Contrary to the perceived ‘satisfaction’ among healthcare professionals as having only 4.4% adolescent pregnancies(24) in Sri Lanka, this large community-based study representing a whole district reveals that adolescents accounted for one-fifth of primiparous pregnancies in Anuradhapura. Underutilization and or inadequacy of pre-conceptional care and SRH education and the need for keeping the adolescents in school are highlighted in this study.
During the past five years, the Sri Lankan national statistics suggest that the percentage of adolescent pregnancies has been gradually declining from 5.2% in 2015 to 4.4% in 2019 (20). However, in the total sample of pregnant women enrolled in the RaPCo study, the corresponding percentage is 6.9%, which is higher than the recent national estimates. The percentage of primiparous mothers in the RaPCo study was 30.8%, which is approximately similar to the corresponding national value of 32.0%; thus, the high rate in this sample could not be attributed to differences in parity. Besides, we observed that there is a gross variation of percentages across health administrative areas (MOH areas) where more than 50% of the areas had one in four primiparous pregnancies being among adolescents. Hence, these findings urgently warrant action.
The socio-demographic characteristics of pregnant adolescents in this sample are similar to those that are documented in global, regional, and local studies (7)(11)(29). In a similar vein, our study findings suggest a significant association of low educational level with adolescent pregnancies. It is expected to have a low level of education since they are still young; yet, our analysis shows that a significantly higher number has not completed Grade 11, which is usually completed at the age of 16 years. Despite having a free education system in Sri Lanka, we observe that early dropouts from school are associated with adolescent pregnancies in the district. Interventions targeting to improve school retention and targeted SRH campaigns for school dropouts in rural areas are some suggestions to improve the situation.
In accordance with the available literature (8, 9), our study suggests that adolescent primiparous mothers are not physically and mentally ready for pregnancy or childbearing. Adolescent mothers had suboptimal BMI, high prevalence of anemia, and poor mental health status, which will have short and long-term effects on both mother and child as well as on the family and society. The findings further emphasize the importance of optimizing the health status of females of the reproductive age group from the pre-conceptional level. Thus, the mechanisms for early identification, referral, and follow-up for health and nutritional problems among female adolescents need to be further strengthened.
In the free education system in Sri Lanka, SRH education is incorporated into the curriculum to be taught before mid adolescents (18). Even though almost all (98.6%) primiparous mothers have completed education beyond Grade 8, in which basic SRH education is supposed to be taught at schools, 47.1% of adolescent mothers compared to 37% of older age group stated that they have not received any SRH before pregnancy. This reflects that despite universal SRH education, adolescents who have become pregnant have less grasped the concepts during their schooling. Given that a multitude of factors could contribute to the high prevalence of adolescent pregnancies, it is an opportune time to evaluate the efficiency of SRH education in the Sri Lankan school curriculum on students of different socio-cultural backgrounds. According to our study, 34.4% of primiparous adolescents were within six months of marriage. Considering the relatively high level of education in the sample, it is obvious that they conceived either while schooling or just after cessation of education. This reflects the importance of keeping the girls in schools and a comprehensive education sector response to preventing adolescent pregnancies. Hence the SRH education and youth-friendly Health service strategies need to be re-evaluated.
Sri Lanka has a well-established maternal care service package delivering accessible field clinic-based and domiciliary care by the area public health team targeted at pre-conceptional, antenatal as well as postnatal care (30). These services include the provision of appropriate family planning services, risk assessment, and health promotion for all newly married couples. The service utilization by adolescents during the pre-conceptional period is significantly lower than the older pregnant women in this sample. It is noteworthy to observe that approximately half of the adolescent primiparous mothers have reported that they have not used any contraceptive method and also that the current pregnancy was unplanned. These results indicate a very high unmet need for family planning. The finding that a high percentage of adolescents conceive within twelve months implies that family planning services including counseling are not met to postpone pregnancy among them. It is also noteworthy that around 17% of adolescent primiparous women have attended pre-conceptional clinics. The reasons for not facilitating postponement of pregnancy by health care providers at this stage need to be investigated further.
Sri Lanka maternal care program had the "safe motherhood" clinics aiming at newly wedded married couples since the introduction of the safe motherhood program. Streamlining these services, the Sri Lankan maternal care program introduced focused pre-pregnancy sessions on important health issues for married couples (30). Living together or married adolescents should be a prime target of pre-conception service package because of their high physical and mental vulnerability levels. However, both the low participation and lack of awareness of pre-pregnancy sessions raise concerns concerning the utilization of these sessions by adolescents in the target group. Availability and access to services and creating awareness of such services among adolescents could contribute to increasing participation. In addition, present strategies of inviting newly married couples to the pre-conceptional sessions need to be revised and expand to include couples who are living together and who intend to marry. Appropriate modes of communication should be used to attract vulnerable groups for the program to improve utilization.
In the view of reducing adolescent pregnancies, Sri Lanka needs to adopt innovative as well as effective multisectoral strategies for adolescent and youth development (14). The findings of this study question the acceptability, awareness, and feasibility of preconception care services in the study area. Exploration of factors that lead to under-utilization of services needs to be addressed. It is of utmost importance to further assess the underlying root causes for not using freely available family planning methods, considering the aspects of awareness, availability, accessibility as well as acceptability. Focusing on micro geographical and ethnic disparities would be essential in planning interventions.
This study has several limitations. All pregnant women registered in the maternal care program of the Anuradhapura district were invited to participate in the study. Although the participation rate was very high as the special clinics that recruited participants were incorporated to the essential service provision pathway, we may have missed recruiting few mothers of the district. Although there is vey high coverage of the maternal care program of the Anuradhapura district (23), a very small percentage of women may have not been captured by the program. As the pre-conceptional services are not streamlined in the system as antenatal care services, service provision may not be the same universally within the district. For this reason, the pattern of pre-conceptional care services utilization should be cautiously interpreted and further investigated to distinguish between service availability and utilization.