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TYPE Opinion
PUBLISHED 02 December 2022
DOI 10.3389/frph.2022.984303

Adolescent pregnancy in
sub-Saharan Africa – a cause
EDITED BY
Samanta Tresha Lalla-Edward,
Ezintsha, a division of the Wits Health
for concern
Consortium, South Africa

REVIEWED BY
Niren Ray Maharaj*
Nomathemba Chandiwana, Department of Obstetrics and Gynaecology, University of KwaZulu-Natal, Durban, South Africa
University of the Witwatersrand, South Africa

*CORRESPONDENCE KEYWORDS
Niren Ray Maharaj
adolescents, sexually transmitted infections, HIV, contraception, pregnancy
obgyn80@gmail.com

SPECIALTY SECTION
This article was submitted to HIV and STIs, a
section of the journal Frontiers in Reproductive
Introduction
Health

RECEIVED 01 July 2022

It is estimated that adolescent girls in low- and middle-income countries (LMICs)
ACCEPTED 15 November 2022 have approximately 21 million pregnancies each year (1). Adolescent pregnancy,
PUBLISHED 02 December 2022 which occurs amongst adolescent girls aged between 10 and 19 years, is associated
CITATION with various public health concerns and increased risks of maternal mortality, low
Maharaj NR (2022) Adolescent pregnancy in birthweight, and other severe neonatal complications (2). They also have an
sub-Saharan Africa – a cause for concern.
unfavourable impact on the mental, physical, and social wellbeing of adolescents, and
Front. Reprod. Health 4:984303.
doi: 10.3389/frph.2022.984303 remain a leading cause of death among adolescent girls globally (2).
COPYRIGHT
Although a decline in adolescent birth rates (ABR) has been observed globally, sub-
© 2022 Maharaj. This is an open-access article Saharan Africa (SSA) continues to have twice the global average, with over 100 births per
distributed under the terms of the Creative 1,000 women, in 2021 (3). The estimated actual number of births among 15–19-year-
Commons Attribution License (CC BY). The use,
distribution or reproduction in other forums is olds was 6 114 000 and 332 000 among younger adolescents aged 10–14 years in SSA
permitted, provided the original author(s) and in 2021 (3). Africa has a higher proportion of youth compared to any other
the copyright owner(s) are credited and that the
continent; and adolescent pregnancy rates are therefore likely to increase further in
original publication in this journal is cited, in
accordance with accepted academic practice. countries in SSA (4). Adolescent pregnancies are therefore a significant health
No use, distribution or reproduction is concern and have been recognised as a key objective in the United Nations
permitted which does not comply with these
terms. Sustainable Development Goals (SDGs) (5). The contributing factors for high ABR in
SSA are heterogenous and differ amongst countries in SSA. Existing data on the
contributing factors for adolescent pregnancies in SSA emanate from country specific
studies and collective data is limited. However, a few studies that combined data from
single country studies on the determinants of adolescent pregnancy have been
conducted (6–8). Collectively, these studies suggest that inter alia, socio economic
status, lack of parental communication and support, early marriage, religion, and low
educational status of adolescents are contributing factors.

Economic, sociocultural, and environmental factors

Poverty is generally considered as an indicator of the economic status of a country.

Studies from Ghana (9), South Africa (10) and Tanzania (11) demonstrate the
relationship between poverty and coerced sexual relations with older men, as a means
for adolescents to meet their basic financial needs. Adolescent girls may also become
pregnant intentionally to receive government support grants intended for teenage
mothers, without considering the consequences of their actions (12). Nigeria, the

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Maharaj 10.3389/frph.2022.984303

country with the largest economy in Africa had an adolescent is in violation of the country’s national law, as well as
pregnancy rate of 106 adolescent births per 1,000 population regional and international instruments to which this country
in 2021 and shows an increasing trend (13). In South Africa is a party (24).
(SA), which has the second largest economy in Africa, the
ABR is also high (14). In SA, the lack of adequate
reproductive health services and appropriate sexuality Individual factors
education are part of the composite etiology that contributes
to increasing ABR’s (15). Between 2017 and 2021, births Individual perceptions about abstinence from sexual
among girls aged 10–14 years and 15–19 years increased in intercourse, early sexual debut, and negative perceptions about
SA by 48.7% and 17.9% respectively, and are likely to increase contraceptive usage among adolescents may contribute to
(16). In contrast, in Burundi, which has the lowest gross adolescent pregnancies. Sexual coercion, low or incorrect use
domestic product per capita in Africa (17), the adolescent of contraceptives, and low self-esteem have also been
fertility rate (births per 1,000 women ages 15–19) was 58/ suggested as contributing factors (6–8). Other personal factors
1,000 compared with the total fertility rate of 5.5/1,000 may include stigma, fear of negative attitudes from parents
women in that country (18). These comparisons suggest that and elders in the community and discrimination by
the economic status of countries in Africa remains part of a healthcare providers. It has been suggested that healthcare
composite etiology, which may also include power imbalances, providers may not appreciate the fears of adolescents
gender-based violence, substance abuse, lack of access to regarding contraception or reproductive health issues, and
termination of pregnancy services, negative attitudes of adolescents themselves may not appreciate comprehensive
caregivers and inadequate reproductive health education. sexuality education (10). Adolescents may also perceive
It has also been suggested that lower levels of education may contraceptive usage as a reserve for married couples, thereby
be associated with adolescent pregnancies. In Niger, Mali, and contributing to low contraceptive uptake and resultant
Chad, where the adolescent fertility rates are amongst the pregnancies (10). Additionally, a lack of awareness,
highest in the world, the expected years of schooling attained misconceptions and poor knowledge about the range and use
by girls between the ages of 4 and 17 is fewer than seven of contraceptive methods exists amongst some adolescents
years (2). On the contrary, other studies suggest that higher (25). Alternatively, some adolescents may desire pregnancy
levels of education are likely to be associated with a lower despite a suitable knowledge and available access to
likelihood of having a first adolescent pregnancy, particularly contraception. Career plans may also be affected, and poorly
in SSA (4, 7). Adolescents with higher levels of education are educated, unemployed and grant dependent youngsters pose
more likely to delay the onset of sexual relations and an economic burden on the fiscus in the long term.
marriage; and are more informed about their rights,
reproductive health, timing of marriage and pregnancy (19).
Child marriages are also implicated as a contributing cause Health related factors
for high ABR’s in SSA, particularly in the Congo and Central
Africa (20). The Congo has one of highest rates of child Teenagers may also face challenges in accessing
marriage globally, with one in three girls married before age reproductive health care in their communities. In some rural
18, and 7% married before the age of 15 (20). Similarly, other areas, the sparsity of clinics, long distances, and lack of
studies have also shown an association between child marriage transport may present barriers to access to reproductive health
and adolescent pregnancy in African countries (21, 22). Most services. Judgemental attitudes of staff, particularly to
girls who experience child marriage have low levels of teenagers seeking contraception or termination of pregnancy
education, live in poor households and often in rural areas, services should be avoided. Poor staff attitudes at termination
increasing their odds of engaging in behaviours that put them of pregnancy clinics, may drive teenagers to seek “back street”
at risk of pregnancy (23). Data also suggests the association of terminations, with potential morbidity and even mortality.
child marriages with first pregnancy among adolescent girls in The Covid epidemic may have exacerbated the problem
SSA (6). Pregnancies in these marriages may occur because of further, with resultant school closures and access to
pressure from partners or family members to start families contraception and healthcare services being unavailable or
earlier or to prove reproductive potential. In most sub- restricted during this period. A lock down of recreational,
Saharan African countries, adolescent girls may face social sporting, and other youth activities that keep youngsters
pressure to marry and, once married, to have children (4). In occupied may also be a contributing factor. During the Covid
parts of South Africa, cultural practices like “ukuthwala” also period, secondary school girls in rural western Kenya were
lead to adolescent pregnancies. This practice involves the more likely to be sexually active, less likely to report their first
arranged marriage of girls below the age 18 mostly to older sexual encounter, and reported increased hours of non-
men, without the bride’s consent (24). This type of marriage school-related work (26). Higher rates of teenage pregnancies

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Maharaj 10.3389/frph.2022.984303

were also seen in SA in the past 2 years, possibly in relation to developed and implemented by both governmental and non-
the Covid 19 pandemic (27). governmental organisations (36). In South Africa, the
Unprotected sex, either consensual or resulting from sexual Department of Basic Education (DBE) has announced their
co-ercion and exploitation, predisposes young girls to implementation of comprehensive sexuality education (CSE)
contracting sexually transmitted infections and HIV. Evidence program in schools, which aims to empower young people
shows that adolescent girls and young women have the with age-appropriate information about the cognitive,
highest rate of acquisition of HIV currently (28). Most emotional, physical and social aspects of sexuality (37).
teenage pregnancies are unplanned and often concealed, and In Uganda, the Ministry of Education published revised
not only have a disruptive effect on the schooling trajectory of guidelines for the prevention and management of teenage
children, but are also associated with complicated pregnancies, pregnancy in school settings, providing a policy to clarify the
difficult labour, challenges with breastfeeding and issues with role of schools in adolescent pregnancies (38). At least 30
the ongoing healthcare of the baby. African Union countries now have laws, policies, and
strategies in place that protect the rights of pregnant students
and adolescent mothers to education (39).
Mapping the way forward Support grants are seen by some as a double edge sword
in preventing teenage pregnancies. Perceptions that some
Bold steps need to be taken and concerted efforts must be recipients do not utilise the grant in the best interest of
made to turn the tide of this trend. There should be a their children exist, and therefore need close monitoring by
consolidation of efforts from various state and non-state authorities. An alternate approach exists in Columbia,
actors to achieve a reduction in ABR’s in SSA and globally. where a conditional cash transfer (CCT) program allows
Data from South Asia, Middle East and North Africa adolescent girls to receive a subsidy if they attended school,
indicates that ABR’s dropped by between 75% and 80% by complete their school year, and enrol in the following year.
2019 and continues to show a consistent decline (2). Activities This initiative was also effective in reducing pregnancy
that have proven to be effective in reducing adolescent among adolescents across all grades included in the
pregnancy include the implementation of sexual and program (40).
reproductive health policies, educational and vocational A paradigm shift is required in the behaviour and attitude
programs, empowerment initiatives, training activities, school amongst teenagers themselves, supported by collective efforts
retention programs and behaviour change campaigns (29). from parents, teachers, healthcare providers and policy makers.
Lessons can also be learnt from other countries which have Policymakers and community organisations should work in
had some success in reducing their ABR. In the Dominican unison to develop and promote adolescent sexual and
Republic, a soft skills and vocational youth training program reproductive health policies and programmes, and emphasis
was shown to reduce the probability of teenage pregnancy by should also be placed on human rights issues and gender
about 20% after implementation (30). In Mexico, the National empowerment programmes. The attitude of healthcare workers
Strategy for the Prevention of Adolescent Pregnancy should be supportive rather than judgemental, and separate
(ENAPEA), a multisectoral approach is currently in the process facilities should be considered for adolescent reproductive
of implementation to curb this phenomenon (31). In Northern health services. Policy development, implementation strategies
Ireland live births from mothers aged 19 and younger dropped and quality assurance programmes are necessary to reduce
in 2020, largely due to progressive improvements in access to adolescent pregnancies and meet the objectives of the United
contraception and sexual education (32), and in the US the Nations Sustainable Development Goals (SDGs) (5).
overall birth rate among 15- to 19-year-old girls dropped to
half of what it had been in 2008 following various initiatives (33).
Similarly, many countries in SSA have developed and
implemented national policies and programmes aimed at
Author contributions
dealing with adolescent sexual and reproductive health
The author confirms being the sole contributor of this work
(ASRH), including adolescent pregnancy (34).
and has approved it for publication.
In Ghana, the adolescent fertility rate declined steadily, and
the country has also made progress in decreasing the rates of
child marriage and school dropouts of girls (2). One of the
key national policies for reducing adolescent pregnancy in Conflict of interest
Ghana is their Adolescent Health Service Policy and Strategy,
which focuses on mainstreaming ASRH information, and The author declares that the research was conducted in the
gender-sensitive and responsive health services (35). These absence of any commercial or financial relationships that could
national policies coexist with programmes which are be construed as a potential conflict of interest.

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Maharaj 10.3389/frph.2022.984303

Publisher’s note affiliated organizations, or those of the publisher, the editors

and the reviewers. Any product that may be evaluated in this
All claims expressed in this article are solely those of the article, or claim that may be made by its manufacturer, is not
authors and do not necessarily represent those of their guaranteed or endorsed by the publisher.

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