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Background Adolescent sexual and reproductive health (ASRH) is a major public health concern in sub-Saharan Africa (SSA). However, inequalities in ASRH have received less attention than many other public health priority areas, in part due to limited data. In this study, we examine inequalities in key ASRH indicators. Methods We analyzed national household surveys from 37 countries in SSA, conducted during 1990–2018, to examine trends and inequalities in adolescent behaviors related to early marriage, childbearing and sexual debut among adolescents using data from respondents 15–24 years. Survival analyses were conducted on each survey to obtain estimates for the ASRH indicators. Multilevel linear regression modelling was used to obtain estimates for 2000 and 2015 in four subregions of SSA for all indicators, disaggregated by sex, age, household wealth, urban–rural residence and educational status (primary or less versus secondary or higher education). Results In 2015, 28% of adolescent girls in SSA were married before age 18, declined at an average annual rate of 1.5% during 2000–2015, while 47% of girls gave birth before age 20, declining at 0.6% per year. Child marriage was rare for boys (2.5%). About 54% and 43% of girls and boys, respectively, had their sexual debut before 18. The declines were greater for the indicators of early adolescence (10–14 years). Large differences in marriage and childbearing were observed between adolescent girls from rural versus urban areas and the poorest versus richest households, with much greater inequalities observed in West and Central Africa where the prevalence was highest. The urban–rural and wealth-related inequalities remained stagnant or widened during 2000–2015, as the decline was relatively slower among rural and the poorest compared to urban and the richest girls. The prevalence of the ASRH indicators did not decline or increase in either education categories. Conclusion Early marriage, childbearing and sexual debut declined in SSA but the 2015 levels were still high, especially in Central and West Africa, and inequalities persisted or became larger. In particular, rural, less educated and poorest adolescent girls continued to face higher ASRH risks and vulnerabilities. Greater attention to disparities in ASRH is needed for better targeting of interventions and monitoring of progress.

The focus of this supplement is on inequalities in the levels and trends of progress on sexual and reproductive health among adolescents in sub-Saharan Africa. Whereas adolescents did not get the attention they deserved in the context of the Millennium Development Goals, there is strong commitment to ensuring that they are not left behind in the context of the Sustainable Development Goals [1]. The need to pay particular attention to their sexual and reproductive health needs was reinforced in the list of key actions for the future implementation of the Programme of Action of the International Conference on Population and Development at the Nairobi Summit [2]. Two recent reports highlight the unequal burden of Sexual and Reproductive Health (SRH) problems in adolescents, and their unequal access to the SRH services. Just-published data suggest that the prevalence of violence against women in relation to intimate partner violence starts early in the lives of girls/young women with nearly one in four of every married/partnered 15–19-year-olds already being subjected to physical and/or sexual violence from an intimate partner at least once, and that the levels of violence in the last 12 months (16%) are higher in this age group [3]. Data released by the Guttmacher Institute stressed that as of 2019, adolescents faced vast unmet needs for sexual and reproductive health services (e.g., 41% of adolescent girls aged 15–19 who wanted to avoid a pregnancy had unmet needs for contraception, whereas the comparable rate in 15–49-year-olds was 24%), and projected that this was likely to worsen in the context of the COVID-19 pandemic’s movement restrictions and service disruptions [4].

Background Single aggregate figures for adolescent pregnancy may fail to demonstrate particular population groups where rates are very high, or where progress has been slow. In addition, most indicators fail to separate younger from older adolescents. As there is some evidence that the disadvantages faced by adolescent mothers are greatest for those at the younger end of the spectrum, this is an important omission. This paper provides information on levels and trends of adolescent first births in 22 countries (at national and regional level) disaggregated by age ( Methodology In this descriptive and trend analysis study we used data from 22 low- and middle-income countries from sub-Saharan Africa that have at least three Demographic and Health Surveys (DHS) since 1990, with the most recent carried out after 2005. Adolescent first births from the most recent survey are analysed by age, wealth, and residence by country and region for women aged 20–24 years at time of survey. We also calculated annual percentage rates of change (using both short- and longer-term data) for adolescent first births disaggregated by age, family wealth and residence and examined changes in concentration indices (CI). Findings Overall percentages of adolescent first births vary considerably between countries for all disaggregated age groups. The burden of first birth among adolescents is significant, including in the youngest age group: in some countries over 20% of women gave birth before 16 years of age (e.g. Mali and Niger). Adolescent first births are more common among women who are poorer, and live in rural areas; early adolescent first births before 16 years of age are particularly concentrated in these disadvantaged groups. Progress in reducing adolescent first births has also been particularly poor amongst these vulnerable groups, leading to increasing inequity. Conclusions Findings from this study show that adolescent births are concentrated among vulnerable groups where progress is often poorest. Strategies and programmes need to be developed to reduce adolescent pregnancies in marginalised young women in low- and middle-income countries.

Background: adolescents in the Latin American and Caribbean region continue to experience poor reproductive health outcomes, including high rates of first birth before the age of 20 years. Aggregate national level data fails to identify groups where progress is particularly poor. This paper explores how trends in adolescent births have changed over time in five countries (Bolivia, Colombia, Dominican Republic, Haiti, and Peru) using data disaggregated by adolescent age group, wealth and urban / rural residence.Methods: the study draws on Demographic and Health Survey data from five countries where three surveys are available since 1990, with the most recent after 2006. It examines trends in adolescent births by wealth status and urban/rural residence.Results: there has been little progress in reducing adolescent first births over the last two decades in these countries. Adolescent first births continue to be more common among the poorest and rural residents, and births among the youngest age-group (Conclusion: adolescent first births continue to be a major issue in these five countries, including amongst the youngest group (

Adolescent sexual and reproductive health (ASRH) continues to be a major public health challenge in sub-Saharan Africa where child marriage, adolescent childbearing, HIV transmission and low coverage of modern contraceptives are common in many countries. The evidence is still limited on inequalities in ASRH by gender, education, urban–rural residence and household wealth for many critical areas of sexual initiation, fertility, marriage, HIV, condom use and use of modern contraceptives for family planning. We conducted a review of published literature, a synthesis of national representative Demographic and Health Surveys data for 33 countries in sub-Saharan Africa, and analyses of recent trends of 10 countries with surveys in around 2004, 2010 and 2015. Our analysis demonstrates major inequalities and uneven progress in many key ASRH indicators within sub-Saharan Africa. Gender gaps are large with little evidence of change in gaps in age at sexual debut and first marriage, resulting in adolescent girls remaining particularly vulnerable to poor sexual health outcomes. There are also major and persistent inequalities in ASRH indicators by education, urban–rural residence and economic status of the household which need to be addressed to make progress towards the goal of equity as part of the sustainable development goals and universal health coverage. These persistent inequalities suggest the need for multisectoral approaches, which address the structural issues underlying poor ASRH, such as education, poverty, gender-based violence and lack of economic opportunity.

IntroductionAdolescent pregnancy is associated with significant risks and disadvantages for young women and girls and their children. A clear understanding of population subgroups with particularly high prevalence of first births in adolescence is vital if appropriate national responses are to be developed. This paper aims to provide detailed data on socioeconomic and geographic inequities in first births to adolescents in Nepal, including wealth quintile, education, rural/urban residence and geographic region. A key element is the use of geospatial modelling to develop estimates for the prevalence of adolescent births at the district level.MethodsThe study uses data from the 2011 Nepal Demographic and Health Survey. Initial cross-tabulations present disaggregated data by socioeconomic status and basic geographic region. Estimates of prevalence of adolescent first births at the district level are creating by regression modelling using the Integrated Nested Laplace Approximation package in R software.ResultsOur findings show that 40% of women had given birth before the age of 20 years, with 5% giving birth before 16 years. First births to adolescents remain common among poorer, less educated and rural women. Geographic disparities are striking, with estimates for the percentage of women giving birth before 20 years ranging from 35% to 53% by region. District level estimates showed even more marked differentials (26%–67% had given birth by 20 years), with marked heterogeneity even within regions. In some districts, estimates for the prevalence of first birth among the youngest age groups (ConclusionImportant geographic and socioeconomic inequities exist in adolescent first births. In some districts and within some subgroups, there remain high levels of adolescent first births, including births to very young adolescents. The use of Bayesian geospatial modelling techniques can be used by policymakers to target resources.

It is assumed that knowing what puts young women at risk of poor sexual health outcomes and, in turn, what protects them against these outcomes, will enable greater targeted protection as well as help in designing more effective programmes. Accordingly, efforts have been directed towards mapping risk and protective factors onto general ecological frameworks, but these currently do not take into account the context of modern armed conflict. A literature overview approach was used to identify SRH related risk and protective factors specifically for young women affected by modern armed conflict.Processes of risk and protectionA range of keywords were used to identify academic articles which explored the sexual and reproductive health needs of young women affected by modern armed conflict. Selected articles were read to identify risk and protective factors in relation to sexual and reproductive health. While no articles explicitly identified ‘risk’ or ‘protective’ factors, we were able to extrapolate these through a thorough engagement with the text. However, we found that it was difficult to identify factors as either ‘risky’ or ‘protective’, with many having the capacity to be both risky and protective (i.e. refugee camps or family). Therefore, using an ecological model, six environments that impact upon young women’s lives in contexts of modern armed conflict are used to illustrate the dynamic and complex operation of risk and protection – highlighting processes of protection and the ‘trade-offs’ between risks.ConclusionWe conclude that there are no simple formulaic risk/protection patterns to be applied in every conflict and post-conflict context. Instead, there needs to be greater recognition of the ‘processes’ of protection, including the role of ‘trade-offs’ (what we term as ‘protection at a price’), in order to further effective policy and practical responses to improve sexual and reproductive health outcomes during or following armed conflict. Focus on specific ‘factors’ (such as ‘female headed household’) takes attention away from the processes through which factors manifest themselves and which often determine whether the factor will later be considered ‘risk inducing’ or protective.

Background: Early adolescent pregnancy presents a major barrier to the health and wellbeing of young women and their children. Previous studies suggest geographic heterogeneity in adolescent births, with clear “hot spots” experiencing very high prevalence of teenage pregnancy. As the reduction of adolescent pregnancy is a priority in many countries, further detailed information of the geographical areas where they most commonly occur is of value to national and district level policy makers. The aim of this study is to develop a comprehensive assessment of the geographical distribution of adolescent first births in Uganda, Kenya and Tanzania using Demographic and Household (DHS) data using descriptive, spatial analysis and spatial modelling methods.Methods: The most recent Demographic and Health Surveys (DHS) among women aged 20 to 29 in Tanzania, Kenya, and Uganda were utilised. Analyses were carried out on first births occurring before the age of 20 years, but were disaggregated in to three age groups: Results: The findings show marked geographic heterogeneity among adolescent first births, particularly among those under 16 years. Disparities are greater in Kenya and Uganda than Tanzania. The INLA analysis which produces estimates from smaller areas suggest “pockets” of high prevalence of first births, with marked differences between neighbouring districts. Many of these high prevalence areas can be linked with underlying poverty.Conclusions: There is marked geographic heterogeneity in the prevalence of adolescent first births in East Africa, particularly in the youngest age groups. Geospatial techniques can identify these inequalities and provide policy-makers with the information needed to target areas of high prevalence and focus scarce resources where they are most needed.

Background Young women in conflict-affected regions are at risk of a number of adverse outcomes as a result of violence, economic deterioration and the breakdown of community structures and services. This paper presents the findings of a systematic review of quantitative literature reporting how key sexual and reproductive health (SRH) outcomes among young women under the age of 20 years are affected by exposure to armed conflict; namely, sexual debut, first marriage and first birth. Increases in these outcomes among young women are all associated with potential negative public health consequences. It also examines and documents possible causal pathways for any changes seen. Methods To fit with our inclusion criteria, all reviewed studies included outcomes for comparable populations not exposed to conflict either temporally or spatially. A total of 19 studies with results from 21 countries or territories met our inclusion criteria; seven presented findings on marriage, four on fertility and eight on both of these outcomes. Only one study reporting on sexual debut met our criteria. Results Findings show clear evidence of both declines and increases in marriage and childbirth among young women in a range of conflict-affected settings. Several studies that showed increases in marriage below the age of 20 years reported that such increases were concentrated in the younger teenagers. Trends in fertility were predominantly driven by marriage patterns. Suggested causal pathways for the changes observed could be grouped into three categories: involuntary, gender and psycho-social and economic and material factors. Conclusion The review reveals a paucity of literature on the impact of conflict on SRH outcomes of young women. Further quantitative and qualitative studies are needed to explore how conflict influences SRH events in young women over both the short- and longer-term. Electronic supplementary material The online version of this article (doi:10.1186/s12889-016-2868-5) contains supplementary material, which is available to authorized users.

There is strong evidence that the health risks associated with adolescent pregnancy are concentrated among the youngest girls (e.g. those under 16 years). Fertility rates in this age group have not previously been comprehensively estimated and published. By drawing data from 42 large, nationally representative household surveys in low resource countries carried out since 2003 this article presents estimates of age-specific birth rates for girls aged 12-15, and the percentage of girls who give birth at age 15 or younger. From these we estimate that approximately 2.5 million births occur to girls aged under 16 in low resource countries each year. The highest rates are found in Sub-Saharan Africa, where in Chad, Guinea, Mali, Mozambique, Niger and Sierra Leone more than 10% of girls become mothers before they are 16. Strategies to reduce these high levels are vital if we are to alleviate poor reproductive health.

Objectives: Evidence on whether removing fees benefits the poorest is patchy and weak. The aim of this paper is to measure the impact of user fee reforms on the probability of giving birth in an institution or undergoing a caesarean section (CS) in Ghana, Burkina Faso, Zambia, Cameroon and Nigeria for the poorest strata of the population.Setting: Women's experience of user fees in 5 African countries.Primary and secondary outcome measures: Using quasi-experimental regression analysis we tested the impact of user fee reforms on facilities’ births and CS differentiated by wealth, education and residence in Burkina Faso and Ghana. Mapping of the literature followed by key informant interviews are used to verify details of reform implementation and to confirm and support our countries’ choice.Participants: We analysed data from consecutive surveys in 5 countries: 2 case countries that experienced reforms (Ghana and Burkina Faso) by contrast with 3 that did not experience reforms (Zambia, Cameroon, Nigeria).Results: User fee reforms are associated with a significant percentage of the increase in access to facility births (27 percentage points) and to a much lesser extent to CS (0.7 percentage points). Poor (but not the poorest), and non-educated women, and those in rural areas benefitted the most from the reforms. User fees reforms have had a higher impact in Burkina Faso compared with Ghana.Conclusions: Findings show a clear positive impact on access when user fees are removed, but limited evidence for improved availability of CS for those most in need. More women from rural areas and from lower socioeconomic backgrounds give birth in health facilities after fee reform. Speed and quality of implementation might be the key reason behind the differences between the 2 case countries. This calls for more research into the impact of reforms on quality of care.

The health and well-being of female adolescents is considered crucial to the continued development of low-income countries. (1) Among the most widely used indicators of health and well-being for female adolescents are age at sexual debut (also described as age at first sex), age at first marriage or first union and age at first birth. Demographic and Health Survey (DHS) data are widely used to estimate these indicators, and DHS country reports routinely present the percentage of women aged 15-49 who experience sexual debut, marry or give birth before age 15, grouped into five-year cohorts, and the percentage of women aged 15-19 at time of survey who have started childbearing, by individual year of age. Despite evidence suggesting that social desirability bias and recall bias may exert a strong influence on reports of childbearing, sexual debut and marriage by adolescents, (2-4) the accuracy of DHS-based estimates of these widely reported indicators is poorly understood. Even less is known about the reliability of data when these events occur in very early adolescence. There is widespread recognition of the vulnerability of and risks faced by sexually active young adolescents (both in or outside of marriage), (5) and growing understanding of the need for appropriate sexual health education and services for this age-group. (6) To support improvements in education and services, age-disaggregated indicators are required to identify need and monitor progress. However, inaccurate data may lead to erroneous interpretations of both the proportions of adolescents experiencing sexual health events and of trends over time. In particular, underestimations of the proportions affected or overestimation of positive trends could lead to complacency about the scale of the problem or false optimism over progress. In this article, we first examine the consistency of DHS data from two consecutive surveys in each of nine countries on adolescent age at sexual debut, marriage or first union, and first birth across cohorts, disaggregated by age in years. We then carry out further analysis to determine which age-group of respondents (ages 15-19 vs. 20-24) is most likely to provide the most accurate estimates. In the discussion, we consider possible underlying causes for the inconsistencies we have identified and the implications the inconsistencies have for policymakers and researchers who use these data. Sources of Errors The DHS relies on retrospective reporting of events and asks all responding women of reproductive age to report on the same events, e.g., age at sexual debut, age at first marriage or union, and age at first birth. Errors in reporting on reproductive and sexual health events can be divided into three categories: recall error, survey completion issues and social desirability bias. While some of these sources of error are universal, others may be more prevalent in particular age-groups. Recall bias, an unintentional error in which an event is omitted or mistimed, is more common among older women than among younger women because more time has elapsed between the survey and the event of interest. (7) Perceptions of an event such as first marriage or union may be another source of unintentional error because the cultural, social and legal conditions defining such an event may vary. (8,9) Marriage and union formation may be fluid and, in many countries, are processes rather than single events, often spread out over many years. (10-13) Responses to questions on the occurrence and timing of marriage or union formation will reflect the current perceptions of respondents when thinking back over the course of their lives, and these perceptions may change as women get older. Survey completion issues may be a source of intentional bias. In the DHS, the backdating of births is a common problem because respondents who have given birth within five years of the survey are required to complete an additional questionnaire for the child. …

Summary Background Adolescents are often noted to have an increased risk of death during pregnancy or childbirth compared with older women, but the existing evidence is inconsistent and in many cases contradictory. We aimed to quantify the risk of maternal death in adolescents by estimating maternal mortality ratios for women aged 15–19 years by country, region, and worldwide, and to compare these ratios with those for women in other 5-year age groups. Methods We used data from 144 countries and territories (65 with vital registration data and 79 with nationally representative survey data) to calculate the proportion of maternal deaths among deaths of females of reproductive age (PMDF) for each 5-year age group from 15–19 to 45–49 years. We adjusted these estimates to take into account under-reporting of maternal deaths, and deaths during pregnancy from non-maternal causes. We then applied the adjusted PMDFs to the most reliable age-specific estimates of deaths and livebirths to derive age-specific maternal mortality ratios. Findings The aggregated data show a J-shaped curve for the age distribution of maternal mortality, with a slightly increased risk of mortality in adolescents compared with women aged 20–24 years (maternal mortality ratio 260 [uncertainty 100–410] vs 190 [120–260] maternal deaths per 100 000 livebirths for all 144 countries combined), and the highest risk in women older than 30 years. Analysis for individual countries showed substantial heterogeneity; some showed a clear J-shaped curve, whereas in others adolescents had a slightly lower maternal mortality ratio than women in their early 20s. No obvious groupings were apparent in terms of economic development, demographic characteristics, or geographical region for countries with these different age patterns. Interpretation Our findings suggest that the excess mortality risk to adolescent mothers might be less than previously believed, and in most countries the adolescent maternal mortality ratio is low compared with women older than 30 years. However, these findings should not divert focus away from efforts to reduce adolescent pregnancy, which are central to the promotion of women's educational, social, and economic development. Funding WHO, UN Population Fund.

BackgroundThe use of a single national figure fails to capture the complex patterns and inequalities in early childbearing that occur within countries, as well as the differing contexts in which these pregnancies occur. Further disaggregated data that examine patterns and trends for different groups are needed to enable programmes to be focused on those most at risk. This paper describes a comprehensive analysis of adolescent first births using disaggregated data from Demographic and Household surveys (DHS) for three East African countries: Uganda, Kenya and Tanzania.MethodsThe study initially produces cross-sectional descriptive data on adolescent motherhood by age (under 16, 16–17 and 18–19 years), marital status, wealth, education, state or region, urban/rural residence and religion. Trends for two or more surveys over a period of 18–23 years are then analysed, and again disaggregated by age, wealth, urban/rural residence and marital status to ascertain which groups within the population have benefited most from reductions in adolescent first birth. In order to adjust for confounding factors we also use multinomial logistic regression to analyse the social and economic determinants of adolescent first birth, with outcomes again divided by age.FindingsIn all three countries, a significant proportion of women gave birth before age 16 (7%-12%). Both the bivariate analysis and logistic regression show that adolescent motherhood is strongly associated with poverty and lack of education/literacy, and this relationship is strongest among births within the youngest age group (ConclusionsAdolescent first births, particularly at the youngest ages, are most common among the poorest and least educated, and progress in reducing rates within this group has not been made over the last few decades. Disaggregating data allows such patterns to be understood, and enables efforts to be better directed where needed.

As the deadline for the millennium development goals approaches, it has become clear that the goals linked to maternal and newborn health are the least likely to be achieved by 2015. It is therefore critical to ensure that all possible data, tools and methods are fully exploited to help address this gap. Among the methods that are under-used, mapping has always represented a powerful way to ‘tell the story’ of a health problem in an easily understood way. In addition to this, the advanced analytical methods and models now being embedded into Geographic Information Systems allow a more in-depth analysis of the causes behind adverse maternal and newborn health (MNH) outcomes. This paper examines the current state of the art in mapping the geography of MNH as a starting point to unleashing the potential of these under-used approaches. Using a rapid literature review and the description of the work currently in progress, this paper allows the identification of methods in use and describes a framework for methodological approaches to inform improved decision-making. The paper is aimed at health metrics and geography of health specialists, the MNH community, as well as policy-makers in developing countries and international donor agencies.

INTRODUCTION: The drive toward universal health coverage (UHC) is central to the post 2015 agenda, and is incorporated as a target in the new Sustainable Development Goals. However, it is recognised that an equity dimension needs to be included when progress to this goal is monitored. WHO have developed a monitoring framework which proposes a target of 80 % coverage for all populations regardless of income and place of residence by 2030, and this paper examines the feasibility of this target in relation to antenatal care and skilled care at delivery.METHODOLOGY: We analyse the coverage gap between the poorest and richest groups within the population for antenatal care and presence of a skilled attendant at birth for countries grouped by overall coverage of each maternal health service. Average annual rates of improvement needed for each grouping (disaggregated by wealth quintile and urban/rural residence) to reach the goal are also calculated, alongside rates of progress over the past decades for comparative purposes.FINDINGS: Marked inequities are seen in all groups except in countries where overall coverage is high. As the monitoring framework has an absolute target countries with currently very low coverage are required to make rapid and sustained progress, in particular for the poorest and those living in rural areas. The rate of past progress will need to be accelerated markedly in most countries if the target is to be achieved, although several countries have demonstrated the rate of progress required is feasible both for the population as a whole and for the poorest.CONCLUSIONS: For countries with currently low coverage the target of 80 % essential coverage for all populations will be challenging. Lessons should be drawn from countries who have achieved rapid and equitable progress in the past.

Introduction: In countries such as Bangladesh many women may only seek skilled care at birth when complications become evident. This often results in higher neonatal mortality for women who give birth in institutions than for those that give birth at home. However, we hypothesise that this apparent excess mortality is concentrated among less advantaged women. The aim of this paper is to examine the association between place of birth and neonatal mortality in Bangladesh, and how this varies by socio-economic status. Methodology: The study is based on pooled data from four Bangladesh Demographic and Household Surveys, and uses descriptive analysis and binomial multivariate logistic regression. It uses regression models stratified for place of delivery to examine the impact of socio-economic status and place of residence on neonatal mortality. Results: Poor women from rural areas and those with no education who gave birth in institutions had much worse outcomes than those who gave birth at home. There is no difference for more wealthy women. There is a much stronger socio-economic gradient in neonatal mortality for women who gave birth in institutions than those who delivered at home. Conclusion: In Bangladesh babies from lower socio-economic groups and particularly those in rural areas have very poor outcomes if born in a facility. This suggests poorer, rural and less educated women are failing to obtain the timely access to quality maternal health care services needed to improve newborn outcomes.