Interventions to Prevent Unintended and Repeat Pregnancy Among Young People in Low- and Middle-Income Countries: A Systematic Review of the Published and Gray Literature

Adoption of contraception following a pregnancy loss in India

OBJECTIVE

The present study was carried out to describe contraceptive adoption following pregnancy terminations that resulted in outcomes other than live birth.

METHOD

Retrospective calendar data on 31486 women who had experienced a pregnancy loss within the last 60 months prior to the survey date were drawn from a nationally representative dataset. Logistic regression was employed to model the associated factors with contraceptive uptake.

RESULTS

Overall, 57.8% reported not adopting any method following the end of the recent pregnancy. There was a significant association between the choice of contraceptive method and timing of adoption. Women with living children were significantly more likely to adopt contraception as compared to women without any child.

CONCLUSION

Contraceptive uptake following a non-live birth is considerably low in India. Interventions in reproductive health should focus on provision of different contraceptive methods and counseling emphasizing on effectiveness and correct use of the methods at the end of any pregnancy.

Effects of the Momentum project on postpartum family planning norms and behaviors among married and unmarried adolescent and young first-time mothers in Kinshasa: A quasi-experimental study

This study evaluated the effect of Momentum-an integrated family planning, maternal and newborn health, and nutrition intervention-on postpartum family planning norms and behaviors among ever married and never-married first-time mothers age 15-24 in Kinshasa, Democratic Republic of the Congo. Using data collected in 2018 and 2020, we conducted an intent-to-treat analysis among 1,927 first-time mothers who were about six-months pregnant at enrollment. Difference-in-differences models were run for panel data and treatment effects models with inverse-probability weighting for endline-only outcomes. Average treatment effects (ATE) were estimated. Momentum had positive effects on partner discussion of family planning in the early postpartum period (ever married 15-19: ATE = 0.179, 95% CI = 0.098, 0.261; never married 15-19: ATE = 0.131, 95% CI = 0.029, 0.232; ever married 20-24: ATE = 0.233, 95% CI = 0.164, 0.302; never married 20-24: ATE = 0.241, 95% CI = 0.121, 0.362) and discussion with a health worker, and on obtaining a contraceptive method in the early postpartum period, except among never married adolescents. Among adolescents, intervention effects on modern contraceptive use within 12 months of childbirth/pregnancy loss were larger for the never married (ATE = 0.251, 95% CI = 0.122, 0.380) than the ever married (ATE = 0.114, 95% CI = 0.020, 0.208). Full intervention exposure had consistently larger effects on contraceptive behaviors than partial exposure, except among ever married adolescents. Momentum had no effect on normative expectations about postpartum family planning use among adolescents, and on descriptive norms and personal agency among those who were never married. Results for normative outcomes and personal agency underscored the intersectionality between young maternal age and marital status. Future programs should improve personal agency and foster normative change in support of postpartum family planning uptake and tailor interventions to different age and marital status subsets of first-time mothers.

Mechanisms behind gender transformative approaches targeting adolescent pregnancy in low- and middle-income countries: a realist synthesis protocol

INTRODUCTION

Adolescent pregnancy is defined as pregnancy at the age of 19 or below. Pregnancy and childbirth complications are the most significant cause of death among 15-19-year-old girls. Several studies have indicated that inequitable gender norms can increase the vulnerability of adolescent girls, including violence exposure, early marriage, and adolescent pregnancy. To address these disparities, gender transformative approaches aim to challenge and transform restrictive gender norms, roles, and relations through targeted interventions, promoting progressive changes. This realist review aims to synthesise existing evidence from a broad range of data sources to understand how, why, for whom, and in what contexts gender transformative approaches succeed in reducing adolescent pregnancy in low- and middle-income countries.

METHOD AND ANALYSIS

We employ a five-step realist synthesis approach: (1) clarify the scope of review and assessment of published literature, (2) development of initial programme theories, (3) systematic search for evidence, (4) development of refined programme theories, and (5) expert feedback and dissemination of results. This protocol presents the results of the first three steps and provides details of the next steps. We extracted data from 18 studies and outlined eight initial programme theories on how gender transformative approaches targeting adolescent pregnancy work in the first three steps. These steps were guided by experts in the field of sexual and reproductive health, implementation science, and realist methodology. As a next step, we will systematically search evidence from electronic databases and grey literature to identify additional studies eligible to refine the initial programme theories. Finally, we will propose refined programme theories that explain how gender transformative approaches work, why, for whom, and under which circumstances.

ETHICS AND DISSEMINATION

Ethics approval is not required because the included studies are published articles and other policy and intervention reports. Key results will be shared with the broader audience via academic papers in open-access journals, conferences, and policy recommendations. The protocol for this realist review is registered in PROSPERO (CRD42023398293).

Adolescent perspectives on peripartum mental health prevention and promotion from Kenya: Findings from a design thinking approach

In Kenya, approximately one in five girls aged 15-19 years old are pregnant or already a mother. Adolescent girls and young women experience significant mental health vulnerabilities during the pregnancy and postpartum periods, leading to poor antenatal and postnatal care attendance and inferior infant and maternal health outcomes. Pregnant adolescents often experience stigma and disenfranchisement due to their pregnancy status and at the same time lack access to mental health support within health settings, schools, religious institutions, and communities. This paper presents the results of qualitative interviews embedded within the human-centered design (HCD) process used to adapt the Helping Adolescents Thrive (HAT) program for Kenyan peripartum adolescents including young fathers. This qualitative study used two phases. First, a HAT advisory group participated in a series of four workshops to help identify and articulate mental health promotion needs and deepened the team's understanding of youth-centered thinking. Second, qualitative interviews were conducted with 39 pregnant and parenting adolescents to understand their perspectives on mental health prevention and promotion. Pregnant and parenting adolescents articulated different needs including poor support, stigma, and psychological disturbances. Parenting adolescents reported disturbed relationships, managing motherhood, poor health, and social empowerment. Participants highlighted sources of stress including economic challenges, fear of delivery, strained relationships, rejection, and stigma. Participants described psychological disturbances such as feeling stressed, worthless, withdrawn, and suicidal. Coping mechanisms reported by participants included engaging in domestic activities, hobbies, and social networking. Peers, family and spirituality were identified as important sources of support, as well as school integration, livelihoods, support groups and mentorships. Findings from this study can be used to strengthen and adapt HAT program, policy and practice for mental health prevention and promotion for pregnant and parenting adolescents.

Vulnerabilities and reparative strategies during pregnancy, childbirth, and the postpartum period: moving from rhetoric to action

Maternal outcomes throughout pregnancy, childbirth, and the postnatal period are influenced by interlinked and interdependent vulnerabilities. A comprehensive understanding of how various threats and barriers affect maternal and perinatal health is critical to plan, evaluate and improve maternal health programmes. This paper builds on the introductory paper of the Series on the determinants of maternal health by assessing vulnerabilities during pregnancy, childbirth, and the postnatal period. We synthesise and present the concept of vulnerability in pregnancy and childbirth, and map vulnerability attributes and their dynamic influence on maternal outcomes in early and late pregnancy and during childbirth and the postnatal period, with a particular focus on low-income and middle-income countries (LMICs). We summarise existing literature and present the evidence on the effects of various reparative strategies to improve pregnancy and childbirth outcomes. Lastly, we discuss the implications of the identified vulnerability attributes and reparative strategies for the efforts of policymakers, healthcare professionals, and researchers working towards improving outcomes for women and birthing people in LMICs.

Continuation of education after marriage and its associated factors among young adult women: findings from the Bangladesh Demographic and Health Survey 2017-2018

OBJECTIVE

To identify the individual and community-level variables associated with the continuation of education among currently married young adult women in Bangladesh.

DESIGN

Cross-sectional data extracted from the Bangladesh Demographic and Health Survey (BDHS), 2017-2018. The BDHS is a stratified cluster sample of households conducted in two and three stages in both rural and urban settings. A multilevel multinomial logistic regression analysis was employed to identify the associated factors.

SETTING

Bangladesh.

PARTICIPANTS

Currently married young adult women aged 15-29 years (n=4595).

PRIMARY OUTCOME

Continuation of education after marriage was measured in the BDHS by asking respondents, 'Did you continue your studies after marriage?' with the response options: no; yes, less than a year; yes, for 1-2 years; yes, for 3-4 years; and yes, for 5+ years.

RESULTS

Among young adult women, 28.2% continued education after marriage for different durations of years (<1 year to 5+ years). The odds of continuing education after marriage for <1 year (adjusted OR (aOR): 0.68; 95% CI 0.50 to 0.90), 1-2 years (aOR: 0.67; 95% CI 0.47 to 0.96) and ≥5 years (aOR: 0.38; 95% CI 0.17 to 0.85) were lower among women who justified wife beating compared with women who did justify it. Compared with the high-literate community, women from the low-literate community were less likely to continue education after marriage for <1 year (aOR: 0.53; 95% CI 0.42 to 0.66), 1-2 years (aOR: 0.47; 95% CI 0.36 to 0.61), 3-4 years (aOR: 0.32; 95% CI 0.22 to 0.46), and for ≥5 years (aOR: 0.29; 95% CI 0.17 to 0.48). Several other individual-level and community-level variables, such as age at marriage, first birth interval, partner educational status, household wealth index, community economic status and region, were found to be associated with the continuation of education after marriage for different durations.

CONCLUSIONS

The proportion of women continuing their education after marriage in this sample is low. This study provides insight into the individual-level and community-level barriers women encounter in continuing their education after marriage. The identification of these barriers helps policy-makers develop effective intervention programmes to promote women's educational attainment.

Investigating the pathways from preconception care to preventing maternal, perinatal and child mortality: A scoping review and causal loop diagram

In recent years, there has been a growing recognition that developing preconception care provides an opportunity to significantly reduce maternal and child mortality and morbidity. This involves targeting multiple risk factors through a large array of medical, behavioural and social interventions. In this study, we created a Causal Loop Diagram (CLD) to describe several pathways by which a set of preconception interventions may lead to women's improved health and better pregnancy outcomes. The CLD was informed by a scoping review of meta-analyses. It summarises evidence on the outcomes and interventions related to eight preconception risk factors. The authors reviewed literature from two databases (PubMed and Embase) and used the framework developed by Arksey and O'Malley. The CLD includes 29 constructs categorised into five different levels (mortality, causes of death, preconception risk factors, intermediate factors, interventions or policies). The model indicates interconnections between five sub-systems and highlights the role of preventing early and rapidly repeated pregnancies, as well as optimising women's nutritional status in the preconception period. It also shows the prevention of preterm birth as a privileged route for lowering child mortality and morbidity. The CLD demonstrates the potential benefits of strategies that address multiple preconception risk factors simultaneously and can be used as a tool to promote the integration of preconception care into efforts to prevent maternal and child mortality. With further improvements, this model could serve as a basis for future research on the costs and benefits of preconception care.

Diverse policy maker perspectives on the mental health of pregnant and parenting adolescent girls in Kenya: Considerations for comprehensive, adolescent-centered policies and programs

The pregnancy rate in Kenya among adolescent girls is among the highest in the world. Adolescent girls experience increased risk of anxiety and depression during pregnancy and postpartum which can result in poor health outcomes for both mother and baby, and negatively influence their life course. Mental health is often given low priority in health policy planning, particularly in Sub-Saharan Africa (SSA). There is an urgent need to address the treatment gap and provide timely mental health promotion and preventative services, there is a need to focus on the shifting demographic of SSA-the young people. To understand perspectives on policymakers on the mental health prevention and promotion needs of pregnant and parenting adolescent girls, we carried out a series of interviews as part of UNICEF funded helping pregnant and parenting adolescents thrive project in Kenya. We interviewed 13 diverse health and social policy makers in Kenya to understand their perspectives on the mental health experiences of pregnant and parenting adolescent girls and their ideas for optimizing mental health promotion. Six principal themes emerged including the mental health situation for adolescent girls, risk factors for poor mental health and barriers to accessing services for adolescent girls, health seeking behavior effect on maternal and child health outcomes, mental health promotion, protective factors for good mental health, and policy level issues. Examination of existing policies is required to determine how they can fully and effectively be implemented to support the mental health of pregnant and parenting adolescent girls.

Magnitude of unmet need for family planning and associated factors among women in the extended postpartum period in Dabat district, Northwest Ethiopia. evidence from Dabat demographic health surveys

BACKGROUND

Due to additional roles and emotional changes that occur during postpartum period, women use contraceptives differs from other times in their life. However, there is limited information about the unmet need for family planning (FP) among women in the extended postpartum period in the study area. Therefore, this study aimed to assess magnitude of unmet need for family planning and associated factors among women in the extended postpartum period in Dabat district, Northwest Ethiopia.

METHODS

A secondary data analysis was performed using the Dabat Demographic and Health Survey 2021. A total sample of 634 women during the extended postpartum period was included in this study. Stata version 14 statistical software was used for data analysis. Descriptive statistics were described using frequencies, percentages, mean, and standard deviation. Multicollinearity was tested using the variance inflation factor (VIF) and we computed Hosmer and Lemeshow goodness of fit. Both bivariable and multivariable logistic regression analyses were carried out to determine the association between independent variables and outcome variable. Statistical significance was declared at a p-value ≤ 0.05 with a corresponding 95% confidence interval.

RESULTS

The overall unmet need for FP during the extended postpartum women was 42.43% (95% CI: 38.62, 46.33), of which 33.44% was unmet need for spacing. Place of residence (AOR = 2.63, 95%CI: 1.61, 4.33), place of delivery (AOR = 2.09, 95%CI: 1.35, 3.24), and availability of radio and or TV (AOR = 1.58, 95% CI: 1.22, 2.13) were significantly associated with unmet need for family planning.

CONCLUSION

The magnitude of unmet need for family planning among women during the extended postpartum period in the study area was high when compared to the national average and the United Nations sphere standard of unmet need for family planning. Place of residence, place of delivery, and availability of radio and or TV were significantly associated with unmet need for family planning. Hence, the concerned bodies are recommended to promote intuitional delivery and give spatial attention to those who are residing in rural areas and to those who have had no media exposure in order to reduce the unmet need for family planning among postpartum women.

Migrant and Refugee Youth's Sexual and Reproductive Health and Rights: A Scoping Review to Inform Policies and Programs

Objectives: Migrants and refugee youth (MRY) in Western nations are less likely to participate in sexual reproductive health (SRH) services. Consequently, MRY are more likely to encounter adverse SRH experiences due to limited access to and knowledge of SRH services. A scoping review was conducted to examine MRY's understanding of and the implications for inclusive sexual and reproductive health and rights (SRHR) programs and policies. Methods: A systematic search of literature across seven academic databases was conducted. Data were extracted following Partners for Dignity and Rights' Human Rights Assessment framework and analysed using the thematic-synthesis method. Results: 38 literature (peer-reviewed, 24 and grey, 14) were considered eligible for inclusion. The findings highlighted significant barriers and the under-implementation of SRHR support and services by MRY. Key policy implications include a need for programs to support MRY's SRHR education, diversity, equity and inclusiveness and privacy protections. Conclusion: The review shows that the emerging evidence on MRY SRHR suggests gaps in practices for resourcing policies and programs that promote sustainable SRH for vulnerable populations. Policies for MRY's SRHR should prioritise programs that focus on diversity, equity and inclusion with targeted education and community resourcing strategies for sustainability.

Unwanted or Mistimed Pregnancy and Developmental Issues in Ecuadorian Children Aged 3 to 5: A Doubly Robust Estimate Using Data from the National Health and Nutrition Survey 2018

BACKGROUND

Past studies in high-income countries have shown an association between unintended (unwanted or mistimed) pregnancy and child development; no national-level studies in low-and-middle-income countries have been conducted. Moreover, extant studies often adjust for potential mediators, underestimating the average population effect.

METHODS

We aimed to estimate the effect of unintended pregnancy on early childhood development in Ecuadorian children aged 3 to 5, participating in the National Health and Nutrition Survey 2018. We used a design-based doubly robust estimate. First, we used propensity score matching (1:1) to identify a subsample equally likely to come from a desired vs. unintended pregnancy based on geographic area, household income, paternal intendedness, the mother's current marital status, age, ethnicity, and educational level, depressive symptoms, and the child's gender and age. Then, we used a logistic regression model to explore the relation of maternal pregnancy intentions with adequate development, as defined by the Early Childhood Development Index (ECDI). While exempt from review by an Institutional Review Board, this secondary research was conducted in accord with prevailing ethical principles.

RESULTS

Among 1694 observations representing 162,285 Ecuadorian children, unintended pregnancy associated with inadequate development (odds ratio: 1.56; 95% confidence interval: 1.06; 2.29), after adjusting for all relevant confounders. Unintended pregnancy was also negatively associated with all four ECDI domains, socio-emotional development being the most affected.

DISCUSSION

Our doubly robust design found evidence of the relation between the maternal perception of pregnancy and early child development. Addressing this relation to achieve reproductive justice entails considering a wide spectrum of population health and legal interventions to allow adequate access to education, contraception, and safe abortion. Moreover, pre- and post-natal check-ups could screen for unintended pregnancy and provide support accordingly.

Interventions to support contraceptive choice and use: a global systematic map of systematic reviews

BACKGROUND

To review the highest level of available evidence, a systematic map identified systematic reviews that evaluated the effectiveness of interventions to improve contraception choice and increase contraception use.

METHODS

Systematic reviews published since 2000 were identified from searches of nine databases. Data were extracted using a coding tool developed for this systematic map. Methodological quality of included reviews was assessed using AMSTAR 2 criteria.

FINDINGS AND CONCLUSION

Fifty systematic reviews reported evaluations of interventions for contraception choice and use addressing three domains (individual, couples, community); Meta-analyses in 11 of the reviews mostly addressed interventions for individuals. We identified 26 reviews covering High Income Countries, 12 reviews covering Low Middle-Income Countries and the rest a mix of both. Most reviews (15) focussed on psychosocial interventions, followed by incentives (6) and m-health interventions (6). The strongest evidence from meta-analyses is for the effectiveness of motivational interviewing, contraceptive counselling, psychosocial interventions, school-based education, and interventions promoting contraceptive access, demand-generation interventions (community and facility based, financial mechanisms and mass media), and mobile phone message interventions. Even in resource constrained settings, community-based interventions can increase contraceptive use. There are gaps in the evidence on interventions for contraception choice and use, and limitations in study designs and lack of representativeness. Most approaches focus on individual women rather than couples or wider socio-cultural influences on contraception and fertility. This review identifies interventions which work to increase contraception choice and use, and these could be implemented in school, healthcare or community settings.

Comprehensive sexuality education linked to sexual and reproductive health services reduces early and unintended pregnancies among in-school adolescent girls in Zambia

BACKGROUND

Advancing the health of adolescents, particularly their sexual and reproductive health, including HIV prevention and care, is a development imperative. A critical part for improving their wellbeing and economic development is the social status accorded to adolescent girls and young women (AGYW). However, AGYW in many countries including Zambia, encounter health challenges that stem from gender inequalities, lack of empowerment, inaccurate knowledge on sexuality, and poor access to sexual and reproductive health (SRH) services and information. Addressing the knowledge gaps through comprehensive sexuality education (CSE) and improving access to SRH services and appropriate information, should reduce school attrition from early and unintended pregnancies (EUP) and enhance realization of their full potential.

METHODS

The aim was to reduce EUP and improve SRH outcomes among AGYW in Zambia through provision of CSE linked to receptive SRH services. A 3-Arm randomized control study collected cross-sectional data at baseline, midline and Endline. Schools where CSE was being routinely provided were randomized into a non-intervention arm (arm1), an intervention arm in which information on available SRH services was provided in schools by health workers to complement CSE, (arm 2), and arm 3 in which pupils receiving CSE were also encouraged or supported to access pre-sensitized, receptive SRH services.

RESULTS

Following 3 years of intervention exposure (CSE-Health Facility linkages), findings showed a significant decline of in-school pregnancies amongst AGYW in both intervention arms, with arm two exhibiting a more significant decline, having recorded only 0.74% pregnancies at endline (p < 0.001), as well as arm 3, which recorded 1.34% pregnancies (p < 0.001). No significant decline was recorded in the CSE only control arm. Trends in decline of pregnancies started to show by midline, and persisted at endline (2020), and when difference in differences test was applied, the incident rate ratios (IRR) between the none and exposed arms were equally significant (p < 0.001).

CONCLUSION

Linking provision of CSE with accessible SRH services that are receptive to needs of adolescents and young people reduces EUP, which provides the opportunity for higher retention in school for adolescent girls.

Determinants of the use of contraceptive methods by adolescents in the Democratic Republic of the Congo: results of a cross-sectional survey

Background

Family planning (FP) is an effective strategy to prevent unintended pregnancies of adolescents. We aimed at identifying the socio-demographic factors underlying the low use of contraceptive methods by teenage girls in the Democratic Republic of the Congo (DRC).

Methods

A secondary analysis targeting teenage girls aged 15–19 was carried out on the Performance, Monitoring and Accountability project 2020 (PMA 2020) round 7 data, collected in Kinshasa and Kongo Central provinces. The dependent variable was the “use of contraceptive methods by sexually active teenage girls”, calculated as the proportion of teenagers using modern, traditional or any contraceptive methods. Independent variables were: level of education, age, province, religion, marital status, number of children, knowledge of contraceptive methods and household income. Pearson's chi-square and logistic regression tests helped to measure the relationship between variables at the alpha significance cut point of 0.05.

Results

A total of 943 teenagers were interviewed; of which 22.6, 18.1 and 19.9% ​​used any contraceptive method respectively in Kinshasa, Kongo Central and overall. The use of modern contraceptive methods was estimated at 9.9, 13.4 and 12.0% respectively in Kinshasa, Kongo Central and overall. However, the use of traditional methods estimated at 8.0% overall, was higher in Kinshasa (12.7%) and lower (4.7%) in Kongo Central (p < .001). Some factors such as poor knowledge of contraceptive methods (aOR = 8.868; 95% CI, 2.997–26.240; p < .001); belonging to low-income households (aOR = 1.797; 95% CI, 1.099–2.940; p = .020); and living in Kongo central (aOR = 3.170; 95% CI, 1.974–5.091; p < .001) made teenagers more likely not to use any contraceptive method.

Conclusion

The progress in the use of contraceptive methods by adolescent girls is not yet sufficient in the DRC. Socio-demographic factors, such as living in rural areas, poor knowledge of FP, and low-income are preventing teenagers from using FP methods. These findings highlight the need to fight against such barriers; and to make contraceptive services available, accessible, and affordable for teenagers.

Applying technology to promote sexual and reproductive health and prevent gender based violence for adolescents in low and middle-income countries: digital health strategies synthesis from an umbrella review

AIM

Adolescents in low-and-middle-income countries (LMICs) are facing numerous developmental, sexual and reproductive health (SRH) challenges including exposure to multidimensional violence. Gender-based violence (GBV) specifically intimate partner violence (IPV) are both highly prevalent in LMICs and are strongly linked with poor SRH outcomes. However, GBV and IPV interventions have not yet been adequately integrated in SRH due to individual, social, cultural, service, and resource barriers. To promote long-term SRH, a more holistic approach that integrates GBV and IPV, and adolescent development needs is imperative. Digital health has the potential to address multiple service setup, provision, and addressing access barriers through designing and providing integrated SRH care. However, there are no guidelines for an integrated digital SRH and development promotion for adolescents in LMICs.

METHODS

An umbrella review was conducted to synthesize evidence in three inter-related areas of digital health intervention literature: (i) SRH, (ii) GBV specifically IPV as a subset, and (iii) adolescent development and health promotion. We first synthesize findings for each area of research, then further analyze the implications and opportunities to inform approaches to develop an integrated intervention that can holistically address multiple SRH needs of adolescents in LMICs. Articles published in English, between 2010 and 2020, and from PubMed were included.

RESULTS

Seventeen review articles met our review inclusion criterion. Our primary finding is that application of digital health strategies for adolescent SRH promotion is highly feasible and acceptable. Although effectiveness evidence is insufficient to make strong recommendations for interventions and best practices suggestions, some user-centered design guidelines have been proposed for web-based health information and health application design for adolescent use. Additionally, several digital health strategies have also been identified that can be used to further develop integrated GBV-IPV-SRH-informed services to improve adolescent health outcomes. We generated several recommendations and strategies to guide future digital based SRH promotion research from our review.

CONCLUSIONS

Rigorous research that focuses on intervention effectiveness testing using a combination of digital health strategies and standardized albeit contextualized outcome measures would be important. Methodological improvement such as adoption of longitudinal experimental design will be crucial in generating evidence-based intervention and practice guidelines for adolescents in LMICs.

Magnitude of unmet need for family planning and its predictors among reproductive age women in high fertility regions of Ethiopia: Evidence from Ethiopian Demographic and Health Survey

BACKGROUND

Unmet need for family planning refers to fertile women who want to limit or space their delivery but are not using contraceptive methods. Despite multiple studies were conducted to address family planning in Ethiopia, there is limited information on unmet need in high fertility regions. Knowing the magnitude and predictors of unmet need in the study area helps as an impute for interventions. Therefore, this study aims to assess the magnitude and predictors of unmet need for family planning among reproductive age women in high fertility regions of Ethiopia.

METHODS

A secondary data analysis was performed using the Ethiopian Demographic and Health Survey 2016. A total sample weight of 4312 currently married reproductive age women were included in this study. A multilevel mixed-effect binary logistic regression model was fitted. Finally, the odds ratios along with the 95% confidence interval were generated to determine the individual and community level factors of unmet need for family planning. A p-value less than 0.05 was declared as statistical significance.

RESULTS

The overall unmet need for family planning among currently married reproductive-age women in high fertility regions of Ethiopia was 29.78% (95% CI: 28.26, 31.3). Women with no formal education (AOR: 1.65, 95% CI: 1.17, 2.15), women in the poor wealth quantile (AOR: 1.67, 95% CI: 1.34, 2.09), women with no media exposure (AOR: 1.32, 95% CI: 1.09, 1.58), multiparous women (AOR: 1.57, 95% CI: 1.15, 2.16), sex of household head (AOR: 1.39, 95% CI: 1.11, 1.77) and rural residency (AOR: 2.45, 95% CI: 1.12, 3.59) were predictors of unmet need for family planning.

CONCLUSION

The magnitude of unmet need for family planning among currently married reproductive-age women in high fertility regions of Ethiopia was high when compared to the national average and the United Nations sphere standard of unmet need for family planning. Education, wealth index, mass media, parity, sex of household head, and residence were independent predictors of unmet need for family planning among reproductive-age women in high fertility regions of Ethiopia. Any interventional strategies that reduce the unmet need for family planning should consider these factors to overcome the problems in the regions.

Prevalence, trend and determinants of adolescent childbearing in Burundi: a multilevel analysis of the 1987 to 2016-17 Burundi Demographic and Health Surveys data

BACKGROUND

Very little is known about factors influencing adolescent childbearing despite an upward trend in adolescent childbearing prevalence in Burundi, and its perceived implications on the rapid population growth and ill-health of young mothers and their babies. To adress this gap, this study aimed to examine the prevalence, trends and determinants of adolescent childbearing in Burundi.

METHODS

Secondary analyses of the 1987, 2010 and 2016-17 Burundi Demographic and Health Surveys (BDHS) data were conducted using STATA. Weighted samples of 731 (1987 BDHS), 2359 (2010 BDHS) and 3859 (2016-17BDHS) adolescent girls aged 15-19 years old were used for descriptive and trend analyses. Both bivariable and multivariable two-level logistic regression analyses were performed to identify the main factors associated with adolescent childbearing using only the 2016-17 BDHS data.

RESULTS

The prevalence of adolescent childbearing increased from 5.9% in 1987 to 8.3% in 2016/17. Factors such as adolescent girls aged 18-19 years old (aOR =5.85, 95% CI: 3.54-9.65, p <  0.001), adolescent illiteracy (aOR = 4.18, 95% CI: 1.88-9.30, p <  0.001), living in poor communities (aOR = 2.19, 95% CI: 1.03-4.64, p = 0.042), early marriage (aOR = 9.28, 95% CI: 3.11-27.65, p <  0.001), lack of knowledge of any contraceptive methods (aOR = 5.33, 95% CI: 1.48-19.16, p = 0.010), and non-use of modern contraceptive methods (aOR = 24.48, 95% CI: 9.80-61.14), p <  0.001) were associated with higher odds of adolescent childbearing. While factors such as living in the richest household index (aOR = 0.52, 95% IC: 0.45-0.87, p = 0.00), living in West region (aOR = 0.26, 95%CI: 0.08-0.86, p = 0.027) or in South region (aOR = 0.31, 95% CI: 0.10-0.96, p = 0.041) were associated with lower odds of adolescent childbearing.

CONCLUSION

Our study found an upward trend in adolescent childbearing prevalence and there were significant variations in the odds of adolescent childbearing by some individual and community-level factors. School-and community-based intervention programs aimed at promoting girls' education, improving socioeconomic status, knowledge and utilization of contraceptives and prevention of early marriage among adolescent girls is crucial to reduce adolescent childbearing in Burundi.

Women's experience of unintended pregnancy and changes in contraceptive methods: evidence from a nationally representative survey

Background

Ineffective or no use of contraception following an unintended pregnancy contributes to a subsequent unintended pregnancy. This study aimed to determine whether women’s experiences of unintended pregnancies affect changing their contraceptive using patterns.

Methods

We analysed the 2017/2018 Bangladesh Demographic and Health Survey data. The contraceptive switching pattern was computed by comparing women’s contraceptives using data before and after pregnancy. Women were categorised into the following three groups, depending on their patterns of contraceptive use before and after pregnancy: no change, if there were no change in contraceptive using pattern; switched to higher effective contraceptives, if changed from pre-pregnancy less effective contraceptives to post-pregnancy more effective contraceptives; switched to less effective contraceptives, if changed from pre-pregnancy more effective contraceptives to post-pregnancy less effective contraceptives. Women’s intention in the most recent pregnancy was our primary explanatory variable, classified as wanted, mistimed and unwanted. Multinomial multilevel logistics regression was used to determine the association between women’s intention in the most recent pregnancy and women’s contraceptive methods switching patterns from before to after pregnancy.

Results

Around 20% of the most recent pregnancies that ended with a live birth were unintended at conception. No contraceptive use was reported by 37% of women before their pregnancies which decreased to 24% after pregnancies. Overall, around 54% of women who reported no contraceptive use before pregnancy used modern contraceptives after pregnancy. The rate was higher among women who experienced unwanted pregnancy (73.4%) than mistimed (58.8%) and wanted (53.4%) pregnancy. Experience of mistimed pregnancy was associated with a higher likelihood of no contraceptive change (aOR, 1.84, 95% CI 1.41–2.39) and switching to less effective contraceptives (aOR, 1.58, 95% CI 1.10–2.26) than switching to more effective contraceptives. However, unwanted pregnancy was not associated with any significant change in contraceptives use from before to after pregnancy.

Conclusion

Experience of unintended pregnancy did not change women’s contraception using patterns, which indicates the risk of repeat unintended pregnancies and associated adverse consequences, including maternal and child morbidity and mortality. Policies to ensure access to and use of modern contraceptives among women facing unwanted or mistimed pregnancies are recommended.

Unintended pregnancy is considered a public health challenge in low- and middle-income countries (LMICs). Around 89% of the global occurrences of unintended pregnancies occur in LMICs. In absolute numbers, this is equivalent to nearly 88 million pregnancies. Adverse pregnancy consequences, including bleeding, haemorrhage and maternal mortality are common in this group. The adverse consequences are even higher among women facing unintended pregnancies more than once, i.e., repeat unintended pregnancies, which represent around half of the total occurrences of unintended pregnancies in LMICs. Ensuring proper access to effective contraceptives following birth is key to reducing repeat unintended pregnancies and associated adverse consequences. It is critical to know the patterns of women’s pre-pregnancy contraceptive methods use and whether experiences of unintended pregnancies affect their contraceptive methods uptake and their types. However, this data is completely lacking in the context of LMICs. Using nationally representative survey data from Bangladesh, we examined women’s contraceptive switching patterns from before to after pregnancy and their association with pregnancy types. We found increased likelihood of no change in contraceptive using pattern or switching to less effective contraceptives among women after they experienced mistimed pregnancy compared to those whose pregnancy was wanted. This pattern increases the risk of repeat unintended pregnancies in Bangladesh and associated adverse consequences, including maternal and child morbidity and mortality.

Factors Associated with Adolescent Pregnancy in Sub-Saharan Africa during the COVID-19 Pandemic: A Review of Socioeconomic Influences and Essential Interventions

Objective: A literature review was conducted to analyze the impact of COVID-19 on documented preexisting determinants of adolescent pregnancy in sub-Saharan Africa such as poverty, inequitable gender norms, low access to education, and reproductive health services. Methods: The terms "sub-Saharan Africa," "Gender Norms," "Poverty," and "Adolescent Pregnancy" were used to search the literature for preexisting determinants of adolescent pregnancy in academic and grey literature. "COVID-19" was added to investigate the potential consequences of the pandemic. The literature revealed similar experiences in adolescent girls during the Ebola outbreak, which lead to the analysis of government and healthcare official responses to previous epidemics. Results: The literature review revealed that the relationship between identified micro (inequitable gender norms, transactional sex, sexual and gender-based violence, early marriage, and menstruation) and macro (poverty, education, and healthcare) factors contributing to adolescent pregnancy were exacerbated by the COVID-19 pandemic. Conclusion: Three realistic targets including, expanding and communicating available reproductive health resources, prioritizing the role of women in the economy, and ensuring return to school should be included as part of current COVID-19 mitigation programs. Additionally, these interventions should be incorporated in future public health preparedness plans to reduce the risk of adolescent pregnancy during public health emergencies.

Impact of social protection on gender equality in low- and middle-income countries: A systematic review of reviews

Background

More than half of the global population is not effectively covered by any type of social protection benefit and women's coverage lags behind. Most girls and boys living in low-resource settings have no effective social protection coverage. Interest in these essential programmes in low and middle-income settings is rising and in the context of the COVID-19 pandemic the value of social protection for all has been undoubtedly confirmed. However, evidence on whether the impact of different social protection programmes (social assistance, social insurance and social care services and labour market programmes) differs by gender has not been consistently analysed. Evidence is needed on the structural and contextual factors that determine differential impacts. Questions remain as to whether programme outcomes vary according to intervention implementation and design.

Objectives

This systematic review aims to collect, appraise, and synthesise the evidence from available systematic reviews on the differential gender impacts of social protection programmes in low and middle-income countries. It answers the following questions: 1.What is known from systematic reviews on the gender-differentiated impacts of social protection programmes in low and middle-income countries?2.What is known from systematic reviews about the factors that determine these gender-differentiated impacts?3.What is known from existing systematic reviews about design and implementation features of social protection programmes and their association with gender outcomes?

Search Methods

We searched for published and grey literature from 19 bibliographic databases and libraries. The search techniques used were subject searching, reference list checking, citation searching and expert consultations. All searches were conducted between 10 February and 1 March 2021 to retrieve systematic reviews published within the last 10 years with no language restrictions.

Selection Criteria

We included systematic reviews that synthesised evidence from qualitative, quantitative or mixed-methods studies and analysed the outcomes of social protection programmes on women, men, girls, and boys with no age restrictions. The reviews included investigated one or more types of social protection programmes in low and middle-income countries. We included systematic reviews that investigated the effects of social protection interventions on any outcomes within any of the following six core outcome areas of gender equality: economic security and empowerment, health, education, mental health and psychosocial wellbeing, safety and protection and voice and agency.

Data Collection and Analysis

A total of 6265 records were identified. After removing duplicates, 5250 records were screened independently and simultaneously by two reviewers based on title and abstract and 298 full texts were assessed for eligibility. Another 48 records, identified through the initial scoping exercise, consultations with experts and citation searching, were also screened. The review includes 70 high to moderate quality systematic reviews, representing a total of 3289 studies from 121 countries. We extracted data on the following areas of interest: population, intervention, methodology, quality appraisal, and findings for each research question. We also extracted the pooled effect sizes of gender equality outcomes of meta-analyses. The methodological quality of the included systematic reviews was assessed, and framework synthesis was used as the synthesis method. To estimate the degree of overlap, we created citation matrices and calculated the corrected covered area.

Main Results

Most reviews examined more than one type of social protection programme. The majority investigated social assistance programmes (77%, N = 54), 40% (N = 28) examined labour market programmes, 11% (N = 8) focused on social insurance interventions and 9% (N = 6) analysed social care interventions. Health was the most researched (e.g., maternal health; 70%, N = 49) outcome area, followed by economic security and empowerment (e.g., savings; 39%, N = 27) and education (e.g., school enrolment and attendance; 24%, N = 17). Five key findings were consistent across intervention and outcomes areas: (1) Although pre-existing gender differences should be considered, social protection programmes tend to report higher impacts on women and girls in comparison to men and boys; (2) Women are more likely to save, invest and share the benefits of social protection but lack of family support is a key barrier to their participation and retention in programmes; (3) Social protection programmes with explicit objectives tend to demonstrate higher effects in comparison to social protection programmes without broad objectives; (4) While no reviews point to negative impacts of social protection programmes on women or men, adverse and unintended outcomes have been attributed to design and implementation features. However, there are no one-size-fits-all approaches to design and implementation of social protection programmes and these features need to be gender-responsive and adapted; and (5) Direct investment in individuals and families' needs to be accompanied by efforts to strengthen health, education, and child protection systems. Social assistance programmes may increase labour participation, savings, investments, the utilisation of health care services and contraception use among women, school enrolment among boys and girls and school attendance among girls. They reduce unintended pregnancies among young women, risky sexual behaviour, and symptoms of sexually transmitted infections among women. Social insurance programmes increase the utilisation of sexual, reproductive, and maternal health services, and knowledge of reproductive health; improve changes in attitudes towards family planning; increase rates of inclusive and early initiation of breastfeeding and decrease poor physical wellbeing among mothers. Labour market programmes increase labour participation among women receiving benefits, savings, ownership of assets, and earning capacity among young women. They improve knowledge and attitudes towards sexually transmitted infections, increase self-reported condom use among boys and girls, increase child nutrition and overall household dietary intake, improve subjective wellbeing among women. Evidence on the impact of social care programmes on gender equality outcomes is needed.

Authors' Conclusions

Although effectiveness gaps remain, current programmatic interests are not matched by a rigorous evidence base demonstrating how to appropriately design and implement social protection interventions. Advancing current knowledge of gender-responsive social protection entails moving beyond effectiveness studies to test packages or combinations of design and implementation features that determine the impact of these interventions on gender equality. Systematic reviews investigating the impact of social care programmes, old age pensions and parental leave on gender equality outcomes in low and middle-income settings are needed. Voice and agency and mental health and psychosocial wellbeing remain under-researched gender equality outcome areas.

Combining photo-elicitation and discourse analysis to examine adolescents' sexuality in rural Zambia

INTRODUCTION

This article aimed to analyse constructions of adolescents' sexualities and sexual health and the consequences of these discourses for adolescents' exercise of their sexual reproductive health and rights (SRHR) in rural Zambia.

METHODS

Interpretative repertoires, which is rooted in discursive psychology was used to analyse data from photo-elicitations interviews and focus group discussions. Our participants included 25 adolescents who participated in a SRHR intervention that aimed to reduce adolescents' pregnancies and early marriages.

RESULTS

We identified three interpretative repertories: 1) sex is for mature people in which adolescents positioned themselves as 'immature, and young to engage in sex; 2) gendered respectful behaviours in which what was considered disrespectful (and respectful) behaviour in relation to sexuality were strongly influenced by gender, and more clearly defined for girls than it was for boys. Sexuality was not only about individual choices but about being respectful to parents; and 3) acquiring and using knowledge about sexuality in which adolescents conflicted between having and applying SRHR knowledge.

CONCLUSION

These repertories offer an important context that shape how adolescents negotiate, adopt and resist SRHR interventions. Future interventions that target adolescents' SRHR must aim to address the sexual scripts that serve to erect barriers against positive sexual behaviours, including access to SRHR services that promote safer sex.

Interventions Promoting Child Sexual and Reproductive Health and Rights in LMICs: A Systematic Review

OBJECTIVE

Middle childhood is a critical period for physical, social, behavioral, and cognitive changes. A positive and healthy sexual and reproductive health and rights (SRHR) foundation can minimize SRHR risks, leading to better outcomes. Our objective is to identify effective educational interventions promoting or supporting the SRHR of school-age children in low and middle-income countries.

DATA SOURCES

Medline, Embase, CINAHL, APA PsycInfo, ERIC, Cochrane Central Register of Controlled Trials, Education Source, Web of Science, SciELO Citation Index, Global Health, and Sociological Abstract were searched from 2000 to December 2020.

STUDY SELECTION

Eligible articles had a sample mean age between 5 and 10 years, quantitatively tested the effects of educational interventions against a comparison group, and measured SRHR related outcomes.

DATA EXTRACTION

Data extracted from the 11 eligible articles were study methods, participant characteristics, interventions and comparisons, outcome measures, and results.

RESULTS

The review found evidence of significant intervention effects on protective knowledge, attitudes, behaviors, and skills for preventing sexual violence and HIV infection. The strongest evidence was for significant improvements in children's knowledge of child sexual abuse prevention concepts and strategies.

LIMITATIONS

A meta-analysis could not be performed because most studies lacked randomization, included no information on the magnitude of effects, and had inadequate follow-up evaluations to truly assess retention. Only a few studies contributed to findings on protective attitudes, behaviors, and skills against child sexual abuse, gender-based violence, and human immunodeficiency virus infection, as well as physiologic outcome.

CONCLUSIONS

The educational interventions demonstrated significant improvements in primary school children's protective capacities, especially in their protective knowledge against sexual abuse.

Single motherhood, social independence and non-communicable disease (NCD) outcomes among young females (15-24 years old) in South Africa

Background: Non-communicable diseases (NCDs) acquired during youth follow into and affect adulthood. The association between young mother’s social independence and NCD status is of policy interest due to its effect on economic and social development. This study aimed to determine the causal relationship between social independence and NCD outcomes among young, single mothers in South Africa. Methods: Data from the South African National Income Dynamics Survey (NIDS) in 2008 and 2017 was used to determine if single mothers developed hypertension, diabetes or asthma by various indicators of social independence, including highest level of education and employment status. The sample was initially made-up of unmarried females (15-24 years old) without any children in 2008. Both fertility and social independence was followed-up to 2017. Results: In total, 66 young females developed an NCD by 2017 and 87% (n=57) of these women had a child in the interim period. Employment of young females increased from 4.78% in 2008 to 37.79% in 2017, but completion of secondary or tertiary education declined from 67.94% in 2008 to 56.01% in 2017. In addition, half (50.88%) of the young females were partially independent by 2017, with only 11.03% being fully independent at this time. Finally, logistic regression results showed that the likelihood of developing an NCD increased if young females with children were not socially independent. Conclusions: The relationship between social independence and NCDs suggest that policies and programmes in South Africa need to incorporate socioeconomic status as a determinant of disease and in particular, need to address socioeconomic indicators as additive measures and not autonomous indicators.

Adolescent pregnancy, public policies, and targeted programs in Latin America and the Caribbean: a systematic review

OBJECTIVE

To present and assess evidence from Latin America and the Caribbean (LAC) on public policies and targeted programs which may have influenced variations in adolescent pregnancy or its proximate determinants, and to identify knowledge gaps that require further research.

METHODS

A systematic review was performed based on the 2015 PRISMA protocol. Five databases were searched for articles published between 2000 and 2019 that refer to at least one country in LAC. The outcomes of interest were adolescent pregnancy or its proximate determinants (sexual behavior, contraceptive use, and/ or abortion). Only studies exploring correlations between the outcomes of interest and public policies or targeted programs were included in the analysis.

RESULTS

Thirty studies spanning 14 countries were selected for analysis. Twenty-three of these (77%) were not included in prior systematic reviews on adolescent pregnancy. Public policies related to conditional cash transfers and compulsory education have the strongest evidence of correlation with adolescent pregnancy prevention. Emerging research points to the potential positive impact of life-skills programs for adolescents. Evidence from public health policies and programs was limited.

CONCLUSIONS

Further research which incorporates an intersectional analysis is needed to better understand which policies and programs could lead to steeper declines in adolescent pregnancy in the region. Evidence on effects of expanded family planning services and secondary school attainment upon adolescent pregnancy are particularly absent.

"We Don't Fear HIV. We Just Fear Walking around Pregnant.": A Qualitative Analysis of Adolescent Sexuality and Pregnancy Stigma in Informal Settlements in Kisumu, Kenya

In Kenya, adolescent pregnancy rates are high, contraception utilization is low, and adolescent sexuality is stigmatized. We describe how perceptions of sexuality and pregnancy stigma influence decision-making among adolescents in the informal settlements of Kisumu. We used purposive sampling to recruit 120 adolescent boys and girls aged 15-19 for focus group discussions. A semistructured interview guide was used to elicit social norms and community attitudes about sexual and reproductive health. We analyzed the data using the Framework Approach. The social stigma of adolescent sexuality and the related fear of pregnancy as an unambiguous marker of sexual activity emerged as main themes. This stigma led adolescents to fear social retribution but did not lead to more frequent contraception use due to additional stigma. The intensity of this fear was most acutely expressed by girls, leading some to seek unsafe, sometimes fatal, abortions, and to contemplate suicide. Fear of pregnancy outweighed fear of contracting HIV that was viewed as both treatable and less stigmatized. Our findings illustrate how fear of pregnancy among these adolescents is driven primarily by fears that their community will discover that they are sexually active. Interventions are urgently needed to address adolescent sexual stigma and to prevent negative outcomes.

Adolescent pregnancy and young motherhood in rural Zimbabwe: Findings from a baseline study

Pregnant adolescents and young mothers comprise a vulnerable group, particularly in low and middle income countries, yet there is limited research describing this population, particularly in rural Zimbabwe. Using tablet-administered questionnaires concerning maternal and child health, sexual and reproductive health, psychosocial well-being and parenting, we recruited 442 pregnant and young mothers (14-24 years) with the support of social workers from health facilities. We found high levels of poverty amidst increased rates of marriage, including child marriage (almost 20%). Participants had poor sexual and reproductive health knowledge and uptake of contraception was low (only 35% respondents reported current use). Although almost 60% girls had completed Form 2, 24% had only completed Grade 1 and just 4% were still engaged in schooling. Girls reported inadequate social support amidst high caretaking responsibilities and change in relocation for marriage, compromising mental health. Most of the pregnancies were unintended (approximately 60%) which had consequences on attachment and parenting where roughly 40% of our sample reported difficulties and lack of enjoyment in caring for their babies. Investments in interventions that address these vulnerabilities for pregnant adolescents and young mothers, and capitalise on available resources, are critical to improve health and interrupt cycles of risk for the next generation.

Reproductive Life Planning in Adolescents

Unplanned pregnancy in adolescents contributes to the burden of disease, mortality, and health and educational disparities experienced by young people during this vulnerable period between childhood and adulthood. Reproductive life planning (RLP) is an approach that has been endorsed and adopted internationally, which prompts individuals and couples to set personal goals regarding if and when to have children based on their own personal priorities. This review discusses RLP tools, their acceptability, effectiveness, and issues in implementation across different contexts, with a specific focus on how RLP has been applied for adolescents. While a range of RLP tools are available and considered acceptable in adult populations, there is minimal evidence of their potential benefits for adolescent populations. Online platforms and information technology are likely to promote reach and implementation of RLP interventions in adolescents. Consideration of the socioecological contexts where adolescent pregnancies are more common should be integral to much needed future work that explores RLP interventions in adolescents.

Unequal access and use of contraceptives among parenting adolescent girls in sub-Saharan Africa: a cross-sectional analysis of demographic and health surveys

OBJECTIVE

We examined the divergent patterns, prevalence and correlates of contraceptive use among parenting adolescents in sub-Saharan Africa using the Demographic and Health Survey datasets of 17 countries.

DESIGN

We included a weighted sample of 9488 parenting adolescent girls in our analysis. Current contraceptive use was defined as the use of any methods to delay or avoid getting pregnant at the survey time. We reported the prevalence of any contraceptive use for all countries and used multilevel binary logistic regression analysis to examine the individual and contextual factors associated with contraceptive use.

OUTCOME MEASURES

Contraceptive use.

RESULTS

We found an overall contraceptive prevalence of 27.12% (CI 27.23% to 28.03%) among parenting adolescent girls in sub-Saharan Africa, ranging from 70.0% (CI 61.76% to 77.16%) in South Africa to only 5.10% (CI 3.04% to 8.45%) in Chad. The prevalence of contraceptive use was lowest in West andCentral Africa, with most countries having less than 20% prevalence. Increasing age (adjusted OR (aOR)=1.46, 95% CI 1.28 to 1.65), being married (aOR=1.63, 95% CI 1.43 to 1.87), having a secondary or higher level of education (aOR=2.72, 95% CI 2.25 to 2.3.27), and media exposure (aOR=1.21, 95% CI 1.08 to 1.36), were associated with higher odds of contraceptive use in the pooled data but preference for a higher number of children (more than five children) (aOR=0.61, 95% CI 0.52 to 0.72) was related to lower likelihood of use. Significant heterogeneity was observed in the country-level disaggregated results.

CONCLUSION

African countries differ widely when it comes to contraceptive use among parenting adolescent girls, with only three countries having a relatively high prevalence of use. The governments of countries in sub-Saharan Africa, particularly those in West and Central Africa, should invest in expanding access to contraceptives for adolescent mothers to prevent repeat pregnancy and improve the overall well-being of parenting adolescent girls.

Prevalence and determinants of unintended pregnancy in Ethiopia: narrative synthesis and meta-analysis

BACKGROUND

Unintended pregnancy has enormous health, social and psychological impacts. Thus, comprehensive local evidence is required to guide interventions to prevent the occurrence and consequences of unintended pregnancy. This systematic review was conducted to examine the prevalence and determinants of unintended pregnancy in Ethiopia.

METHODS

The review was done following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) and Synthesis Without Meta-analysis (SWiM) guideline. Electronic databases including Medline/PubMed, Cochrane Library, CINAHL, Google scholar, and African journal online were searched to retrieve studies published from January 1/1990 to October 30/2020. Grey literatures were accessed from the online libraries of academic institutions in Ethiopia using the Google search engine. The qualities of the studies were assessed using Joanna Briggs Institute critical appraisal checklists. The retrieved studies were analyzed using STATA software version 13. The prevalence of unintended pregnancy was pooled using the random-effects model. The evidences on the determinants of unintended pregnancy were summarized in a narrative format. The statistical heterogeneity between studies was quantified by using the I-square values. Sub-group analysis and meta-regressions were done to identify the sources of heterogeneity among studies.

RESULTS

A total of 250 studies were retrieved of which 25 studies with 23,030 women were included for meta-analysis. Only 24 studies scrutinized the determinants of unintended pregnancy. The overall prevalence of unintended pregnancy was 30 % (95% CI; 27-33 %) with high heterogeneity among studies (I2 = 95.06 %). The pooled prevalence of unwanted and mistimed pregnancy was 12 &17% respectively. The study region was the source of heterogeneity whereas study setting, study year, sample size, and study quality score were not the sources of heterogeneity (p > 0.1). Unintended pregnancy was positively associated with a low level of education, poverty, multiparity, rural residence, extreme ages, being unmarried, lack of decision-making power, inaccessibility of health facilities, poor knowledge, and non-use of contraceptives.

CONCLUSIONS

The pooled prevalence of unintended pregnancy in Ethiopia was high. Empowering women and ensuring the accessibility of quality family planning services can reduce the prevailing high prevalence of unintended pregnancy. Interventions that target rural, poor, unmarried, multiparous, less-educated, and adolescent women are also important to avert untended pregnancy in Ethiopia.

Individual and context correlates of the oral pill and condom use among Brazilian female adolescents

Background

Studies have examined the impact of contextual factors on the use of contraceptives among adolescents and found that many measures of income and social inequality are associated with contraceptive use. However, few have focused on maternal and primary health indicators and its influence on adolescent contraceptive use. This paper assesses whether maternal mortality rates, antenatal care visits, and primary healthcare coverage are associated with pill and condom use among female adolescents in Brazil.

Methods

We used data from the Study of Cardiovascular Risks in Adolescents (ERICA), a national, school-based cross-sectional study conducted in Brazil. A subsample of all female adolescents who had ever had sexual intercourse and were living in one of the 26 State capitals and the Federal District was selected (n = 7415). Multilevel mixed effects logistic regression models were estimated to examine the effect of contextual variables on pill and condom use.

Results

Sixty-five percent of female adolescents reported using pill while 21.9% reported using condom during the last sexual intercourse. Adolescents living in municipalities with low maternal mortality and high antenatal care coverage were significantly more likely to use pill during the last sexual intercourse compared to those from municipalities with high maternal mortality and low antenatal care coverage. Primary healthcare coverage (proportion of the population covered by primary healthcare teams) was not significantly associated with either condom or pill use during the last sexual intercourse.

Conclusion

Our findings suggest that promoting the use of pill among female adolescents may require approaches to strengthen healthcare systems rather than those focused solely on individual attributes.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12905-021-01447-6.

"Spoiled" girls: Understanding social influences on adolescent contraceptive decision-making in Kenya

OBJECTIVES

Despite significant public health emphasis on unintended pregnancy prevention among adolescent girls and young women in Sub-Saharan Africa, there is a gap in understanding how adolescents' own reproductive priorities and the social influences on their decision-making align and compete. We examined the social context of contraceptive decision-making among Kenyan female adolescents.

METHODS

Using community-based sampling, we conducted 40 in-depth interviews and 6 focus group discussions among sexually-active or partnered adolescent girls and young women aged 15-19 in the Nyanza region of Kenya. We analyzed the data in Dedoose using an inductive, grounded theory approach, and developed a conceptual model from the data illustrating social influences on adolescent contraceptive decision-making.

RESULTS

Participants viewed adolescent pregnancy as unacceptable, and described severe social, financial, and health consequences of unintended pregnancy, including abortion under unsafe conditions. Yet, their contraceptive behaviors often did not reflect their desire to delay pregnancy. Contraceptive decision-making was influenced by multiple social factors, centering on the intersecting stigmas of adolescent female sexuality, pregnancy, and contraceptive use, as well as unequal power in sexual relationships. To prioritize pregnancy prevention, adolescents must navigate conflicting social norms and power dynamics, and put their perceived future fertility at risk.

CONCLUSIONS

Contraceptive decision-making among Kenyan female adolescents is strongly influenced by opposing social norms within families, communities, and sexual relationships, which compel them to risk stigma whether they use a contraceptive method or become pregnant as adolescents. These findings put into perspective adolescents' seemingly incongruent pregnancy preferences and contraceptive behaviors. Interventions to address adolescent unintended pregnancy should focus on supporting adolescent decision-making agency, addressing fertility-related contraceptive concerns, and promoting innovative contraceptive access points rather than increasing contraceptive prevalence.

Single motherhood, social independence and non-communicable disease (NCD) outcomes among young females (15-24 years old) in South Africa

Background: Non-communicable diseases (NCDs) acquired during youth follow into and affect adulthood. The association between young mother’s social independence and NCD status is of policy interest due to its effect on economic and social development. This study aimed to determine the causal relationship between social independence and NCD outcomes among young, single mothers in South Africa. Methods: Data from the South African National Income Dynamics Survey (NIDS) in 2008 and 2017 was used to determine if single mothers developed hypertension, diabetes or asthma by various indicators of social independence, including highest level of education and employment status. The sample was initially made-up of unmarried females (15-24 years old) without any children in 2008. Both fertility and social independence was followed-up to 2017. Results: In total, 66 young females developed an NCD by 2017 and 87% (n=57) of these women had a child in the interim period. Employment of young females increased from 4.78% in 2008 to 37.79% in 2017, but completion of secondary or tertiary education declined from 67.94% in 2008 to 56.01% in 2017. In addition, half (50.88%) of the young females were partially independent by 2017, with only 11.03% being fully independent at this time. Finally, logistic regression results showed that the likelihood of developing an NCD increased if young females with children were not socially independent. Conclusions: The relationship between social independence and NCDs suggest that policies and programmes in South Africa need to incorporate socioeconomic status as a determinant of disease and in particular, need to address socioeconomic indicators as additive measures and not autonomous indicators.

A Rapid Review of Interventions to Prevent First Pregnancy among Adolescents and Its Applicability to Latin America

STUDY OBJECTIVE

To summarize recent literature on the effectiveness of interventions to prevent adolescent pregnancy and to explore the applicability of these interventions to Latin America (LA). Design, Setting, Participants, Interventions, and Main Outcome Measures: We carried out a rapid review of the literature (2005-2019). Studies were included if: they evaluated interventions targeting adolescents and prevention of pregnancy; they used a randomized controlled design; and pregnancy was measured as an outcome. Applicability of the interventions to LA was assessed using the following information: target population; intervention design and resources; type, skills, and training of providers; system arrangements; and acceptability and social context.

RESULTS

Nine studies were included, 5 described interventions in African countries, 2 in the United Kingdom, and 2 in the United States. Interventions were rated as highly applicable to LA in the context of target population, profile of the providers, and design; however, variations arose when assessing system arrangements and social context. Incentive-based interventions showed significant effects in the prevention of adolescent pregnancy and were rated as highly applicable.

CONCLUSION

This review provides professionals, policymakers, researchers, and educators potential criteria to consider when adapting successful evidence-based interventions to prevent adolescent pregnancy in LA.

Engaging young people in the design of a sexual reproductive health intervention: Lessons learnt from the Yathu Yathu ("For us, by us") formative study in Zambia

BACKGROUND

Meeting the sexual and reproductive health (SRH) needs of adolescents and young people (AYP) requires their meaningful engagement in intervention design. We describe an iterative process of engaging AYP to finalise the design of a community-based, peer-led and incentivised SRH intervention for AYP aged 15-24 in Lusaka and the lessons learnt.

METHODS

Between November 2018 and March 2019, 18 focus group discussions, eight in-depth interviews and six observations were conducted to assess AYP's knowledge of HIV/SRH services, factors influencing AYP's sexual behaviour and elicit views on core elements of a proposed intervention, including: community-based spaces (hubs) for service delivery, type of service providers and incentivising service use through prevention points cards (PPC; "loyalty" cards to gain points for accessing services and redeem these for rewards). A total of 230 AYP (15 participated twice in different research activities) and 21 adults (only participated in the community mapping discussions) participated in the research. Participants were purposively selected based on age, sex, where they lived and their roles in the study communities. Data were analysed thematically.

RESULTS

Alcohol and drug abuse, peer pressure, poverty, unemployment and limited recreation facilities influenced AYP's sexual behaviours. Adolescent boys and young men lacked knowledge of contraceptive services and all AYP of pre and post exposure prophylaxis for HIV prevention. AYP stated a preference for accessing services at "hubs" located in the community rather than the health facility. AYP considered the age, sex and training of the providers when choosing whom they were comfortable accessing services from. PPCs were acceptable among AYP despite the loyalty card concept being new to them. AYP suggested financial and school support, electronic devices, clothing and food supplies as rewards.

CONCLUSIONS

Engaging AYP in the design of an SRH intervention was feasible, informative and considered responsive to their needs. Although AYP's suggestions were diverse, the iterative process of AYP engagement facilitated the design of an intervention that is informed by AYP and implementable.

TRIAL REGISTRATION

This formative study informed the design of this trial: ClinicalTrials.gov, NCT04060420. Registered 19 August, 2019.

Single motherhood, social independence and non-communicable disease (NCD) outcomes among young females (15-24 years old) in South Africa

Background: Non-communicable diseases (NCDs) acquired during youth follow into and affect adulthood. The association between young mother’s social independence and NCD status is of policy interest due to its effect on economic and social development. This study aimed to determine the causal relationship between social independence and NCD outcomes among young, single mothers in South Africa. Methods: Data from the South African National Income Dynamics Survey (NIDS) in 2008 and 2017 was used to determine if single mothers developed hypertension, diabetes or asthma by various indicators of social independence, including highest level of education and employment status. The sample was initially made-up of unmarried females (15-24 years old) without any children in 2008. Both fertility and social independence was followed-up to 2017. Results: In total, 66 young females developed an NCD by 2017 and 87% (n=57) of these women had a child in the interim period. Employment of young females increased from 4.78% in 2008 to 37.79% in 2017, but completion of secondary or tertiary education declined from 67.94% in 2008 to 56.01% in 2017. In addition, half (50.88%) of the young females were partially independent by 2017, with only 11.03% being fully independent at this time. Finally, logistic regression results showed that the likelihood of developing an NCD increased if young females with children were not socially independent. Conclusions: The relationship between social independence and NCDs suggest that policies and programmes in South Africa need to incorporate socioeconomic status as a determinant of disease and in particular, need to address socioeconomic indicators as additive measures and not autonomous indicators.

Effects of preconception care and periconception interventions on maternal nutritional status and birth outcomes in low- and middle-income countries: A systematic review

Background

The preconception period is an ideal time to introduce interventions relating to nutrition and other lifestyle factors to ensure good pregnancy preparedness, and to promote health of mothers and babies. In adolescents, malnutrition and early pregnancy are the common challenges, particularly among those who live in low- and middle-income countries (LMIC) where 99% of all maternal and newborn deaths occur. These girls receive little or no attention until their first pregnancy and often the interventions after pregnancy are too late to revert any detrimental health risks that may have occurred due to malnutrition and early pregnancy.

Objectives

To synthesise the evidence of the effectiveness of preconception care interventions relating to delayed age at first pregnancy, optimising inter-pregnancy intervals, periconception folic acid, and periconception iron-folic acid supplementation on maternal, pregnancy, birth and child outcomes.

Search Methods

Numerous electronic databases (e.g., CINAHL, ERIC) and databases of selected development agencies or research firms were systematically searched for all available years up to July 2019. In addition, we searched the reference lists of relevant articles and reviews, and asked experts in the area about ongoing and unpublished studies.

Selection Criteria

Primary studies, including large-scale programme evaluations that assessed the effectiveness of interventions using randomised controlled trials (RCTs) or quasi-experimental designs (natural experiments, controlled before-after studies, regression discontinuity designs, interrupted time series [ITS]), that targeted women of reproductive age (i.e., 10-49 years) during the pre- and periconceptional period in LMICs were included. Interventions were compared against no intervention, standard of care or placebo.

Data Collection and Analysis

Two or more review authors independently reviewed searches, selected studies for inclusion or exclusion, extracted data and assessed risk of bias. We used random-effects model to conduct meta-analyses, given the diverse contexts, participants, and interventions, and separate meta-analyses for the same outcome was performed with different study designs (ITS, RCTs and controlled before after studies). For each comparison, the findings were descriptively summarised in text which included detailing the contextual factors (e.g., setting) to assess their impact on the implementation and effectiveness of each intervention.

Main Results

We included a total of 43 studies; two of these were included in both delaying pregnancy and optimising interpregnancy intervals resulting in 26 studies for delaying the age at first pregnancy (14 RCTs, 12 quasi-experimental), four for optimising interpregnancy intervals (one RCT, three quasi-experimental), five on periconceptional folic acid supplementation (two RCTs, three quasi-experimental), and 10 on periconceptional iron-folic acid supplementation (nine RCTs, one quasi-experimental). Geographically, studies were predominantly conducted across Africa and Asia, with few studies from North and Central America and took place in a combination of settings including community, schools and clinical. The education on sexual health and contraception interventions to delay the age at first pregnancy may make little or no difference on risk of unintended pregnancy (risk ratio [RR], 0.42; 95% confidence internal [CI], 0.07-3.26; two studies, =490; random-effect; χ 2 p .009; I 2 = 85%; low certainty of evidence using GRADE assessment), however, it significantly improved the use of condom (ever) (RR, 1.54; 95% CI, 1.08-2.20; six studies, n = 1604; random-effect, heterogeneity: χ 2 p .004; I 2 = 71%). Education on sexual health and and provision of contraceptive along with involvement of male partneron optimising interpregnancy intervals probably makes little or no difference on the risk of unintended pregnancies when compared to education on sexual health only (RR, 0.32; 95% CI, 0.01-7.45; one study, n = 45; moderate certainty of evidence using GRADE assessments). However, education on sexual health and contraception intervention alone or with provision of contraceptive showed a significant improvement in the uptake of contraceptive method. We are uncertain whether periconceptional folic acid supplementation reduces the incidence of neural tube defects (NTDs) (RR, 0.53; 95% CI, 0.41-0.77; two studies, n = 248,056; random-effect; heterogeneity: χ 2 p .36; I 2 = 0%; very low certainty of evidence using GRADE assessment). We are uncertain whether preconception iron-folic acid supplementation reduces anaemia (RR, 0.66; 95% CI, 0.53-0.81; six studies; n = 3430, random-effect; heterogeneity: χ 2 p < .001; I 2 = 88%; very low certainty of evidence using GRADE assessment) even when supplemented weekly (RR, 0.70; 95% CI, 0.55-0.88; six studies; n = 2661; random-effect; heterogeneity: χ 2 p < .001; I 2 = 88%; very low certainty of evidence using GRADE assessments),and in school set-ups (RR, 0.66; 95% CI, 0.51-0.86; four studies; n = 3005; random-effect; heterogeneity: χ 2 p < .0001; I 2 = 87%; very low certainty of evidence using GRADE assessment). Data on adverse effects were reported on in five studies for iron-folic acid, with the main complaint relating to gastrointestinal side effects. The quality of evidence across the interventions of interest was variable (ranging from very low to moderate) which may be attributed to the different study designs included in this review. Concerning risk of bias, the most common concerns were related to blinding of participants and personnel (performance bias) and whether there were similar baseline characteristic across intervention and comparison groups.

Authors' Conclusions

There is evidence that education on sexual health and contraception interventions can improve contraceptive use and knowledge related to sexual health, this review also provides further support for the use of folic acid in pregnancy to reduce NTDs, and notes that weekly regimes of IFA are most effective in reducing anaemia. However the certainty of the evidence was very low and therefore more robust trials and research is required, including ensuring consistency for reporting unplanned pregnancies, and further studies to determine which intervention settings (school, community, clinic) are most effective. Although this review demonstrates promising findings, more robust evidence from RCTs are required from LMICs to further support the evidence.

Acceptability of immediate postpartum and post-abortion long-acting reversible contraception provision to adolescents: A systematic review

INTRODUCTION

Long-acting reversible contraception (LARC) methods are safe for adolescents and provide the greatest assurance against rapid repeated pregnancy when inserted during the immediate postpartum (IPP) and immediate post-abortion (IPA) period. Despite increasing enthusiasm for IPP/IPA LARC insertion, adolescents' preferences and experiences have seldom been examined. The objective of this review was to examine the attitudes of adolescents (aged 10-19 years) towards IPP/IPA LARC, their experiences and perceptions around having an LARC device fitted IPP/IPA and the factors involved in decision-making to use, not use or discontinue IPP/IPA LARC.

MATERIAL AND METHODS

In January 2021, we searched seven bibliographic databases for original research articles published in English, from the year 2000. Studies of any design focused on IPP/IPA LARC were eligible for inclusion. Three of the authors assessed articles for eligibility and extracted data relevant to the outcomes of the review. Joanna Briggs Institute Critical Appraisal Tools were used to assess methodological quality. Key themes emerging from the data were synthesized and reported narratively.

RESULTS

We identified 10 relevant articles, four of which were entirely adolescent-focused. Only three addressed IPA LARC. IPP availability was important for ensuring access to LARC postpartum. Attitudes towards LARC IPP were associated with adolescents' sociodemographic characteristics and positive perceptions related to the long duration of action. Determinants of discontinuation and nonuse included poor-quality contraceptive counseling, intolerable side effects and subsequent distress, misconceptions about LARC safety IPP and the influence of partners and community on autonomy. No factors involved in IPA LARC decision-making were available. Limited evidence demonstrated that adolescents may favor contraceptive implants over intrauterine devices, and in certain contexts may face greater barriers to IPA LARC access than adult women do.

CONCLUSIONS

Immediate insertion of LARC postpartum appears acceptable to adolescents who do not experience side effects and those with the opportunity to make autonomous contraception decisions. This important topic has been addressed in few studies involving an entirely adolescent population. Very limited evidence is available on IPA LARC. Further research on adolescents' lived experiences of IPP/IPA LARC access and use is necessary to inform the provision of person-centered care when assisting adolescents' contraceptive choice following pregnancy.

Developing a framework for cash transfer programs that foster sustained economic empowerment to reduce sexual risk among adolescent girls and young women: a qualitative study

Background

Transactional sexual relationships contribute to a high incidence of HIV infection among adolescent girls and young women (AGYW) living in low-resource settings. Cash transfers (CT) are a structural approach to reduce sexual risk behaviors, but their positive economic effects frequently fade after the program ends. We aimed to understand AGYW’s decision-making processes related to sexual, relationship, and financial decisions, in order to design a framework for a CT program that could lead to long-term financial independence and reduced transactional sex among AGYW.

Methods

We conducted qualitative research with AGYW participating in a CT program in Tanzania. Phase one was formative research to understand the context and experiences of AGYW regarding sexual behavior, relationships, and finances. Participants included 36 AGYW (15–23 years old), 15 influencers of AGYW (mothers and male partners) and 10 financially empowered women (FEW – women aged 20–30 with a sustained, reliable source of income independent of their partner). Decisions and decision-making contexts of AGYW that we identified in phase one informed the content of phase two. In phase two we simulated scenarios for decision-making and economic goals with 80 AGYW and 40 FEW, in order to identify key principles or intervention opportunities to guide development of a CT program framework.

Results

Through phases one and two of our research we identified three key themes in AGYW’s vision of their desired future economic state: 1) positive social image, 2) power balance and respect, and 3) emotional and economic security. An important theme distinguishing AGYW from FEW was that AGYW lacked a vision to build self-agency.

Conclusions

Our findings suggest that providing economic resources to AGYW through CT without ensuring self-agency is unlikely to be an effective long-term intervention for economic empowerment. Using these findings we developed a framework for CT programs with three key pillars for developing self-agency: 1) emotional efficacy, to increase AGYW’s perception of rewards associated with developing self-agency; 2) social efficacy, to build constructive relationships and exit negative relationships that inhibit self-agency, and 3) economic efficacy, to help AGYW build a resilient stream of financial resources.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-020-10130-8.

Mega-map of systematic reviews and evidence and gap maps on the interventions to improve child well-being in low- and middle-income countries

Background

Despite a considerable reduction in child mortality, nearly six million children under the age of five die each year. Millions more are poorly nourished and in many parts of the world, the quality of education remains poor. Children are at risk from multiple violations of their rights, including child labour, early marriage, and sexual exploitation. Research plays a crucial role in helping to close the remaining gaps in child well-being, yet the global evidence base for interventions to meet these challenges is mostly weak, scattered and often unusable by policymakers and practitioners. This mega-map encourages the generation and use of rigorous evidence on effective ways to improve child well-being for policy and programming.

Objectives

The aim of this mega-map is to identify, map and provide an overview of the existing evidence synthesis on the interventions aimed at improving child well-being in low- and middle-income countries (LMICs).

Methods

Campbell evidence and gap maps (EGMs) are based on a review of existing mapping standards (Saran & White, 2018) which drew in particular of the approach developed by 3ie (Snilstveit, Vojtkova, Bhavsar, & Gaarder, 2013). As defined in the Campbell EGM guidance paper; "Mega-map is a map of evidence synthesis, that is, systematic reviews, and does not include primary studies" (Campbell Collaboration, 2020). The mega-map on child well-being includes studies with participants aged 0-18 years, conducted in LMICs, and published from year 2000 onwards. The search followed strict inclusion criteria for interventions and outcomes in the domains of health, education, social work and welfare, social protection, environmental health, water supply and sanitation (WASH) and governance. Critical appraisal of included systematic reviews was conducted using "A Measurement Tool to Assess Systematic Reviews"-AMSTAR-2 rating scale (Shea, et al., 2017).

Results

We identified 333 systematic reviews and 23 EGMs. The number of studies being published has increased year-on-year since 2000. However, the distribution of studies across World Bank regions, intervention and outcome categories are uneven. Most systematic reviews examine interventions pertaining to traditional areas of health and education. Systematic reviews in these traditional areas are also the most funded. There is limited evidence in social work and social protection. About 69% (231) of the reviews are assessed to be of low and medium quality. There are evidence gaps with respect to key vulnerable populations, including children with disabilities and those who belong to minority groups.

Conclusion

Although an increasing number of systematic reviews addressing child well-being topics are being published, some clear gaps in the evidence remain in terms of quality of reviews and some interventions and outcome areas. The clear gap is the small number of reviews focusing explicitly on either equity or programmes for disadvantaged groups and those who are discriminated against.

Predictors of unmet need for family planning in Ethiopia 2019: a systematic review and meta analysis

Background

unmet need for family planning is a common cause of uninteded pregnancy which mostly end up with abortion. Many studies were conducted on predictors of unmet need of family planning in Ethiopia. But, up until now, single evidence has not been synthesized and various point prevalence estimates of unmet need for family planning have been reported. Therefore, this sytematic review and meta analysis was established to identify the predictors of unmet need for family planning in Ethiopia.

Methods

search engines including PubMed, Embase, CINAHL, Google Scholar, HINARI portal, and Cochrane Library were used to retrieve included articles and reported using the preferred Reporting Items for Systematic Reviews and Meta-Analyses Protocols (PRISMA) checklist guidelines. Joanna Briggs Institute Meta-Analysis of Statistics Assessment and Review Instrument (JBI-MAStARI) was applied for critical appraisal. All observational studies done on reproductive age women and reported on unmet need for family planning were included. Unmet need for family planning is the percentage of women of reproductive age, either married or in a union, who have an unmet need for family planning to stop or delay childbearing. Random effect model was done to estimate the pooled prevalence of unmet need for family planning. Odds ratio with 95% confidence interval was considered to determine the association of identified variables with unmet need of family planning. Cochran’s Q statistic, Egger’s and Begg’s test were carried out to assess heterogeneity and publication bias.

Results

Fifteen articles and 17, 585 reproductive aged women were included to estimate the pooled prevalence of unmet need for family planning and its predictors in Ethiopia. The prevalence of unmet need for family planning in Ethiopia ranges from 26.52 to 36.39%. Age at first marriage < 18 yrs. with OR = 2.3 (95% CI: 1.08, 4.87), women with no formal education with OR = 1.9 (95%CI: 1.19, 3.04), partner with no formal education with OR = 1.78 (95%CI: 1.18, 2.68) and absence of discussion with their partner about family planning with OR = 3.52 (95%CI, 2.56, 4.87) were predictors of unmet need of family planning in Ethiopia.

Conclusion

This meta analysis revealed that, the prevalence of unmet need for family planning in Ethiopia was high as compared with the United Nations sphere standard of unmet need for planning, considered to be high if it is greater than 25%. Early marriage, no formal eduaction and lack of discussion with partner on family planning were predictors of unmet need for family planning. Therefore, efforts are needed to empower women through eduaction, avoiding early marriage and facilitating dicussion of partners about family planning in order to improve family planning usage.

Nature of, and responses to key sexual and reproductive health challenges for adolescents in urban slums in sub-Saharan Africa: a scoping review

BACKGROUND

Addressing adolescents' sexual and reproductive health and rights (SRHR) requires an understanding of the socio-cultural and spatial settings within which they live. One setting of particular importance is the informal settlements or 'slums' that are gradually dominating the urban space. We undertook a scoping review and synthesis of existing evidence on adolescent SRHR in slums in sub-Saharan Africa (SSA) focusing on the characteristics and nature of existing evidence.

METHODS

The scoping review was conducted based on Arksey and O'Malley framework and in accordance with the guidance on scoping reviews from the Joanna Briggs Institute (JBI) and using PRISMA reporting guidelines for scoping reviews. A comprehensive search was undertaken in PubMed, POPLINE, African Journals Online (AJOL), Bioline International and Google Scholar. The search was confined to studies published in peer reviewed journals and reports published online between January 2000 and May 2019. Studies were included in the review if they addressed SRHR issues among adolescents living in urban slums in SSA.

RESULTS

The review included a total of 54 studies. The majority (79.5%) of studies were quantitative. The bulk of studies (85.2%) were observational studies with only eight intervention studies. While half (27) of the studies focused exclusively on adolescents (10-19 years), 12 studies combined adolescents with other young people (10-24 years). The studies were skewed towards sexual behavior (44%) and HIV/AIDS (43%) with very few studies focusing on other SRHR issues such as contraception, abortion, gender-based violence and sexually transmitted infections (STIs) other than HIV. Most of the studies highlighted the significantly higher risks for poor SRHR outcomes among adolescents in slums as compared to their peers in other settlements.

CONCLUSION

Young people growing up in slums face tremendous challenges in relation to their SRHR needs resulting in poor outcomes such as early and unintended pregnancy, STIs, and sexual violence. The results of this review point to several potential target areas for programming, policy, and research aimed at improved adolescent SRHR in slums in SSA.

Effective educational interventions for the promotion of sexual and reproductive health and rights for school-age children in low- and middle-income countries: a systematic review protocol

BACKGROUND

Biological changes underlying the sexual and reproductive maturation of school-age children are linked with various sexual and reproductive health and rights risks. SRHR risks are predictors of poor SRHR outcomes, such as poor knowledge of sexually transmitted diseases and early sexual initiation occurring predominantly among school-age children. The aim of this proposed review, therefore, is to identify educational interventions that have proven to be effective in promoting or supporting the sexual and reproductive health and rights of school-aged children in low- and middle-income countries.

METHODS

A systematic review of studies on the strategies promoting the SRHR of school-aged children shall be conducted. Electronic searches will be conducted from January 2000 onwards on the following databases: MEDLINE(R) ALL (Ovid), Embase (Ovid), CINAHL (EBSCOHost), APA PsycInfo (Ovid), ERIC (Ovid), Cochrane Central Register of Controlled Trials (Ovid), Education Source (EBSCOHost), Web of Science (Clarivate Analytics), SciELO Citation Index (Clarivate Analytics), Global Health (Ovid), and Sociological Abstract (Proquest). Studies eligible for inclusion will be randomized control trials (RCTs), non-randomized trials, quasi-experimental studies (e.g., pre-post tests), and observational studies (cross-sectional and cohort studies). Peer-reviewed studies published in English and/or French and involving school-aged children 5-10 years old will be included. The primary outcomes of interest will include knowledge, awareness, or attitudes about SRHR topics. The secondary outcomes of interest will include sexual and reproductive behaviors. Two reviewers will independently screen all citations, abstract data, and full-text articles, and the methodological quality of each study will be appraised using JBI critical appraisal tools. A narrative synthesis of extracted data will be conducted.

DISCUSSION

The systematic review will synthesize the evidence on existing educational interventions targeting SRHR outcomes of school-aged children in low- and middle-income countries. It will identify which interventions have proven to be effective, and which interventions have not proven to be effective in promoting or supporting their SRHR. Review findings will provide a useful reference for policy-makers, program developers, global health leaders, and decision makers who wish to support the SRHR of school-age children.

SYSTEMATIC REVIEW REGISTRATION

The protocol has been registered at the International Prospective Register of Systematic Reviews (PROSPERO CRD42020173158).

Developing an SMS text message intervention on sexual and reproductive health with adolescents and youth in Peru

Background

Improved access to sexual and reproductive health (SRH) services and information is essential for supporting adolescents and youth in making informed decisions and optimizing each young person’s outcomes related to their SRH, health and well-being and countries’ current and future social and economic development. Mobile phones offer opportunities for young people to privately access SRH content and to be linked to SRH services. The objective of this study was to develop the content for an SMS (short message service or “text message”) platform jointly with adolescents and youth in three regions in Peru (Lima, Ayacucho and Loreto) as part of the ARMADILLO (Adolescent/Youth Reproductive Mobile Access and Delivery Initiative for Love and Life Outcomes) Study.

Methods

Content development was done in three stages. During Stage 1, we held community consultations with 13–17 year old adolescents, 18–24 year old youth and professionals who work with young people through the education and health sectors (“adult advisers”) to identify and rate SRH topics of interest through group free- and guided-brainstorming activities and an individual written sharing activity. During Stage 2, the team developed the preliminary domains, sub-domains and content for the SMS platform. During Stage 3, we held focus groups with adolescents to validate the SMS content, including both individual scoring of and group feedback for each SMS. Group feedback asked about their general impressions and understanding and their thoughts about the language and usefulness of the SMS.

Results

A total of 172 adolescents and youth ages 13–24 and 20 adult advisers participated. Adolescents and youth brainstormed and rated SRH topics and sub-topics that led to the initial structure for the SMS platform, with 9 domains, 25 sub-domains and 146 draft SMS. Adolescents provided high scores for the SMS, with all sub-domains receiving average scores of 3.0 or higher (out of 4.0) for the SMS included. Adolescents also provided suggestions to optimize content, including improvements to unclear messages, resulting in SMS with adolescent-friendly content in simple, straightforward language. This process also revealed that adolescents lacked knowledge and had misconceptions related to contraceptive methods.

Conclusion

This study details the systematic process used to develop relevant and accessible SRH information through a participatory approach. We document critical information about what young people know and how they think, enabling us to understand their perspective and literally speak their language. Results also provide future directions for programmatic, research and policy efforts with young people, in particular around gender norms, interpersonal violence, and access to SRH information and services, in similar settings.

Association between interpregnancy interval and subsequent stillbirth in 58 low-income and middle-income countries: a retrospective analysis using Demographic and Health Surveys

BACKGROUND

About 3 million stillbirths occur each year, 98% of which are in low-income and middle-income countries (LMICs). Interpregnancy interval is a key risk factor of interest, because it is modifiable. We aimed to investigate whether there is a causal relationship between the length of interpregnancy interval and risk of subsequent stillbirth.

METHODS

We used Demographic and Health Surveys (2002-18) from 58 LMICs to study reproductive histories of women and to identify livebirths and stillbirths in the preceding 5 years. Countries were selected on the basis of the availability of interpregnancy interval data and other covariates of interest (age, education, urban or rural residence, and wealth) in surveys done since 2002. Exclusion criteria were being nulliparous, having missing parity data, and not having had at least two births (livebirth or stillbirth) in the 5 years before the survey. We combined two analytic approaches: one that analyses intervals between all births and another that analyses intervals within mothers. We report stratified estimates for the first, second, and third intervals, controlling for all past birth outcomes and intervals in a 5-year period, and other socioeconomic covariates. We also explored effect heterogeneity across key cohort subgroups.

FINDINGS

Between July, 1997, and April, 2018, we identified 716 478 births from 338 223 women in 123 Demographic and Health Surveys from 58 LMICs, of which 9647 were stillbirths. Intervals of less than 6 months were associated with an increased risk of stillbirth in the between-mother models when considering the first interval (risk difference [RD] 0·0096, 95% CI 0·008-0·011). This association was slightly attenuated when considering only the second interval (RD 0·0054, 95% CI 0·0010 to 0·0099) and substantially attenuated when considering only the third interval (0·0007, -0·037 to 0·039). Within-mother modelling showed a null association with intervals of 24-59 months when considering the first and second (RD 0·007, 95% CI -0·001 to 0·016) and first and third (0·040, -0·422 to 0·501) intervals.

INTERPRETATION

Although interpregnancy intervals of less than 12 months were associated with increased risk of stillbirth, these effects were attenuated when considering second and third intervals, suggesting the association in the first interval might not be causal. Future studies should use generalisable cohorts with longitudinal data, and report estimates stratified by birth order.

FUNDING

Canadian Institutes of Health Research.

Postpartum and post-abortion contraceptive use among unmarried young women in Ghana

Pregnancy outcomes impact subsequent contraceptive behaviour. The purpose of this study was to assess the relationship between previous pregnancy outcomes and subsequent contraceptive behaviours among unmarried young women intending to delay childbearing. Using data from the 2014 Ghana Demographic and Health Survey, among 1118 sexually experienced, fecund and non-pregnant unmarried women aged 15-24 years, the study assessed how childbirth and abortion are related to sexual abstinence and use of modern contraception. While about 70% of unmarried young women were nulligravid, approximately 11% had had an abortion and 18.2% were postpartum. The majority of respondents were sexually abstinent while 21% and 27% were using and not using contraception, respectively. Postpartum women were more likely than nulligravid and post-abortion women to use contraceptives. Post-abortion women were least likely to be sexually abstinent. Number of years since the respondent's sexual debut was positively associated with the likelihood of using modern contraception, particularly among postpartum women, and negatively associated with sexual abstinence among those who had aborted. The findings show that prior pregnancy outcomes have significant implications for secondary abstinence and contraceptive use among unmarried young women in Ghana. Post-abortion women are more likely than postpartum women to be sexually active but less likely to use contraceptives. Efforts must be strengthened towards increasing access to modern contraceptives for young women who present for abortion in Ghana.

Improving access to and use of contraception by adolescents: What progress has been made, what lessons have been learnt, and what are the implications for action?

This article sets out the progress that has been made in reducing levels of adolescent childbearing and in meeting adolescent contraceptive needs, over the last 25 years, and also makes the public health, economic, and human rights rationale for continued attention to and investment in these areas. Using an analytic framework that covers the perspectives of both the use and the provision of contraception, it examines the factors that make it difficult for adolescents to obtain and use contraceptives to avoid unintended pregnancies, and outlines what could be done to address these factors, drawing from research evidence and programmatic experience. In doing this, the article provides concrete examples from low- and middle-countries that have made tangible progress in these areas.

A systematic review of sexual and reproductive health interventions for young people in humanitarian and lower-and-middle-income country settings

Background

Accessibility of sexual and reproductive health (SRH) services in many lower-and-middle-income countries (LMICs) and humanitarian settings remains limited, particularly for young people. Young people facing humanitarian crises are also at higher risk for mental health problems, which can further exacerbate poor SRH outcomes. This review aimed to explore, describe and evaluate SRH interventions for young people in LMIC and humanitarian settings to better understand both SRH and psychosocial components of interventions that demonstrate effectiveness for improving SRH outcomes.

Methods

We conducted a systematic review of studies examining interventions to improve SRH in young people in LMIC and humanitarian settings following Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) standards for systematic reviews. Peer-reviewed journals and grey literature from January 1, 2000 to December 31, 2018 were included. Two authors performed title, abstract and full-text screening independently. Data was extracted and analyzed using a narrative synthesis approach and the practice-wise clinical coding system.

Results

The search yielded 813 results, of which 55 met inclusion criteria for full-text screening and thematic analysis. Primary SRH outcomes of effective interventions included: contraception and condom use skills, HIV/STI prevention/education, SRH knowledge/education, gender-based violence education and sexual self-efficacy. Common psychosocial intervention components included: assertiveness training, communication skills, and problem-solving.

Conclusions

Findings suggest that several evidence-based SRH interventions may be effective for young people in humanitarian and LMIC settings. Studies that use double blind designs, include fidelity monitoring, and focus on implementation and sustainability are needed to further contribute to this evidence-base.

Peer Support for Adolescents and Young People Living with HIV in sub-Saharan Africa: Emerging Insights and a Methodological Agenda

PURPOSE

Despite clear need and disproportionate risk, adolescents, and young people living with HIV (AYPLHIV) are underserved within the HIV response. "Peer support" increasingly forms part of adolescent and youth-responsive service packages as a class of implementation strategies that can support adolescents to access, engage, and sustain treatment. This paper examines examples of peer support for AYPLHIV within sub-saharan Africa to explore the determinants of successful implementation, outcomes and scale-up, as well as policy and programmatic implications.

RECENT FINDINGS

Although adolescent peer support has been observed to be widely implemented, there are few examples of detailed program descriptions describing operational logistics or outcomes around peer support interventions. Nevertheless the few examples available provide preliminary support for the potential utility of peer support to improve AYPLHIV outcomes. Implementation science research is an urgent imperative to examine applicability of peer support for this priority population. In the meantime, programs should move forward with implementation based on promising outcomes, programmatic experience, contextual understanding of challenges and gaps, and best practice examples.

The impact of the Adolescent Girls Empowerment Program (AGEP) on short and long term social, economic, education and fertility outcomes: a cluster randomized controlled trial in Zambia

BACKGROUND

Adolescent girls in Zambia face risks and vulnerabilities that challenge their healthy development into young women: early marriage and childbearing, sexual and gender-based violence, unintended pregnancy and HIV. The Adolescent Girls Empowerment Program (AGEP) was designed to address these challenges by building girls' social, health and economic assets in the short term and improving sexual behavior, early marriage, pregnancy and education in the longer term. The two-year intervention included weekly, mentor-led, girls group meetings on health, life skills and financial education. Additional intervention components included a health voucher redeemable for general wellness and reproductive health services and an adolescent-friendly savings account.

METHODS

A cluster-randomized-controlled trial with longitudinal observations evaluated the impact of AGEP on key indicators immediately and two years after program end. Baseline data were collected from never-married adolescent girls in 120 intervention clusters (3515 girls) and 40 control clusters (1146 girls) and again two and four years later. An intent-to-treat analysis assessed the impact of AGEP on girls' social, health and economic assets, sexual behaviors, education and fertility outcomes. A treatment-on-the-treated analysis using two-stage, instrumental variables regression was also conducted to assess program impact for those who participated.

RESULTS

The intervention had modest, positive impacts on sexual and reproductive health knowledge after two and four years, financial literacy after two years, savings behavior after two and four years, self-efficacy after four years and transactional sex after two and four years. There was no effect of AGEP on the primary education or fertility outcomes, nor on norms regarding gender equity, acceptability of intimate partner violence and HIV knowledge.

CONCLUSIONS

Although the intervention led to sustained change in a small number of individual outcomes, overall, the intervention did not lead to girls acquiring a comprehensive set of social, health and economic assets, or change their educational and fertility outcomes. It is important to explore additional interventions that may be needed for the most vulnerable girls, particularly those that address household economic conditions. Additional attention should be given to the social and economic environment in which girls are living.

TRIAL REGISTRATION

ISRCTN29322231. Trial Registration Date: March 04, 2016; retrospectively registered.

Effects of Preconception Care and Periconception Interventions on Maternal Nutritional Status and Birth Outcomes in Low- and Middle-Income Countries: A Systematic Review

Pregnancy in adolescence and malnutrition are common challenges in low- and middle-income countries (LMICs), and are associated with many complications and comorbidities. The preconception period is an ideal period for intervention as a preventative tactic for teenage pregnancy, and to increase micronutrient supplementation prior to conception. Over twenty databases and websites were searched and 45 randomized controlled trials (RCTs) or quasi-experimental interventions with intent to delay the age at first pregnancy (n = 26), to optimize inter-pregnancy intervals (n = 4), and supplementation of folic acid (n = 5) or a combination of iron and folic acid (n = 10) during the periconception period were included. The review found that educational interventions to delay the age at first pregnancy and optimizing inter-pregnancy intervals significantly improved the uptake of contraception use (RR = 1.71, 95% CI = 1.42-2.05; two studies, n = 911; I2 = 0%) and (RR = 2.25, 95% CI = 1.29-3.93; one study, n = 338), respectively. For periconceptional folic acid supplementation, the incidence of neural tube defects were reduced (RR = 0.53; 95% CI = 0.41-0.77; two studies, n = 248,056; I2 = 0%), and iron-folic acid supplementation improved the rates of anemia (RR = 0.66, 95% CI = 0.53-0.81; six studies; n = 3430, I2 = 88%), particularly when supplemented weekly and in a school setting. Notwithstanding the findings, more robust RCTs are required from LMICs to further support the evidence.