forms of interviews (six cohorts). One study used Q-methodology (Schwartz et al. 2010 ).

Most authors used thematic analysis to interpret data (ten cohorts). Two studies employed a hermeneutic approach to data analysis and one used by-person factor analysis of Q-sort data. One author used a method proposed by Giorgi ( 1970 ) (Montgomery 2001 , 2002 , 2004 ) and in one cohort the methods were described as both thematic analysis and hermeneutic analysis (Spear 2001 , 2004 ).

Four articles (Coleman and Cater 2006 ; Montgomery 2001 , 2002 , 2004 ) had a primary focus intended teenage pregnancy. The remaining studies included in the review were designed to answer questions not immediately related to the subject, but incorporated direct examination of pregnancy intendedness. Four studies examined adolescents attitudes and perceptions of teen pregnancy, three studies sought to explore experiences of teenage motherhood, three investigated women’s perceptions of pregnancy intendedness, and two explored qualitative reasons for failing to use contraception.

Characteristics of Included Studies

The total number of participants in the reviewed cohorts was n = 920. Number of participants in each individual study ranged from 5 to 247 (mean n = 66). The majority of studies only recruited females, while three cohorts also included male adolescents (Herrman 2008 ; Kegler et al. 2001 ; Redwood et al. 2012 ). The age of participants ranged from 12 to 38 years, with the majority of cohorts (eight) involving adolescents within the 14–18 years category.

Participants reproductive status varied across studies. Two studies examined the attitudes of adolescents who were pregnant at the time of data collection, five cohorts consisted of teenagers who had given birth prior to the data collection, and two studies did not explicitly report the parenting status of participants. The remaining cohorts comprised mixed samples of parenting, pregnant or not pregnant participants (three cohorts).

The findings from the synthesis were grouped in six main areas. The six themes and associated sub-themes are presented in Fig. 2 and described in below sections. Full delineations of themes, sub-themes and item level descriptors are contained in Appendix C of supplementary material. Table 2 illustrates the mapping of sub-themes to included articles.

Main themes and sub-themes

Desire and Closeness

This theme consisted of five sub-themes reflecting reasons for becoming pregnant or wanting to be a parent. A detailed diagram of the theme and some exemplary quotations are available in Appendix Ci of supplementary material. Self - oriented desire includes visions of parenting as an attractive life pathway alternative to educational or professional career, which were not always perceived as real possibilities by the participants. Liking babies and desire to play with them were listed as key reasons for becoming pregnant. For example, a participant in Montgomery ( 2002 , p. 287) took pleasure in looking after children and “wanted a baby around”. For some participants becoming pregnant served as means for filling the gap left by something they felt was lacking from their lives, or compensating for something that they were resentful about. Examples of items in the former category are fighting loneliness and providing some form of occupation: “I’d be there for it and it will give me something to do” (Montgomery 2002 , p. 287). The need for positive change in one’s life was also grouped in this category: “[G]rowing up she was often separated from her siblings and that this separation also contributed to her wanting to become pregnant, again to keep someone close to her and for the stability that it provided” (Montgomery 2001 , p. 24). Further examples of positive changes expected to be brought by pregnancy included gaining a new sense of identity as a parent, or provision of a motivating factor to stop engaging in risky behaviors.

This theme also incorporated compensation for negative experiences from the past such as unhappy childhood or the recent disappointment of a miscarriage. Self-oriented desire also included items related to timing of pregnancy such as pressure to complete reproduction early in life and fear of being infertile. Pregnancy was also viewed as an attempt to secure the relationship with boyfriend or bring it to the next level by starting a family ( Relationship with boyfriend/partner ). Seeking attention from parents, trying to mend their marital conflict, or wanting to follow ones mother’s example in early pregnancy were grouped in Relationship with family . Motivations related to Relationship with peers included seeking their attention, wanting to “fit in”, or proving ones womanhood or manhood. The last category in this theme was linked to the Relationship with baby . Desire to have somebody to love or to be unconditionally loved was mentioned in a number of studies: “I want to have someone that can love me when I want them to love me” (Herrman 2008 , p. 47). Some participants reported (often retrospectively) a natural and inexplicable drive to be a mother and some regarded motherhood as a way of proving to others their capability of bringing up a child of their own.

Negative Perceptions of Pregnancy and “Fears”

This group of sub-themes identified perceptions of negative aspects of teenage pregnancy as well as content expressing young people’s fears and anxieties (as shown in detail in Appendix Cii of supplementary material). Some participants were unable to describe any advantages of adolescent pregnancy and some openly regretted their decision to become mothers. Pregnancy was seen as restricting ones freedom, impeding achievement of one’s life goals as well as imposing a negative change to an adolescents relationships with a romantic partner and parents. Furthermore, participants mentioned lack of preparedness and general competence to have children in one’s teenage years: “I really don’t think anybody that’s underage or anybody at school because they have like no experience for that kind of stuff” (Kegler et al. 2001 , p. 248). Practical disadvantages of pregnancy such as impediments to education or employment as well as being stigmatized were also described.

Benefits and Positive Aspects of Pregnancy

A detailed diagram of the theme and exemplary quotations are available in Appendix Ciii of supplementary material. Some young people saw adolescent pregnancy in a more favorable light, including claiming it had no disadvantages at all. Some agreed that teenage pregnancy is manageable, even when not intended. Receiving public aid and support from family and peers were described as benefits. Pregnancy was reported to impose a positive change on an adolescent’s life in a number of ways. Becoming pregnant was seen as making young people more mature (in terms of changing their priorities and attitudes toward life), triggering a modification of one’s living arrangements, and improving relationships with romantic partners, family and peers:

“Young mothers alluded to holding on to true friends, making better choices in friends and activities, developing new friends as a result of the pregnancy or parenting, and receiving support and child care assistance from peers” (Herrman 2008 , p. 45). Moreover, being closer in age to one’s child was seen as a factor improving parent–child relationship.

Ambivalence and Fatalism

This theme covers items relating to indifference and ambivalence regarding sexual relations, pregnancy and parenting (as shown in Appendix Civ of supplementary material). Attitudes presented here are less clear-cut in terms of pregnancy intentions. This may be partially attributable to a spillover effect, as content was often identified in studies primarily focused on contraceptive failure. Sub-themes for Ambivalence and Fatalism include reasons for not using contraception effectively despite awareness of the potential of conceiving, a conviction that pregnancy does not significantly affect an adolescent’s life “(It [having a child] won’t affect me that much; I have my mom. I don’t have to grow up faster, ‘cause my mom’s gonna help me and stuff” Spear 2001 , p. 577); and identification of an external locus of control (“You can try to get in the way of fate, but it won’t do you any good … we’re just not in control in this life.” Burns 1999 , p. 497 and “It just happens—it’s one of those things that happen. It’s gonna happen.” (Kendall et al. 2005 , p. 303). These last two quotes relate to the view that the individual has no actual control over their fertility.

“Others’” Perceptions

This theme reflects an aggregation of commonly held views about adolescent pregnancy (as shown in Appendix Cv of supplementary material). It is divided into three main sub-themes: views about adolescent mothers, adolescent pregnancy, and pregnancy timing. The first sub-theme reflects both positive and negative perceptions of teenage mothers, such as deserving respect for managing their lives as young parents, and being treated differently by professionals because of their young age (regardless of the intendedness of pregnancy). Comments about adolescents being unaware of burdensome responsibilities associated with pregnancy and the fact that teenagers who are aware of them avoid pregnancy were also categorized in this group.

Views about adolescent pregnancy included opinions about its prevalence (“My whole school is pregnant” and “Every girl I grew up with is pregnant” Crump et al. 1999 , p. 37). There were also observations that acceptance of, and attitudes toward, adolescent pregnancies vary across social groups and backgrounds, a notion that some adolescents do plan their pregnancies. Finally, some participants also expressed the belief that teenage pregnancy has little impact on an adolescent’s life.

Opinions regarding pregnancy timing were also varied, with little consistency emerging from the literature. Some participants stated that one should wait until after the teenage years. Others stated that capability to raise a child is not age related, but depends on other factors: “You should be financially stable, emotionally stable, able to take care of the kids, finish high school. It isn’t really about age.” (Kendall et al. 2005 , p. 304). Other factors identified included independence from one’s family of origin, vocational stability, or the stability of the relationship with the partner.

Common Characteristics of Adolescents Who Become Pregnant

This theme reflects participant’s beliefs that adolescents who become pregnant share specific common characteristics. A detailed diagram of this theme is available in Appendix Cvi of supplementary material. The items grouped in this theme reflect an aggregation of observations provided by adolescent mothers, non-parenting and non-pregnant peers and researchers’ findings are also included. However, a noticeably consistent set of themes emerged across these diverse samples. We also highlight that this theme is closely linked to Theme 3.3.5 “ Others ” perceptions .

The first sub-theme consists of characteristics related to family background, such as growing up in an unsettled environment (parental conflict, violence, frequent house moves, etc.) or involvement in the social care system, and being raised in a community where early motherhood was a social norm. There is an underlying implication that adolescent intended pregnancy either occurs within, or as a response to a context of disruption.

The second sub-theme includes observations regarding adolescent mothers’ personal experiences preceding the conception. Examples of items in this group are: experiencing previous pregnancy (resolved by abortion, miscarriage or birth; keeping the infant or surrendering it for adoption), having a history of fighting behaviors, and having negative experiences and attitudes toward formal education.

The next sub-theme groups reflections relating to post-birth circumstances of adolescent mothers. Such observations include: strong motivation to do well in life and to be a good parent, and not remaining in a relationship with the father of the first child. Furthermore, adolescents who intentionally became pregnant may see less negative aspects of early motherhood than females who had unplanned pregnancies.

This theme also includes researchers’ reflections about common beliefs of adolescent mothers, with evidence of compartmentalization of different sets of concepts. For instance, separation of pregnancy, motherhood, and marriage was mentioned by Spear ( 2001 ), and separation of pregnancy, motherhood, and continuing the relationship with the father of the child was noted by Kendall et al. ( 2005 ). Conviction that one’s education or employment options were limited and confidence in one’s competence to be a mother were also described (e.g., Coleman and Cater 2006 ).

A last sub-theme relates directly to intended pregnancy and the degree to which the romantic partner is involved in pregnancy planning. Three profiles of romantic partners’ participation were identified: involved, ambivalent, or not involved. In the first circumstance, partners had a conversation about intentions and agreed to try to become parents in the near future; in the second option, the father’s opinion was not clear; and in the last circumstance there was no clear communication between partners regarding pregnancy intentions:

“I wanted to have a baby; I told him (the boy who likely fathered her baby) I wanted to. It seems like he was havin’ sex just to have sex. He didn’t care about what I had to go through now. I think I might quit havin’ sex, it can hurt. I want to know who the baby’s father is” (Spear 2004 , p. 341) Discussion between the adolescent mothers and their romantic partners regarding becoming pregnant was sometimes mentioned, but the father’s level of involvement in the actual decision to conceive was not always clear.

Quality Criteria Findings

Quality review indicated that the included studies had considerable variation in methodological quality (see Table 3 ). However, given the limited nature of research conducted to explore young people’s views and the variety of methods used to collect data, this level of variance between studies is not unexpected. (Rich and Ginsburg 1999 ).

The most consistent limitation noted in the included studies was poor quality reporting regarding procedures used. Vague or limited description of methods and inadequate description of data collection were commonly noted across studies. Divergence in descriptions of the research process was also observable between the articles reporting findings from the same cohort (e.g., Montgomery 2001 , 2002 ). In addition, sampling reporting was inconsistent. There were also concerns regarding generalizability, in terms of the extent to which theory derived from qualitative research is applicable to other individuals in similar situations (Horsburgh 2003 ).

The primary aim of the current review was to identify and evaluate the major themes emerging from qualitative studies exploring intended adolescent pregnancy. Six overarching themes emerged from the synthesis of the included studies: Desire and Closeness; Negative perceptions of pregnancy and “fears”; Benefits and positive aspects of pregnancy; Ambivalence and Fatalism; Others perceptions; Common characteristics of adolescents who become pregnant. The majority of the data collected in these studies express a sampling of young people’s views. In this respect, the review provides a synthesis of themes that represent the perspectives of adolescents’ themselves on the topic of intended adolescent pregnancy. The participants were adolescents of different reproductive status (pregnant, not pregnant, or parenting), and therefore the synthesis results combined accounts of young people’s views from several vantage points.

In terms of the predominant themes emerging from the synthesis, Desire and Closeness was prominent, reflecting the high frequency and salience within the articles of a rationalization of the desire to become pregnant or to “have a baby”. Items in this theme emphasized relational aspects of motherhood, in contrast with more practical aspects. The latter consideration was reflected in the theme Benefits and positive aspects of pregnancy .

Although it is estimated that the majority of teenage pregnancies are unintended and “the first conscious decision that many teenagers make about their pregnancy is whether to have an abortion or to continue with the pregnancy” (Social Exclusion Unit 1999 , p. 28), the findings of the review show that for some adolescents a certain degree of decision-making occurs prior to conception. Despite the common belief that adolescent pregnancies are outcomes of inadequate sexual education and ignorance about contraception (Drife 2004 ), many participants described a coherent awareness of the connection between sexual intercourse and pregnancy, and clear intentions to conceive.

One possibility is that the desire theme reflects an attachment or relational perception of the baby as a contributor to the mother’s emotional wellbeing (Goldberg 2000 ). For instance, longing for love from parents, partner, or the future child, was a notable construct. Similarly, the need for stability in life and compensation for emotional neglect experienced from carers were frequently mentioned motives. It is noteworthy, however, that for some participants a desire to have a baby was not directly linked to being a parent as presented by one of Montgomery’s ( 2002 ) interviewees who wanted a baby around, but said that a younger sibling would have been equally satisfying.

The perceived drawbacks of pregnancy were grouped in the theme Negative perceptions of pregnancy and “fears” . Particularly relevant to the subject of the reviews the notion that some adolescents who became pregnant intentionally were disappointed with how reality did not meet their expectations. This post-birth construct juxtaposed with the striking optimism presented by some pregnant interviewees (e.g., Spear 2001 ) draws attention to the role of the possibility of having an idealized image of what life would be like after conception. It has been suggested that cognitive maturity plays a role in sexual and reproductive decision-making (Shearer et al. 2002 ) and, depending on an individual’s cognitive stage, the ability to accurately envisage the consequences of pregnancy may be limited (Gordon 1990 ). Sheeder et al. ( 2009 ) noted that adolescents are prone to define benefits and costs of parenting by the circumstances of their relationship with their partner rather than in consideration of life plans.

Perceived benefits of early childbearing were grouped in Benefits and positive aspects of pregnancy. Although a great part of the literature emphasizes the disadvantages of teenage parenthood (Coleman 2011 ), observations such as that pregnancy causes a favorable change in an adolescent’s life and is not an obstacle for vocational accomplishments are supported by some more recent studies (e.g., Ermish and Pevalin 2003 ). Zeck et al. ( 2007 ) examined long term outcomes of Austrian females who gave birth at the age of 17 or younger and found that within 5 years from delivery a significant part of mothers obtained higher level education and were more satisfied in certain aspects of life compared with a reference group. Such reports of young mothers’ subjective assessment indicate that the common belief that adolescent pregnancy generates hardship may not be true for all teenage mothers, although this may itself be subject to contextual considerations, such as cultural background.

In contrast to the unequivocal perceptions depicted above, the synthesis revealed a group of concepts expanding beyond a simplistic desire to become pregnant. Some statements indicated young people’s ambivalence toward pregnancy and a fatalistic vision of conception as an event being beyond their control. Such voices were grouped in the theme Ambivalence and Fatalism. In some cases the reason for failure to use contraception was an intention to conceive. However, for a percentage of participants there was no conscious intent to do so, and yet they deliberately neglected to use contraception. Equivocal viewpoints have also been observed in quantitative investigations of adolescents’ attitudes toward childbearing. Stevens-Simon et al. ( 1996 ) found that in a group of 200 pregnant teenagers 20 % said they did not use contraception because they “did not mind getting pregnant” (p. 48). Additionally, Jaccard et al. ( 2003 ) in their longitudinal study showed that between 15 and 30 % of participating teenagers presented “some degree of ambivalence toward becoming pregnant relative to their peers” (p. 79). Therefore, our themes and existing research suggest that there is a lack of coherence and contradiction within adolescent’s attitudes to intended pregnancy that fits with the position of adolescence as a developmental period where individuals demonstrate fluidity in their identity and beliefs.

Our synthesis also clarifies how much existing health education and/or folk beliefs regarding adolescent childbearing inform young people’s subjective understanding of intended pregnancy. General statements about teenage motherhood were distinguished from more specific observations regarding common characteristics of adolescent pregnant females. Views that went beyond participants’ personal experiences were grouped in the theme Others perceptions . For example, opinions such as that teenage pregnancy is a common and acceptable event, and that pregnancy does not significantly alter one’s life were placed in this theme. Such beliefs suggest that in some social contexts early childbearing may be a norm. We also note that the observation that “[t]he social networks of young people in their families and communities are significant sources of cultural beliefs and of social support” has significant implications (Jones 2005 , p. 3). In communities where early parenting is acceptable and encouraged, ordinary attempts to reduce unintended pregnancy rates may prove unsuccessful.

Findings from qualitative research cannot be statistically representative of other populations (Horsburgh 2003 ), however, some of the Common characteristics of adolescents who become pregnant identified in the synthesis are consistent with findings from quantitative studies. For example, risk factors for teenage pregnancy identified by Dennison ( 2004 ) include experiencing deprivation, being a child of an adolescent mother, and low educational achievement. However, a USA longitudinal study that used pregnancy intentions as a variable showed that in terms of social milieu features (such as parental relationship status, household-social problems, and having a friend who experienced pregnancy) teenage pregnant females who wanted a baby did not differ from participants for whom pregnancy “just happened” (Rubin and East 1999 ). Further research should address these contradictory findings.

Limitations

We acknowledge several limitations of the current review, both in terms of the implementation of the review and the limitations of the primary research. Firstly, with regard to the review methodology, there are several approaches to integrating qualitative research (e.g., meta-ethnography, grounded theory, case survey, narrative summary), and this review was naturally constrained by the limitations of the chosen method (Saini and Shlonsky 2012 ). The process of qualitative synthesis is inherently interpretive, therefore open to subjectivity and potential bias (Dixon-Woods et al. 2005 ). In this respect, we acknowledge the first author’s midwifery background and the second author’s training as Clinical Psychologist could have influenced their interpretation.

Secondly, we note limitations inherent to the reporting of the primary research included in the review. The quality of the review may have been constricted by the variability of the included studies. Methodological shortcomings of the included studies including lack of clarity regarding what constitutes a theme, and differences in reporting made it difficult to extract and synthesize data. These difficulties are common weaknesses in synthesizing findings from qualitative studies. (Sandelowski and Barroso 2002 ). Nevertheless, given the scarcity of eligible data in this emerging field, it may be justified to have broad inclusion criteria to accurately summarize the literature. It has, however, been noted that general standards regarding systematic synthesis of qualitative data are needed (Carroll et al. 2012 ).

A further limitation was multiple reporting from similar cohorts (e.g., Montgomery 2001 , 2002 ), including discrepancies in documented procedures within different publications from the same cohort. Furthermore, data could be extracted in different quantities from various articles due to the diversity of included studies. For example, a great proportion of original data was extracted from studies focusing primarily on planned teenage pregnancy (e.g., Montgomery 2002 ), while studies such as Schwartz et al. ( 2010 ), which used a nearly quantitative design, provided little qualitative data that could be synthesized.

Implications for Research and Practice

Studies used various forms of pregnancy intentions measurements and many used retrospective assessment of such intentions. Retrospective evaluation of attitudes toward conception may be a source of recall bias due to ex post rationalization (Joyce et al. 2002 ). Therefore, a more unified, efficient, and reliable tool to assess pregnancy attitudes among young people is needed (Smith et al. 2013 ). Both qualitative and quantitative longitudinal studies exploring pregnancy intentions may help achieve that goal.

Another explanation for the disparate findings of the review may be the lack of clarity regarding definitions in this area (Rocca et al. 2010 ). Further research is warranted to illuminate how young people, practitioners, and researchers understand these constructs. Likewise, more practical aspects of attitudes toward pregnancy should be further explored. A previous quantitative study found that, regardless of age, and in comparison with those who conceive unintentionally, adolescents who intend to become pregnant do so from a position of personal and social strength; yet this strong background was not reflected in more healthy behaviors (Sheeder et al. 2009 ). Identifying whether negative outcomes associated with teenage pregnancy (e.g., Fraser et al. 1995 ) apply equally to pregnancies that are anticipated as to unwanted conceptions could be the goal of future research. Similarly, clarification of characteristics placing adolescents at higher risk for pregnancy due to positive attitude toward early childbearing will aid development of mental and physical health policies tailored to the needs of this specific group.

The research on intended teenage pregnancy reviewed in the article was heterogeneous and presented several methodological shortcomings. That said, the findings draw attention to the complexity of adolescent pregnancy intentions and indicate the potential differences in attitudes that occur across various social contexts (Carter and Spear 2002 ). This variance has important implications for needs-matched health care as different groups may require different approaches. Moreover, inaccurate perceptions of the benefits associated with pregnancy suggest there may be a need for more comprehensive reproductive health education. The identified shortcomings in the research in this field could be addressed by selecting adequate designs and emphasizing the need for transparency in reporting. Future research should focus on providing a greater understanding of pregnancy intentions among adolescents and developing more efficient measures of these attitudes.

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The authors gratefully acknowledge Francesca Soliman (NSPCC/University of Edinburgh Child Protection Research Centre) for writing assistance, proof reading, and general support throughout the review process. The article was completed as part of the first author’s MSc dissertation.

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Macutkiewicz, J., MacBeth, A. Intended Adolescent Pregnancy: A Systematic Review of Qualitative Studies. Adolescent Res Rev 2 , 113–129 (2017). https://doi.org/10.1007/s40894-016-0031-2

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Received : 05 February 2016

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DOI : https://doi.org/10.1007/s40894-016-0031-2

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Teenage pregnancy and associated factors in Ethiopia: a systematic review and meta-analysis

Materials and methods

Limitations of the study, implications for practice, disclosure statement, additional information, review article.

This article reports on teenage pregnancy and associated factors in Ethiopia. All studies available to the year 2020 conducted on teenage pregnancy in Ethiopia were included. The purpose of this systematic review and meta-analysis was to synthesize evidence on the prevalence and associated factors with teenage pregnancy in Ethiopia. The preferred reporting items for systematic review and meta-analysis (PRISMA) guidelines to conduct this meta-analysis were followed by the reviewers. The pooled estimated prevalence of teenage pregnancy in Ethiopia was 23.59% (95% CI: 14.75, 32.43). Sexual practice before the age of 15 years (OR = 1.75(95%CI 1.06, 2.44), no history of contraceptive use OR =3.53 (95%CI 1.94, 5.12) and Marital status OR=2.35 (95%CI1.36, 3.34) were factors associated with teenage pregnancy. Sex education in schools and enhanced contraceptive utilization among adolescents are recommended. Future quantitative as well as qualitative researches should focus on personal as well as social determinants to teenage pregnancy.

World Health Organization (WHO) defines the age group 13–19 years of teenagers. Pregnancy between this age group (teenage pregnancy) is a global reproductive health promotion problem that affects female teenagers, families, and communities, both in developed and developing countries, as children aged 10 to 19 years, unmarried and still at school, become pregnant. It is directly related to the high incidence of pregnancy-related complications that contribute to maternal morbidity and mortality, and social problems. Approximately 16 million adolescent girls aged 15–19 years and 2 million adolescents under the age of 15 years give birth annually in the world. Pregnancy and childbearing in adolescence contribute to increased risks of maternal mortality and morbidity, especially in very young adolescents(Mchunu et al., Citation 2012 ; World Health Organization (WHO), Citation 1999 ).

According to the UNFPA report, each year, an estimated 14 million adolescents between the ages of 15 and 19 give birth globally, and more than 90% of these live births occur in developing countries (Caffe et al., Citation 2017 ). An estimated 70,000 teenaged girls die each year during pregnancy and childbirth, and more than one million infants born to adolescent girls die before their first birthday. Because of such grave health consequences, teenage pregnancies are termed a death sentence in the poorest countries. About 2 million or more of them suffered chronic illness or disabilities, shame, and abandonment. Moreover, each year 2.2 to 4 million adolescents resort to unsafe abortion(Caffe et al., Citation 2017 ; Reynolds et al., Citation 2006 ; United Nations Population Fund, Citation 2007 ).

Adolescent pregnancy and childbearing have distinct and important deleterious consequences at global, societal, and personal levels. Globally, population growth is more rapid when women have their first child in their teenage as the early initiation of giving birth lengthens the reproductive period and subsequently increases fertility. At the societal level, the strong association observed between adolescent childbearing and low levels of educational achievement brings a negative impact on their position and potential contribution to society. Individually, adolescent fertility is associated with adverse maternal and child health outcomes including obstructed labour, low birth weight, foetal growth retardation, and high infant and maternal mortality rate(McDevitt et al., Citation 1996 ; Rafalimanana, Citation 2006 ).

Complications from pregnancy and childbirth are the leading cause of death for adolescent girls between the ages of 15 and 19 in poor countries. Girls in this age group are twice as likely to die from pregnancy and childbirth-related causes, compared with older women. Children born to teenage mothers are 50% more likely to die before the age of one than those born to women in their twenties. Furthermore, among teenagers who become pregnant only a few of them seek antenatal and delivery care from health professionals (Bearinger et al., Citation 2007 ; United Nations Population Fund, Citation 2007 ).

Approximately 16 million adolescent girls aged 15–19 years and 2 million adolescents under the age of 15 years give birth annually. These births constitute roughly 11% of all births worldwide; nearly 95% occur in developing countries. The proportion of adolescents giving birth ranged from 2% in China, to 18% in Latin America and the Caribbean, to more than 50% in sub-Saharan Africa (World Health Organization, Citation 2008 ).

Evidence has shown that factors associated with teenage pregnancy include the age of mother at pregnancy, mother’s educational status, place of residence, employment, contraceptive use, contraceptive non-use, educational status, poverty, breakdown of parental homes, inequality, and poor participation in decision-making, housemaid, monthly income, absence of communication on reproductive health issues with parents, having parental teenage pregnancy, religion ethnicity, being sexually active before the age of 15, and being married before the age of 18 (Ayele, W. M, Citation 2013 ; Beyene et al., Citation 2015 ; Tewodros and et al., Citation 2010 ).

This systematic review and meta-analysis was conducted with the objectives of determining the magnitude of teenage pregnancy and identifying factors associated with teenage pregnancy in Ethiopia. The result from this systematic review and meta-analysis may benefit policy makers and stakeholders to improve the prevention as well as management strategies for teenage pregnancy.

Study design and search strategy

A systematic review and meta-analysis of published and unpublished studies were conducted to assess the pooled prevalence and associated factors of adolescent pregnancy in Ethiopia. Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines(AKERS, Citation 2009 ) were strictly followed in doing this review. The databases used to search for studies were; PubMed, Directory of Open Access Journals search, Google Scholar, and African Journals Online (AJOL). All search terms for ‘Prevalence OR Incidence OR Epidemiology AND Adolescent pregnancy OR teen pregnancy OR teenage pregnancy OR young maternal age AND Africa’ were used separately and in combination using the Boolean operators like ‘OR’ or ‘AND’. Also, terms like ‘determinant factors’ OR ‘determinant factors’ OR ‘associated factors’ were used in combination with the above search terms.

Eligibility criteria study selection

All available studies conducted until the year 2020 were included in this review. All cross-sectional studies, case-control studies, and Demographic and Health Survey (DHS) analyses on teenage pregnancy were included in this review. Reviews, commentaries, editorial, case series/reports, and patient stories and studies conducted among the non-adolescent populations were excluded from the analysis. Articles, where their full texts were inaccessible, were excluded. The references of the selected articles were also screened to retrieve any additional articles which could be incorporated in this review.

Quality assessment and data extraction

Articles were screened using their titles, abstracts, and full paper reviews prior to including in the meta-analysis. The Joanna Briggs Institute (JBI) critical appraisal checklistThe Joanna Briggs Institute Reviewer’s Manual, Citation 2008 ) was used to assess the quality of included studies. The tool contains information on sample representativeness of the target population, participant recruitment, adequacy of the sample size, detailed description of the study subjects and study setting, sufficient coverage of the data analysis, objective criteria in the measurement of the outcome variable and identification of subpopulation, reliability, appropriate statistical analysis, and identification of confounding variables. The quality scores of the included studies were assessed and presented using the mean scores to designate as high or low-quality. The JBI tool for prevalence studies (Institute, Citation 2017 ) was used as a guideline for data extraction from the finally selected articles. The data extraction tool contains information on the author and year of the study, title, year study was conducted and year of publication, study area and country, sub-region, study design and type, study population, age range of adolescent participants, sample size, response rate, the outcome measured, and prevalence rate of adolescent pregnancy. Information regarding the publication status was also collected. Additionally, for the factors, a separate data extraction tool was prepared. The tool contains information on author’s name, year of publication, number of pregnant adolescents and total adolescents by residence, marital status, adolescent’s and their family educational status, and parent to adolescent communication on SRH issues was collected.

Data synthesis

Meta-analysis was conducted using STATA 11 Software to compute the pooled prevalence of teenage pregnancy in Ethiopia. A random-effect meta-analysis model was used to pool the overall prevalence of teenage pregnancy in Ethiopia. The heterogeneity test of included studies was assessed by using the I 2 statistics. The p -value for I 2 statistics less than 0.05 was used to determine the presence of heterogeneity. Low, moderate and high heterogeneity was assigned to I 2 test statistics results of 25, 50, and 75% respectively(Higgins et al., Citation 2003 ). The publication bias was assessed using the Egger regression asymmetry test(Begg & Mazumdar, Citation 1994 )(Egger et al., Citation 1997 ). For meta-analysis results which showed the presence of publication bias (Egger test = p < 0.05), and fill analysis using the random effect analysis was conducted to account for publication bias(Duval, Citation 2000 ).

Ethical consideration

Articles included in the analysis of this review were all available in the public domain; as a result no special ethical considerations were required.

Identification of studies

systematic review of adolescent pregnancy

Published online:

Figure 1. PRISMA flow chart of review researches

systematic review of adolescent pregnancy

Characteristics of included studies

Table 1. characteristics of included studies, quality of included studies.

The Joanna Briggs Institute (JBI)(Institute, Citation 2017 ) Checklist for Analytical Cross Sectional Studies was used to check the methodological quality of studies included in the review. Accordingly, seven studies were of high methodological quality (>80%) and three studies were moderate methodological quality (60–80%). (Supplementary file)

Pooled prevalence teenage pregnancy in Ethiopia

Figure 2. Pooled prevalence of teenage pregnancy in Ethiopia

systematic review of adolescent pregnancy

Publication bias

Figure 3. Forest plot indicating publication bias

systematic review of adolescent pregnancy

Factors associated with teenage pregnancy

Table 2. factors associated with teenage pregnancy in ethiopia.

Teenage pregnancy is a major public health concern with diverse health consequences on adolescents globally with a higher magnitude in developing countries including Ethiopia. The study reviewed available evidence on the prevalence of teenage pregnancy and associated factors in Ethiopia. A total of 10 studies were included in the analysis, cautiously selected based on specific inclusion criteria. The findings of the review provide insights into the overall magnitude of teenage pregnancy in Ethiopia. This systematic review and meta-analysis was aimed to estimate the prevalence of teenage pregnancy and associated factors in Ethiopia. The pooled prevalence of teenage pregnancy in Ethiopia in this meta-analysis was 23.59% (95% CI: 14.75, 32.43). The estimate showed that it is higher than studies conducted in African countries. A retrospective study conducted in southern Nigeria has reported that the prevalence of teenage pregnancy to be 1.5% (Onwubuariri & Kasso, Citation 2019 ). Cameroonian studies conducted in 2015 and 2017 showed that the prevalence was 13.3% and 8.7%, respectively (Egbe et al., Citation 2015 ; Njim & Agbor, Citation 2017 ). While similar findings have been reported from rural western Kenya teenage pregnancy is 23.3%(Omoroa et al., Citation 2018 ), Nigeria 22.9%. (Amoran, Citation 2012 ) and South Africa 19.2% (Mchunu et al., Citation 2012 ) a study from Cameroon show a high prevalence (60.75%) of teenage pregnancy (Donatus et al., Citation 2018 ).

The review also identifies factors associated with teenage pregnancy. Sexual experience before the age of 15 years, no history of contraceptive use and marital status were factors significantly associated with teenage pregnancy. Adolescents who initiated sexual intercourse before the age of 15 years were more than 1.7 times more likely to get pregnant compared to their counterparts (OR = 1.75(95%CI 1.06, 2.44). Teenagers who started sexual intercourse before the age of 15 years were more than 1.7 times more likely to get pregnant compared to their counterparts (OR = 1.75 (95%CI 1.06, 2.44). Adolescence represents a vulnerable phase in human development as it is a transition from childhood to physical and psychological maturity. During this period, adolescents learn and develop knowledge and skills to deal with critical aspects of their health and development while their bodies mature (UNICEF, Citation 2019 ). As they started to grow physically, emotionally and psychologically they will start to explore. And there are different factors which motivates them to engage in sexual activities like poor economic conditions, peer pressure to be sexually active to prove one’s gender identity, the centrality of sexual activity to definitions and practices of adult masculinity, and gendered inequalities of power. Adolescent girls identified money, fun, and pleasure as important factors. The mass media stimulated adolescents through erotic visual images, music, soap operas and pornographic movies (Kempadoo & Dunn, Citation 2001 ). Furthermore girls at their early ages are more likely to get coerced to sexual intercourse. The younger the teen at the time of coitarche, the more likely it is that the sexual episode was not voluntary(Anderson Moore et al., Citation 1989 ). In many societies, the communal recognition of sexual maturation in girls brings expectations of increased household responsibilities, restricts movement around boys and men, and increases pressures for sexual initiation early in their age which may lead them to get pregnant during their adolescence age (World Bank, Citation 2007 ).

Teenagers who do not use contraceptives were more likely have an early teenage pregnancy OR = 3.53 (95%CI 1.94, 5.12). Contraception is the most effective way to prevent teenage pregnancy among adolescents however due to different reasons like accessibility and lack of awareness contraceptive prevalence in the SSA countries is 38.6% (Chandra-Mouli et al., Citation 2014 ; Greene & Merrick, Citation 2015 ; Sánchez-Páez & Ortega, Citation 2018 ). Effective counselling regarding contraceptive options and provision of resources to increase access are key components of adolescent health care however contraception utilization is still low and different reasons have been reported for adolescents not to use contraceptives, occurrence of an unintended pregnancy, reports of side effects, behaviour issues and desire for pregnancy (Borovac-Pinheiro et al., Citation 2016 ) (Care, Citation 2017 ). During adolescence, young people navigate numerous physical, cognitive, emotional, and behavioural changes as they acquire increasing autonomy and experiment in many areas. Experimentation may include alcohol or drug use, smoking, and sexual activity, all of which may be associated with sexual and reproductive health risks such as unintended teenage pregnancy and sexually transmitted infections (STIs) (Todd & Black, Citation 2020 )

The review also indicated married adolescents were prone to get pregnant early. Compared to single adolescents married adolescents were more than two times more likely to get pregnant OR = 2.35 (95%CI1.36, 3.34). Consistently a systematic reviews in Africa and a qualitative study from Lao have shown that adolescents who were married are more likely to be pregnant(Gm et al., Citation 2018 ; Sychareun et al., Citation 2018 ). In many societies, adolescents are under pressure to marry and bear children early (World Health Organization (WHO), Citation 2020 ).

This meta-analysis has some limitations. The first limitation of this study was only English articles were considered to estimate the pooled prevalence of teenage pregnancy and associated factors in Ethiopia. Six out of 10 included studies were analysis of EDHS the result of this meta-analysis may be affected with social desirability bias. Except for the analysis of EDHS articles the rest are conducted in four regions of the country which may not fully representative of the complete picture of the status of teenage pregnancy in the country.

For teenagers to have a smooth transition to healthy and effective adulthood they need to be observed and cared starting from early adolescence, since this could be an important opportunity for public health intervention. All responsible bodies including Ministry of health, health care facilities and others should work to reduce teenage pregnancy. A comprehensive approach to prevent teenage pregnancy should implemented including school-based sex educations, contraceptive accessibility and prevention of early marriage. School-based sex education programmes can reduce early age sexual initiations and promote contraceptive use among adolescents in school. Contraceptive accessibility and uptake should be guaranteed by the health facilities.

The analysis showed that teenage pregnancy is still high in Ethiopia. Sexual experience before the age of 15 years, not using contraceptive and marital status were factors associated with teenage pregnancy. Prevention of early marriage and creating awareness about contraceptive and ensuring its accessibility is recommended to prevent teenage pregnancy. Further investigations should be carried out to observe for the reproductive health, and sexual practice among adolescents and psychological and physiological explanations and cultural assumptions needs to be explored to establish the causes that lead adolescents to early sexual debut and subsequent complications.

No potential conflict of interest was reported by the author(s).

Data availability statement

Data sharing is not applicable to this article since there is no new data created or analyzed in this study.

Notes on contributors

Melese siyoum, adamu birhanu.

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