Yakubu and Salisu Reproductive Health (2018) 15:15

DOI 10.1186/s12978-018-0460-4

R E V I E WOpen Access

Determinants of adolescent pregnancy in sub-Saharan Africa: a systematic review

Ibrahim Yakubu1* and Waliu Jawula Salisu2

Abstract

Background: Adolescent pregnancy has been persistently high in sub-Saharan Africa. The objective of this review is to identify factors influencing adolescent pregnancies in sub-Saharan Africa in order to design appropriate intervention program.

Methods: A search in MEDLINE, Scopus, Web of science, and Google Scholar databases with the following keywords: determinants, factors, reasons, sociocultural factors, adolescent pregnancy, unintended pregnancies, and sub- Saharan Africa. Qualitative and cross-sectional studies intended to assess factors influencing adolescent pregnancies as the primary outcome variable in sub- Saharan Africa were included. Our search was limited to, articles published from the year 2000 to 2017 in English. Twenty-four (24) original articles met the inclusion criteria.

Results: The study identified Sociocultural, environmental and Economic factors (Peer influence, unwanted sexual advances from adult males, coercive sexual relations, unequal gender power relations, poverty, religion, early marriage, lack of parental counseling and guidance, parental neglect, absence of affordable or free education, lack of comprehensive sexuality education, non-use of contraceptives, male’s responsibility to buy condoms, early sexual debut and inappropriate forms of recreation). Individual factors (excessive use of alcohol, substance abuse, educational status, low self-esteem, and inability to resist sexual temptation, curiosity, and cell phone usage). Health service-related factors (cost of contraceptives, Inadequate and unskilled health workers, long waiting time and lack of privacy at clinics, lack of comprehensive sexuality education, misconceptions about contraceptives, and non-friendly adolescent reproductive services,) as influencing adolescent pregnancies in Sub-Saharan Africa

Conclusion: High levels of adolescent pregnancies in Sub-Saharan Africa is attributable to multiple factors. Our study, however, categorized these factors into three major themes; sociocultural and economic, individual, and health service related factors as influencing adolescent pregnancies. Community sensitization, comprehensive sexuality education and ensuring girls enroll and stay in schools could reduce adolescent pregnancy rates. Also, provision of adolescent-friendly health services in schools and healthcare centers and initiating adolescent empowerment programs could have a positive impact.

Keywords: Adolescent pregnancy, Determinants, Sub-Saharan Africa

Plain English summary

Adolescent pregnancies have been persistently high in sub-Saharan Africa. This study seeks to identify factors influen-cing adolescent pregnancies in sub-Saharan Africa through a systematic review of published scientific articles.

A total of two hundred and twenty nine (229) original articles published between 2000 and 2017 were first identified from various data bases. Finally, twenty-four

* Correspondence: [email protected]

1School of Public Health, Tehran University of Medical Sciences, International Campus, Tehran, Iran

Full list of author information is available at the end of the article

(24) original articles met the inclusion criteria and were included in the study. All articles were studies con-ducted in sub-Saharan Africa.

The study identified Sociocultural, environmental and Economic factors (Peer influence, unwanted sexual advances from adult males, coercive sexual relations, unequal gender power relations, poverty, religion, early marriage, lack of parental counseling and guidance, par-ental neglect, absence of affordable or free education, lack of comprehensive sexuality education, non-use of contraceptives, male’s responsibility to buy condoms,

© The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

Yakubu and Salisu Reproductive Health (2018) 15:15Page 2 of 11

early sexual debut and inappropriate forms of recre-ation). Individual factors (excessive use of alcohol, sub-stance abuse, educational status, low self-esteem, and inability to resist sexual temptation, curiosity, and cell phone usage). Health service-related factors (cost of contraceptives, Inadequate and unskilled health workers, long waiting time and lack of privacy at clinics, lack of comprehensive sexuality education, misconceptions about contraceptives, and non-friendly adolescent repro-ductive services,) as influencing adolescent pregnancies in Sub-Saharan Africa.

We believe that Community sensitization, sex educa-tion and ensuring girls enrol and stay in schools could reduce adolescent pregnancy rates. Also, provision of adolescent friendly health services at schools and initiat-ing adolescent empowerment programs could have positive impact.

Background

The long-lived belief in the African society where females were not prioritized for education is fading out. With this, it expected that female education will increase in sub-Saharan Africa [1]. Unfortunately, adolescent pregnancy contributes to denying brilliant students edu-cation and has potential to retard their growth and development including that of their children.

According to WHO about 17 million adolescent girls give birth every year and most of these births occur in low- and middle-income countries [2]. Adolescent health and development are of global concern. The need to prevent early pregnancy among adolescent girls in Sub-Saharan Africa has been recognized increasingly over re-cent years [3]. African countries lead the world in teen pregnancies: With Niger on the top list of 203.604 births per 100,000 teenage women. Mali follows with 175.4438, Angola (166.6028), Mozambique (142.5334), Guinea (141.6722), Chad (137.173), Malawi (136.972), and Cote d’Ivoire (135.464) [4].

Adolescent girls continue to experience the dispropor-tionately high burden of sexual and reproductive ill health, particularly in Sub-Saharan Africa [3]. High ado-lescent pregnancies with adverse health and social consequences are urgent problems facing low- and middle-income countries [2]. Adolescents are likely to have complications of pregnancy including unsafe abor-tion and more likely to become young mothers a second time [2, 5, 6]. Their infants are also more likely to be born premature and to die in the perinatal period [7]. Babies born to adolescent mothers face a substantially higher risk of dying than those born to women aged 20 to 24 [2, 5, 8]. They are at risk of malnutrition, low men-tal and physical development, inappropriate social connection with parents and poor education [5, 9].

Adolescents develop psychological problems from social stigma, suffer physical and domestic violence in their attempt to meet the demands of pregnancy and childbearing [9, 10]. Also, they most likely would drop out and may not get the chance to return to school [11]. The inadequate resources of low and middle-income countries would have to be channeled to cater for the health needs of pregnant and teen mothers including their children [5]. Economic opportunities are limited to adolescents who could not complete school because of unintended pregnancies. This could be the beginning of a poverty cycle in families, however, some are able to face the challenge and become productive later in life.

Factors associated with unintended pregnancies amongst adolescents are early marriages, culture, religion, gender [12], poor social and economic support [13, 14]. Curiosity and peer pressure [15, 16], lack of comprehensive sexuality education [17–19], poor reproductive health services provision [19, 20], poor attitude of health workers to pro-viding contraceptive services for adolescents [15, 21]. Also, unmet need for contraceptives by adolescents [22] and fear of contraceptive side effects [16]. Barriers to contraceptive use among adolescents include inadequate sexual know-ledge and risk perceptions. Also, lack of skills and power to negotiate safer sex options, ambivalence towards sex, and negative social norms around premarital sexual activity and pregnancy [23].

Policy makers in Sub-Saharan Africa need to understand the determinants of adolescent pregnancy in their context in order to design pragmatic interventional programs to reduce unintended pregnancies amongst adolescents. Since there has not been any review of literature on the determinants of adolescent pregnancy in Sub-Saharan Africa, this study aims to identify the determinants of high adolescent pregnancy in Sub-Saharan Africa.

Methods

Search strategy

MEDLINE, Scopus, web of science and Google Scholar databases were searched in July 2017 with the following keywords: determinants, factors, reasons, sociocultural factors, adolescent pregnancy, unintended pregnancies, and sub- Saharan Africa. Qualitative and cross-sectional studies intended to assess the factors influencing adoles-cent pregnancies either intended or unintended as the primary outcome variable in sub- Saharan Africa was included. Our search was limited to articles published in English from 2000 to 2017.

Inclusion and exclusion criteria

Qualitative and cross-sectional studies that assessed the factors associated with adolescent pregnancy, conducted in sub-Saharan Africa, whether the pregnancy was intended or not, from the year 2000 to 2017 were

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included. Studies that addressed factors associated with adolescent pregnancy, yet conducted outside Sub-Saharan Africa were excluded from the study.

Identification of reviews

A search framework was constructed and implemented through a broad scope and exhaustive search using Tehran University of Medical Sciences electronic library to identify applicable studies published in English. The search identified a total of 229 articles, which composed of 244 original research articles and 5 review articles. After the screening of titles and abstracts, 54 articles were excluded because they did not address adolescent pregnancy. Articles that addressed adolescent pregnancy were 170 and 5 reviews. All the review articles were excluded because 3 were conducted outside the study setting, and the other 2 did not assess the determinants of adolescent pregnancy. With the rest of the articles, 40 did not assess determinants of adolescent pregnancy, 16 were conducted before the year 2000, 56 were not full text and 34 were duplicated. Therefore, 24 research articles were sieved and included in the study. Figure 1 demonstrates articles selection criterion.

Variables assessed

The main variables assessed were age, lack of money, lack of family support, the culture of not talking about sex at home, peer influence, broken homes, early mar-riages, and religion. Service-related factors such as lack of adolescent-friendly services, inadequate comprehen-sive sexuality education, non-availability and cost of con-traceptives, inadequate health personnel, judgmental attitude of service providers and inadequate counseling. Personal behavioral factors such as alcohol and tobacco use, fear of stigma and being judged by the service pro-vider, low self-efficacy, low self-esteem, vulnerability and

rape, curiosity, inadequate education and knowledge about contraceptives.

Articles appraisal

The Joanna Briggs appraisal tool [24] was used inde-pendently by the authors to appraise and certify for in-clusion or exclusion of articles. Both authors, before inclusion, reached consensus. The tool consists of a checklist of ten questions for qualitative studies, eight for cross-sectional studies and 11 for systematic reviews and research syntheses.

Strengths of the study

The study has revealed, through a comprehensive search the determinants of adolescent pregnancy in Sub-Saharan Africa. The results of the study are similar to global reports [25]. In addition, the study revealed a gap in research regarding lit-erature on determinants of adolescent pregnancy in the five sub-Saharan Africa countries with the highest rates [4].

Weaknesses of the study

Diverse disciplines deal with adolescents and adolescent pregnancies; this makes it possible to miss some articles during the search process since their findings may not be published in scientific based journals which were our main source of data. Secondly, grey literature, reports, and unpub-lished studies were not included in this review. In addition, some articles reported findings from small sample sizes.

Operational definition of concepts

Adolescent reproductive services

Healthcare services offered to assist adolescents access sexual and reproductive health information.

		5 review			5 review articles excluded
A total of 229
		articles			3 not in Africa
original articles
					2 not measured
were identified
					the outcome of
		224 original			interest
		articles

24 original articles included

200articles excluded

								54 articles were
						40 articles not
								excluded through
34 duplicated		56 articles		16articles		measured the
								abstract and title
articles were		were not full		conducted		outcome of
								screening
excluded		text		before 2000		interest

Fig. 1 Inclusion and exclusion criteria

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Comprehensive sexuality education	Sexual advances
Teaching abstinence as the best method for avoiding un-	Purposeful visual, verbal or physical conduct of a sexual
intended pregnancy, but also teaching about condoms	nature.
and contraception to reduce the risk of unintended preg-
nancy. It also involves empowering adolescents to resist	Substance abuse
sexual temptations and peer pressure.
	Excessive and uncontrolled use of illicit and addictive
Curiosity	substances such as tobacco, marijuana.
A strong desire to discover new things, especially about	Results
sex and relationships.
	Articles included in this review were studies conducted
Early marriage	in Sub-Saharan African countries with a focus on adoles-
	cent pregnancies.
Union between two people in which one or both parties
	Out of 24	articles, eight (8) were qualitative re-
are younger than 18 years of age:
	search [19, 23, 26–31], 15 were cross-sectional studies
Early sexual debut	[15, 32–45], and one article used mixed method [46]
	(Table 1).
Having had first sexual intercourse at or before age 14.
	Participants in this study were mostly adolescents. The
Excessive use of alcohol	study settings	were	both rural and urban, with an
	approximated	total	population of 11,651 participants.
Uncontrolled and widespread alcohol usage.
	Participants per study varied from 10 as the least to
Family dysfunction	3122 as the highest. Refer to Table 2 for a detailed de-
	scription of participant’s characteristics.
Unhealthy interactions, conflict, misbehaviour, and child	At least 12	key	informants composed of parents,
neglect of parents.
	school teachers, health providers, and adolescent
Gender power relations	mothers/fathers were involved in some of the included
	studies. They provided information regarding some of
The culturally determined social status of men and	the determinants of adolescent pregnancy.
women in relationships.	It is interesting to note that there is no published data
	within this review years from the top five sub-Saharan
Inability to resist sexual temptation	African countries with adolescent pregnancy above 140
Inability to avoid or say no to sexual desires and pres-	births per 100,000 adolescents [47].
sure from both internal and external sources, and acting	The study revealed three major themes influencing
on it.	adolescent pregnancy in sub-Saharan Africa: Sociocul-
	tural, environmental and Economic, Individual, and
Inappropriate recreation	Health-Related Factors.
Recreational activities, which creates a risky sexual en-
vironment e.g. disco dances, clubbing etc.	Sociocultural, environmental and economic factors
Low self-esteem	Peer influence was reported by 11 studies [15, 23, 26, 31,
	34–36, 39, 41, 45, 46], Unwanted sexual advances from
Lacking self-confidence to turn down sexual advances	adult males which often led to coercive sexual relations
from men.
	[19, 28, 31, 35]. Also, unequal gender power relations
Peer influence	[19, 27, 28, 30, 31, 35, 38, 39], poverty [19, 23, 26, 28,
	31–34, 36, 38, 41, 45], religion and early marriage [28,
Social pressure by members of one’s peer group to take	39, 40]. In addition, lack of parental counseling and
a certain action, adopt certain values, or otherwise con-	guidance, severe family dysfunction with parental neglect
form in order to be accepted.	[23, 26, 31, 33–37, 40, 41, 45, 46]. The absence of afford-
	able or free education [41]. Lack of comprehensive sexu-
Positive attitude towards early sexual relationships	ality education, both in schools and at home with family
Having a good feeling or emotion towards early sexual	members [15, 19, 23, 26, 29, 31, 32, 34, 36, 37, 41, 45,
relationships.	46]. Lack of knowledge, misconceptions, and non-use of
	contraceptives [19, 23, 29, 30, 35, 38, 40, 44, 45], male’s
Religion	responsibility to buy condoms [23]. Positive attitude
A system of faith and worship.	towards early	sexual relationships, and early sexual

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Table 1 Main determinants of unintended pregnancy amongst adolescents

Title	Year/country	Study type	Determinants of adolescent pregnancy
Understanding sexual and reproductive health	2015 Uganda	Qualitative study	Sexual advances from adult males, rape, defilement,
needs of adolescents: evidence from a formative			alcohol, marijuana, lack of youth counsellors, lack of
evaluation in Wakiso district, Uganda			sex education, inadequate education on family
			planning, cost of contraceptives, inadequate health
			workers and fear of stigma in seeking help form
			health workers.
Barriers to access reproductive healthcare for	2015 Tanzania	Qualitative study	They viewed condoms as ineffective for preventing
pregnant adolescent girls: a qualitative study			STIs and pregnancies and unnecessary for those in
in Tanzania			committed relationships. Stigma and long waiting
			times. Lack of privacy in the clinics discouraged
			young females from seeking reproductive healthcare,
			lack of privacy, unkind health care workers
Relationship dynamics and teenage pregnancy	2001 south Africa	Exploratory study	Forced sexual initiation, unwillingness to confront
in South Africa			unfaithful partner, partners of adolescents were
			older, unequal power relations, living in extended
			family, non-use of contraceptives, peer influence,
			and curiosity.
Who’s that girl? A qualitative analysis of	2016 Ghana.	Qualitative study	Material gain, positive attitude towards relationship,
adolescent girls’ views on factors associated			early sexual debut, peer influence, most parents
with teenage pregnancies in Bolgatanga, Ghana			don’t talk about safe sex with their children, male
			should be responsible to buy condoms, fear of
			ridicule, misconceptions about family planning,
			inability to resist temptation,
Gendered norms, sexual exploitation and	2013, Tanzania	Qualitative study	Poverty, inability to exercise control over sexual
adolescent pregnancy in rural Tanzania			decisions, adolescents sexual relationship with
			older men, early marriage, sexual expectations
			from men, rape, coerced sex
Adolescent pregnancy and associated factors	2012 south Africa	Cross sectional	Unemployment, poverty, high sexual permissive
in South African youth		study	attitude, contraceptive use, didn’t understand the
			risk of pregnancy, to prove their maturity, unequal
			power in relationship
Family and community support to adolescent	2003 Swaziland	Mixed method	Peer influence, lack of sexual and reproductive
mothers			information from families and communities
in Swaziland
Factors influencing the adolescent pregnancy	2015 south Africa	Descriptive and	Inconvenient health services, poor relationship with
rate in the Greater Giyani Municipality, Limpopo		explorative survey	health workers, peer pressure, inadequate sexual
Province – South Africa			knowledge, changing attitude toward sex.
Determinants of Sexual Activity and Pregnancy	2015 Kenya	Cross-Sectional	Education level, religion, employment status,
among Unmarried Young Women in Urban Kenya:		Study	household size, family planning knowledge,
A Cross-Sectional Study			misconceptions, and early sexual debut.
Unmet social needs and teenage pregnancy in	2014 Nigeria	Cross-Sectional	The unmet material and financial supports expected
Ogbomosho, South-western Nigeria		Study	from parents, the lack of free education from
			government up until secondary school level, the lack
			of sex education and knowledge needs for signs of
			maturity, and discouragement from friends not to
			have boyfriend.
Adolescent girls, illegal abortions and “sugar-	2001 Tanzania	Qualitative study	Material benefits from men, high-risk sexual activity,
daddies” in Dar es Salaam: vulnerable victims			lack of family planning information, sex education
and active social agents			and poor health services.
Teenage pregnancy experiences in rural Kenya	2003 Kenya	Community based	Sexual active adolescents, unmet reproductive
		survey	health needs, education level of adolescents
Health workers’ attitudes toward sexual and	2012 Ethiopia	descriptive cross-	Negative attitude of health workers towards
reproductive health services for unmarried		sectional survey	providing RH services to unmarried adolescents,
adolescents in Ethiopia			low education of health workers, and lack of
			training on RH services.
Nurse-Midwives’ Attitudes towards Adolescent	2006 Kenyan and	cross-sectional	Negative attitudes of health workers towards
Sexual and Reproductive Health Needs in	Zambia	survey	adolescent sexual activity, contraceptive use and
Kenya and Zambia			seeking reproductive health services.
Determinants of teenage pregnancies: The case	2007 Kenya	Cross sectional	Level of education, sex education, peer pressure,
of Busia District in Kenya		survey	inappropriate form of recreation, lack of parental

Yakubu and Salisu Reproductive Health (2018) 15:15Page 6 of 11

Table 1 Main determinants of unintended pregnancy amongst adolescents (Continued)

TitleYear/countryStudy typeDeterminants of adolescent pregnancy

guidance and counselling, poverty, knowledge of contraception.

Blood Blockages and Scolding Nurses: Barriers to Adolescent Contraceptive Use in South Africa

A participatory action research approach to developing youth-friendly strategies for the prevention of teenage pregnancy

Socio-Cultural Determinants of Contraceptives

Use Among Adolescents in Northern Ghana

Predictors of Sexual Debut Among Young

Adolescents in Nairobi’s Informal Settlements

Early Pregnancy of Junior High School Girls: Causes and Implications on Academic Progression in the Talensi District of the Upper East Region Of Ghana

Teenage Pregnancy in the Builsa District: A Focus Study in Fumbisi.

The cause and effect of teenage pregnancy: case of kontagora local government area in niger state, northern part of nigeria

2006 south Africa	Qualitative study	Pressure from male partners, fears about the effects
		of contraception, health workers attempt to
		stigmatize teenage sexuality, scolding and hash
		treatment of adolescents, unwillingness to
		acknowledge adolescent experience as
		contraceptive users.
2016 South Africa	participatory action	Sexual curiosity, alcohol consumption, unprotected
	research approach	sex, peer influence, lack of family support, parental
		absence, low family socioeconomic status, gender
		power inequality, relationship with elder men, lack
		of youth-friendly clinics
2015 Ghana	Descriptive cross-	Early sexual debut, educational level, parental
	sectional study	neglect, money, curiosity, peer pressure
2014 kenya	Descriptive cross-	School dropout, education, severe family dysfunction,
	sectional study	lack of parental control.
2015 Ghana	Cross-sectional	Cell phone usage by teenagers, inadequate
	study	contraceptives, peer group influence, family
		neglect and poverty, peer group influence, lack of
		sex education.
2013 Ghana	Cross-sectional	Poverty, prostitution, inadequate sex education,
	study	inadequate family support.
2013 Nigeria.	Cross-sectional	Early sexual debut, socio-economic background, early
	study	marriage and traditional gender roles, peer pressure,
		lack of sex education and non-used of contraceptive
		during sexual intercourse.

Poverty the Cause of Teenage Pregnancy in	2015 south Africa	Cross-sectional	Poverty, low socio-economic family status, lack of
Thulamela Municipality		study	parental support, inadequate sex education from
			parents, peer influence.
The Effects of Teenage Pregnancy on the Educational	2013 Ghana	Qualitative study	Poor parenting, poverty, peer influence and school
Attainment of Girls at Chorkor, a Suburb of Accra			dropout.

debut [14, 22, 29, 31, 37–39, 41]. Inappropriate forms of recreation [45].

Individual factors

Excessive use of alcohol and substance abuse [19, 31], educational status [26, 32, 37, 42], low self-esteem and inability to resist sexual temptation [23, 28, 30, 31, 35, 38, 39], and curiosity [31, 32, 35]. Cell phone usage by teenagers [34].

Health service-related factors

Cost of contraceptives [19]. Inadequate and unskilled health workers [19, 27, 43]. Long waiting time and lack of privacy at clinics [27], lack of comprehensive sexuality education, and misconceptions about contra-ceptives [15, 19, 23, 27, 29, 30, 34, 35, 38, 40, 45, 46]. Also, non-friendly adolescent reproductive services, and negative attitude of health workers towards pro-viding reproductive health services for adolescents [15, 19, 27, 29, 43, 44].

Discussion

Sociocultural, economic, individual and health service factors were identified as the main determinants of ado-lescent pregnancy. These factors were found to influence high rates of adolescent pregnancy in sub-Saharan Africa, similar to the developed world [25].

A study by Fearon et al. reported peers to be influen-tial in romantic and sexual behaviors of adolescents [48]. Their finding is consistent with the findings of this review. Studies from Ghana, Nigeria, Swaziland, Kenya, Tanzania, and South Africa reported the influence of peers in adolescent pregnancy. Particularly mentioned in a study from Nigeria [41], peers encourage their friends to get boyfriends.

Low socioeconomic status of parents makes adoles-cents vulnerable to unintended pregnancies since the means to afford basic needs, and sometimes contracep-tives is a challenge. Some adults take advantage of this situation to provide basic needs to unsuspecting adoles-cents and engage in sexual relationships with them. This creates a power difference between adolescents and their adult partners making them powerless to negotiate for

Table 2 Participants Characteristics

Author	Study setting/country	Number of	Gender % (n)	Age range	Ethnicity	Socio-economic status	Marital status
		participants		(years)
Atuyambe et al. (2015) [19]	Wakiso district/Uganda	156	Females 50.6% (79),	10–19	not described	No employment status	not indicated
			Males 49.4% (77)			described
Hokororo et al. (2015) [27]	Mwanza region/Tanzania	49	Females 100% (49)	15-20	Sukuma tribe	Non was employed	Legally married (2) Living
							with partner/boyfriend
							(40) Single or not living
							with partners (7)
R. Jewkes et al. (2001) [35]	Gugulethu and Khayelitsha,	544	Females 100% (544)	below 19 years	not described	No employment status	not indicated
	Cape Town/South Africa					described
Krugu et al. (2016) [23]	Bolgatanga Municipality/	20	Females 100% (20)	14-19	not described	High school students	non was married
	Ghana
McCleary-Sills et al. (2013) [28]	Tanzania	82	Females 100% (82)	12–17	not described	No employment status	not indicated
						described
G. Mchunu et al. (2012) [38]	Eastern Cape, Gauteng,	3123	Female 45.4% (1418),	18-24	not described	No employment status	not indicated
	KwaZulu-Natal and		Males 54.6% (1705)			described
	Mpumalanga/ South
	Africa
P.T. Mngadi et al. (2003) [46]	Mbabane/Swaziland	31	Females 100% (31)	15-19	not described	Non was employed	not indicated
Mushwana et al. (2015) [15]	Greater Giyani Municipality/	147	Females 100% (147)	10–19	not described	No employment status	Married (5), Single (136),
	South Africa					described	Other (4)
Okigbo & Speizer (2015) [40]	Nairobi,Mombasa,Kisumu,	2020	Female 100% (2020)	15-24	not described	Not employed 467,	non has ever been
	Machakos, Kakamega/					Student 658, Employed	married
	Kenya					895
Salami et al. (2014) [41]	Ogbomosho, Oyo State/	participants	Females 100% (174 +	10-20 and above	not described	Not employed 34,	not indicated
	Nigeria	174, key	12)			Student 62, Trading 45,
		informants 12				Others 33
Silberschmidt & Rasch	Dar es Salaam/Tanzania	51	Females 100% (51)	15-19	Not specific	Students 25, Employed	non was married
(2001) [29]						26
Taffa et al. (2003) [42]	Nyanza region/Kenya	1247	Females 100% (1247)	12–19	Not specific	students 233, not in	married or co-habiting
						school 331	(253), not married (331)
Tilahun et al. (2012) [43]	Eastern Hararghe, Oromia	394	Females 301 (301),	18-24 (219),	Oromiffa	Nurses (119), Health	Married (245), Single
	region/Ethiopia		Males 23.6% (93)	25-35 (143),		Extension Workers (236),	(149)
				36 and above		Health Assistants [21]
				[32]
Warenius et al. (2006) [44]	Kenya and Zambia	707	Females 92% (651),	22-60	Not specific	Enrolled Nurses (502),	not indicated
			Male 8% (56)			Registred Nurses (200),
						Dispensary Techs [5]
M. Were (2007) [45]	Busia District/Kenya	258	Females 78.7% (203),	10–19	not described	No employment status	not indicated
			Male 21.3% (55)			described
K Wood & R Jewkes	Limpopo Province/South	35	Females 100% (35)	14-20	Not specific	No employment status	non was married
(2006) [30]	Africa					described
	South Africa	24		Below 18 years	not described	grade 11 learners	not indicated

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Table 2 Participants Characteristics (Continued)

	Author	Study setting/country	Number of	Gender % (n)	Age range	Ethnicity	Socio-economic status	Marital status
			participants		(years)
L. Wooda & F. Hendricks (2016)				Females 58.3% (14)
[31]				Males 41.7% (10)
A. Yidana et al. (2015) [32]		Yendi Municipality /Ghana	400	Females 62.8% (251),	14-19	Dagomba	No employment status	Cohabiting (19), Divorced
				Males 37.3% (149)			described	(1), Married (76), Single
								(292), Widowed (12)
M. Marston et al. (2013) [37]		Korogocho and Viwandani/	1754		12–16	Swahili	No employment status	not indicated
		Kenya					described
E. Alhassan (2015) [34]		Talensi District/Ghana	310	Females 100% (310)	not specific	Telensi	Junior High School	not indicated
							Students
S. P. Adzitey et al. (2013) [33]		Fumbisi, Builsa District/	20	Females 100% (20)	14-20	Builsa (65%),	Students (95%), No	Married (19), Single (1)
		Ghana				Kasena (15%),	education (5%)
						Mamprusi (10%),
						Bimoba (5%) and
						Sisala (5%)
Ogori et al. (2013) [39]		Kontagora LocalGovernment	40	Not specific	Not specific	Not specific	No employment status	not indicated
		Area, Niger State/Nigeria					described
Lambani M.N (2015) [36]		Limpopo Province/South	10	Females 10% (10)	17-18	not described	Non was employed	not indicated
		Africa
Gyan C. (2013) [26]		Chorkor, Greater Accra	55	Females 100% (55)	not specific	Ga-Dangme and	No employment status	not indicated
		Region/Ghana				Akan	described

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safer sex. The effect of this is teenage pregnancy and the spread of sexually transmitted infections. Studies from Ghana [23], South Africa [31] and Tanzania [29] demon-strate how poverty leads adolescents to engage in sexual relations with elderly men in order to meet their basic needs. Lambani [36], reported that adolescents intentionally get pregnant to receive government support intended for teenage mothers to improve their economic condition not considering the consequence of their action.

Lack of parental counseling and guidance, severe fam-ily dysfunction with parental neglect were found as risk factors for adolescent pregnancies [26, 33, 35, 40, 45]. Parental counseling and guidance improves communica-tion between parents and adolescents and enables parents to address challenges of adolescents. Improved family communication and parent involvement in adolescents pregnancy prevention programs could delay adolescent sexual activity and pregnancy [49].

Inadequate knowledge, misconceptions and non-use of contraceptives [15, 19, 23, 26, 29, 31, 32, 34, 36, 37, 41, 45, 46] were identified as determinants of adolescent pregnancy. As indicated by Wood and Hendricks [31], health practitioners don’t relate health education to sociocultural context of adolescents but rather on bio-medical facts and warn of negative consequences. They do not as well explore their fears regarding contracep-tion; therefore, adolescents do not feel the impact of comprehensive sexuality education. Uninformed adoles-cents perceive contraceptives as a reserve for married couples [29].

Inappropriate modes of recreation in the form of unmonitored nightclubs or mixed-sex partying. These expose adolescents to early sex since they socialize easily with men [45].

We found the positive attitude towards early sexual rela-tionship and early sexual debut as factors contributing to adolescent pregnancy, consistent with findings from some developed countries [50–52]. The participants mostly lived in a social environment where adolescents had free will to choose sexual partners at an early age without much criticism from parents, caregivers, and peers [23]. In other reports, adolescents intentionally became preg-nant as proof of love and commitment to their sexual partners [30].

Religion and early marriages were also found to contrib-ute to high reports of adolescent pregnancies, which is consistent with a study by Parsons et al. [53]. Adolescents affected by early marriages are deprived of economic empowerment and self-efficacy and are at risk of early pregnancies [3]. They are also prone to maternal morbid-ity and mortality [54]. WHO’s guidelines on prevention of unintended pregnancy stressed on policies to reduce early marriage [6]. Rape, coerced sex, sexual advances from

adult men and unequal gender power in relationships identified in this review, undermines adolescents’ decision-making ability to either reject sex or negotiate the use of contraceptives [55].

Individual factors that influence adolescent pregnan-cies include excessive use of alcohol and substance abuse. This behavior makes adolescent girls vulnerable, and an easy target for sexual exploits. This is consistent with previous findings which reported an association between high-risk sexual behavior, adolescent pregnancy and substance abuse [56]. Cell phone usage promotes easy communication among peers and their partners and also gives them easy access to the internet which they use without regulation, to surf explicit content motivating early sex [34].

Health service-related factors include the cost of con-traceptives [19], healthcare centers lacking the adequate and skilled staff to attend to adolescents who need reproductive health services [19, 27, 43]. Long waiting time and lack of privacy at clinics discourage adolescents from visiting the facilities for services [27]. Also, inadequate comprehensive sexuality education and mis-conceptions about contraceptives [15, 19, 23, 27, 29, 30, 34, 35, 38, 40, 45, 46] were identified. Similarly, lack of friendly adolescent reproductive services and negative attitude of health workers towards providing reproduct-ive health services for adolescents [15, 19, 27, 29, 43, 44] were all associated with adolescent pregnancy.

Conclusion

High levels of adolescent pregnancies in Sub-Saharan Africa is attributable to multiple factors. Our study, however, categorized these factors into three major themes; Sociocultural, environmental and Economic factors (Peer influence, unwanted sexual advances from adult males, coercive sexual relations, unequal gender power relations, poverty, religion, early marriage. In addition, lack of parental counseling and guidance, par-ental neglect, the absence of affordable or free education, lack of comprehensive sexuality education, misconcep-tions, and non-use of contraceptives, male’s responsibil-ity to buy condoms, positive attitude towards early sexual relationships, early sexual debut and inappropri-ate forms of recreation). Individual factors (excessive use of alcohol, substance abuse, educational status, low self-esteem, and inability to resist sexual temptation, curiosity, and cell phone usage). Health service-related factors (cost of contraceptives, Inadequate and unskilled health workers, long waiting time and lack of privacy at clinics, lack of comprehensive sexuality education, mis-conceptions about contraceptives, non-friendly adoles-cent reproductive services, and negative attitude of health workers towards providing reproductive health

Yakubu and Salisu Reproductive Health (2018) 15:15

services for adolescents) as influencing adolescent pregnancies.

Seemingly unique to sub-Saharan Africa, our study found determinants of adolescent pregnancy to be asso-ciated with religious factors, early marriages, low level of education, and poverty. Also, cost of contraceptives, lack of adolescent-friendly health service provision, inad-equate and unskilled health workers, and lack of com-prehensive sexuality education.

Policymakers and opinion leaders should focus on community sensitization, comprehensive sexuality edu-cation and ensure girls enroll and stay in schools. Also, peers and significant others should be involved in designing interventional programs for adolescent preg-nancy prevention. This could reduce adolescent preg-nancy rates. Moreover, provision of adolescent-friendly health services at schools and healthcare centers, and initiating adolescent empowerment programs could have a positive impact on reducing adolescent pregnancy.

Further research is required on the determinants of adolescent pregnancy in the top five sub-Saharan African countries— Niger, Mali, Angola, Mozambique, and Guinea– with rates of adolescent pregnancy above 140 births per 100,000 adolescent women.

Acknowledgments

We would like to thank the staff of Health Education and Health Promotion Department, School of Public Health, Tehran University of Medical Sciences for their support during this study. We also wish to express our appreciation to Tehran University of Medical Sciences for granting us the opportunity to have access to the school’s subscribed online databases and libraries during our data collection. Finally, our appreciation goes to the various authors of our included studies.

Funding

The authors received no funding for the study.

Availability of data and materials

The data set supporting the conclusions of this article is included in the article’s Table 1.

Authors’ contributions

YI conceptualized and wrote the original script. Both YI and WJS participated in data extraction and together determined the methodology, validated, reviewed and edited the final manuscript. Both authors read and approved the final manuscript.

Ethics approval and consent to participate

Not applicable

Consent for publication

Not applicable

Competing interests

The authors declare that they have no competing interests.

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Page 10 of 11

Author details

1School of Public Health, Tehran University of Medical Sciences, International Campus, Tehran, Iran. 2School of Nursing and Midwifery, Tehran University of Medical Sciences, International Campus, Tehran, Iran.

Received: 4 November 2017 Accepted: 22 January 2018

References

1. Browne AW, Barrett HR. Female education in sub-Saharan Africa: the key to development? Comp Educ. 1991;27(3):275–85.
2. World Health Organization: Adolescent pregnancy Factsheet [Internet]. World Health Organization. 2014 [cited September 2014]. Available from: http://www.who.int/mediacentre/factsheets/fs364/en/.

3. Phillips SJ, Mbizvo MT. Empowering adolescent girls in sub-Saharan Africa to prevent unintended pregnancy and HIV: a critical research gap. Int J Gynaecol Obstet. 2016;132(1):1–3.

4. world atlas. World Facts: Highest Teen Pregnancy Rates Worldwide 2015 [updated April 25, 2017. Available from: http://www.worldatlas.com/articles/ highest-teen-pregnancy-rates-worldwide.html.

5. Ganchimeg T, Ota E, Morisaki N, Laopaiboon M, Lumbiganon P, Zhang J, et al. Pregnancy and childbirth outcomes among adolescent mothers: a World Health Organization multi-country study. BJOG. 2014;121(Suppl 1):40–8.

6. Chandra-Mouli V, Camacho AV, Michaud P-A. WHO guidelines on preventing early pregnancy and poor reproductive outcomes among adolescents in developing countries. J Adolesc Health. 2013;52(5):517–22.

7. Horgan RP, Kenny LC. Management of teenage pregnancy. Obstet Gynaecol. 2007;9(3):153–8.

8. Officials NAoCCH. Meeting the needs of pregnant and parenting teens. Washington: Local Health Department Programs and Services; 2009.
9. Hodgkinson S, Beers L, Southammakosane C, Lewin A. Addressing the mental health needs of pregnant and parenting adolescents. Pediatrics. 2014;133(1):114–22.

10. Atuyambe L, Mirembe F, Johansson A, Kirumira EK, Faxelid E. Experiences of pregnant adolescents–voices from Wakiso district, Uganda. Afr Health Sci. 2005;5(4):304–9.

11. Aransiola JO, Asa S, Obinjuwa P, Olarewaju O, Ojo OO, Fatusi AO. Teachers' perspectives on sexual and reproductive health interventions for in-school adolescents in Nigeria. Afr J Reprod Health. 2013;17(4):84–92.

12. Warenius L, Pettersson KO, Nissen E, Höjer B, Chishimba P, Faxelid E. Vulnerability and sexual and reproductive health among Zambian secondary school students. Cult Health Sex. 2007;9(5):533–44.

13. Ahorlu CK, Pfeiffer C, Obrist B. Socio-cultural and economic factors influencing adolescents' resilience against the threat of teenage pregnancy: a cross-sectional survey in Accra, Ghana. Reprod Health. 2015;12:117.

14. Kumi-Kyereme A, Awusabo-Asare K, Darteh EK. Attitudes of gatekeepers towards adolescent sexual and reproductive health in Ghana. Afr J Reprod Health. 2014;18(3):142–53.

15. Mushwana L, Monareng L, Richter S, Muller H. Factors influencing the adolescent pregnancy rate in the Greater Giyani municipality, Limpopo Province - South Africa. Int J Afr Nurs Sci. 2015;2:10–8.

16. A Yidana, SD Ziblim, TB Azongo, Abass YI. Socio-cultural determinants of contraceptives use among adolescents in northern Ghana. Public Health Res. 2015;5(4):83–89.

17. Adinma JI, Agbai AO, Okeke AO, Okaro JM. Contraception in teenage Nigerian school girls. Adv Contracept. 1999;15(4):283–91.
18. Ahlberg BM, Jylkas E, Krantz I. Gendered construction of sexual risks: implications for safer sex among young people in Kenya and Sweden. Reprod Health Matters. 2001;9(17):26–36.

19. Atuyambe LM, Kibira SP, Bukenya J, Muhumuza C, Apolot RR, Mulogo E. Understanding sexual and reproductive health needs of adolescents: evidence from a formative evaluation in Wakiso district, Uganda. Reprod Health. 2015;12:35.

20. Atuyambe L, Mirembe F, Annika J, Kirumira EK, Faxelid E. Seeking safety and empathy: adolescent health seeking behavior during pregnancy and early motherhood in central Uganda. J Adolesc. 2009;32(4):781–96.

21. Adekunle AO, Arowojolu AO, Adedimeji AA, Roberts OA. Adolescent contraception: survey of attitudes and practice of health professionals. Afr J Med Med Sci. 2000;29(3-4):247–52.

Yakubu and Salisu Reproductive Health (2018) 15:15

22. Abdul-Rahman L, Marrone G, Johansson A. Trends in contraceptive use among female adolescents in Ghana. Afr J Reprod Health. 2011;15(2):45–55.
23. Krugu JK, Mevissen FE, Prinsen A, Ruiter RA. Who's that girl? A qualitative analysis of adolescent girls' views on factors associated with teenage pregnancies in Bolgatanga, Ghana. Reprod Health. 2016;13:39.
24. The Joanna Briggs Institute. Joanna Briggs institute reviewers’ manual. 2011.

25. Sedgh G, Finer LB, Bankole A, Eilers MA, Singh S. Adolescent pregnancy, birth, and abortion rates across countries: levels and recent trends. J Adolesc Health. 2015;56(2):223–30.
26. Gyan C. The effects of teenage pregnancy on the educational attainment of girls at Chorkor, a suburb of Accra. J Educ Soc Res. 2013;3(3):53.
27. Hokororo A, Kihunrwa AF, Kalluvya S, Changalucha J, Fitzgerald DW, Downs JA. Barriers to access reproductive health care for pregnant adolescent girls: a qualitative study in Tanzania. Acta Paediatrica (Oslo, Norway: 1992). 2015; 104(12):1291–7.

28. McCleary-Sills J, Douglas Z, Rwehumbiza A, Hamisi A, Mabala R. Gendered norms, sexual exploitation and adolescent pregnancy in rural Tanzania. Reprod Health Matters. 2013;21(41):97–105.
29. Silberschmidt M, Rasch V. Adolescent girls, illegal abortions and "sugar-daddies" in Dar es salaam: vulnerable victims and active social agents. Soc Sci Med. 2001;52(12):1815–26.

30. Wood K, Jewkes R. Blood blockages and scolding nurses: barriers to adolescent contraceptive use in South Africa. Reprod Health Matters. 2006; 14(27):109–18.

31. Wood L, Hendricks F. A participatory action research approach to developing youth-friendly strategies for the prevention of teenage pregnancy. Educ Action Res. 2017;25(1):103–18.

32. Yidana A, Ziblim SD, Azongo TB, Abass YI. Socio-cultural determinants of contraceptives use among adolescents in northern Ghana. Public Health Res. 2015;5(4):83–9.

33. Adzitey SP, Adzitey F, Suuk L. Teenage pregnancy in the Builsa District: a focus study in Fumbisi. 2011.

34. Alhassan E. Early pregnancy of junior high school girls: causes and implications on academic progression in the Talensi District of the upper east region of Ghana. UDS Int J Dev. 2015;2(2):47–59.
35. Jewkes R, Vundule C, Maforah F, Jordaan E. Relationship dynamics and teenage pregnancy in South Africa. Soc Sci Med. 2001;52(5):733–44.
36. Lambani MN. Poverty the cause of teenage pregnancy in Thulamela municipality. 2015.

37. Marston M, Beguy D, Kabiru C, Cleland J. Predictors of sexual debut among young adolescents in Nairobi's informal settlements. Int Perspect Sex Reprod Health. 2013;39(1):22–31.

38. McHunu G, Peltzer K, Tutshana B, Seutlwadi L. Adolescent pregnancy and associated factors in south African youth. Afr Health Sci. 2012;12(4):426–34.
39. Ogori AF, Ajeya SHiTU fatima, Yunusa AR. The cause and effect of teenage pregnancy: case of Kontagora local government area in Niger state, northern part of Nigeria. J Educ Res 2013;Vol. 1,( No. 7): 01-15.
40. Okigbo CC, Speizer IS. Determinants of sexual activity and pregnancy among unmarried young women in urban Kenya: a cross-sectional study. PLoS One. 2015;10(6):e0129286.

41. Salami KK, Ayegboyin M, Adedeji IA. Unmet social needs and teenage pregnancy in Ogbomosho, South-western Nigeria. Afr Health Sci. 2014; 14(4):959–66.

42. Taffa N, Omollo D, Matthews Z. Teenage pregnancy experiences in rural Kenya. Int J Adolesc Med Health. 2003;15(4):331–40.
43. Tilahun M, Mengistie B, Egata G, Reda AA. Health workers' attitudes toward sexual and reproductive health services for unmarried adolescents in Ethiopia. Reprod Health. 2012;9:19.

44. Warenius LU, Faxelid EA, Chishimba PN, Musandu JO, Ong'any AA, Nissen EB. Nurse-midwives' attitudes towards adolescent sexual and reproductive health needs in Kenya and Zambia. Reprod Health Matters. 2006;14(27):119–28.

45. Were M. Determinants of teenage pregnancies: the case of Busia District in Kenya. Econ Hum Biol. 2007;5(2):322–39.

46. Mngadi PT, Zwane IT, Ahlberg BM, Ransjo-Arvidson AB. Family and community support to adolescent mothers in Swaziland. J Adv Nurs. 2003; 43(2):137–44.

47. worldatlas. Highest Teen Pregnancy Rates Worldwide. In: Dillinger J, editor. 2017.

48. Fearon E, Wiggins RD, Pettifor AE, Hargreaves JR. Is the sexual behaviour of young people in sub-Saharan Africa influenced by their peers? A systematic review. Soc Sci Med. 2015;146:62–74.

Page 11 of 11

49. Silk J, Romero D. The role of parents and families in teen pregnancy prevention. J Fam Issues. 2014;35(10):1339–62.

50. Cavazos-Rehg PA, Krauss MJ, Spitznagel EL, Schootman M, Bucholz KK, Peipert JF, et al. Age of sexual debut among US adolescents. Contraception. 2009;80(2):158–62.

51. Lohman BJ, Billings A. Protective and risk factors associated with adolescent boys’ early sexual debut and risky sexual behaviors. J Youth Adolesc. 2008;37(6):723.

52. Mott FL, Fondell MM, Hu PN, Kowaleski-Jones L, Menaghan EG. The determinants of first sex by age 14 in a high-risk adolescent population. Fam Plan Perspect. 1996;28(1):13–8.

53. Parsons J, Edmeades J, Kes A, Petroni S, Sexton M, Wodon Q. Economic impacts of child marriage: a review of the literature. Review Faith Int Affairs. 2015;13(3):12–22.

54. Ebeigbe PN, Gharoro EP. Obstetric complications, intervention rates and maternofetal outcome in teenage nullipara in Benin City, Nigeria. Trop Dr. 2007;37(2):79–83.

55. Leclerc-Madlala S. Age-disparate and intergenerational sex in southern Africa: the dynamics of hypervulnerability. AIDS. 2008;22:S17–25.
56. Homma Y, Wang N, Saewyc E, Kishor N. The relationship between sexual abuse and risky sexual behavior among adolescent boys: a meta-analysis. J Adolesc Health. 2012;51(1):18–24.

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