Sexuality education is key to addressing adolescent pregnancies in Tanzania; a cross-sectional study and content analysis of vital national reports

doi:10.21203/rs.3.rs-2497299/v1

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Sexuality education is key to addressing adolescent pregnancies in Tanzania; a cross-sectional study and content analysis of vital national reports

https://doi.org/10.21203/rs.3.rs-2497299/v1

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Background

Tanzania is among the countries with higher rates of adolescent pregnancy. In some parts of the country, 45% of teenage girls become pregnant before their nineteenth birthday; and the strategies to alleviate the situation remain partially understood. The current study aimed to assess the knowledge level of adolescents on sexuality issues and the factors contributing to teenage pregnancy, as well as the progress made by Tanzania in addressing this problem.

Methods

A cross-sectional study was carried out on students from four randomly selected secondary schools in Morogoro municipality; an area with a high rate of adolescent pregnancy in Tanzania. Data were collected using structured questionnaires. Qualitative data from the study and data from the Demographic Health Surveys and Household Budget Surveys were analyzed by content analysis.

Results

Among the 250 respondents, 83.6% (n = 209) were in the age group 13–18 years and the rest (16.4%) were 19 + years. Most (96%, n = 240) mentioned that adolescent pregnancy is more common in poor societies, and 73.6% (n = 190) cited a lack of knowledge of reproductive health as a major contributing factor. More than 55% did not know any other method of contraception, apart from a male condom. Only 41.6% of female and 18.8% of male respondents correctly knew about the day of ovulation. From content analysis, it was revealed that girls’ enrolment declines from 50% of the total in primary education to 30% of the total students’ enrolment in colleges and universities. The overall teenage pregnancy rate in the country increased by 4 percentage points; from 23% in 2010 to 27% in 2016.

Conclusions

Adolescent girls in Tanzania are less empowered because they lack comprehensive sexuality education, hence, the higher rates of adolescent pregnancy. Introducing age-appropriate sexuality education and increasing girls’ enrolment in secondary and tertiary education will significantly reduce the rate of teenage pregnancy.

Sexuality education

Adolescents

Pregnancy

Sustainable Development Goals

Adolescent or teenage pregnancy refers to a pregnancy diagnosis at the age of 19 years or younger, and is a major health concern. Adolescent pregnancy is associated with serious obstetric complications such as eclampsia, fistula, puerperal infections, and maternal death, mainly due to immaturity and lack of readiness of the reproductive organs to accommodate the physiological changes of pregnancy. Infants born to adolescent mothers are also at an increased risk of dying due to various complications [1, 2].

The global adolescent birth rate (ABR) declined from 64.5 in 2000 to 42.5 births per 1000 women in 2021. There are, however, uneven statistics of adolescent birth rates among regions, within regions, and within countries. While remarkable progress was observed in Europe and Southern Asia by end of 2021, Latin America and sub-Saharan African regions still have the highest ABR in the world at 53.2 and 101 births per 1000 women, respectively [3]. In these developing regions, about 21 million adolescent girls aged 15–19 years become pregnant every year, and nearly 57% of them give birth [4]. The sub-Saharan African region is heavily burdened with adolescent pregnancies and it recorded the highest number of adolescent childbirths at 6,114,000 births in 2021. Among these, 332,000 childbirths were registered to adolescents aged 10–14 years. In contrast, the Central Asian region registered only 68,000 childbirths to adolescent girls in the same year [3].

Differences are also noticed within regions. In the sub-Saharan African region for instance, the prevalence of adolescent pregnancy is highest in East Africa (21.5%) and lowest in Northern Africa (9.2%) [5, 6]. Adolescent birth rates also vary from one region to another within countries. A study conducted in Zambia [7], found that 14.9% of adolescent girls aged 15–19 years were either pregnant or have had a birth in the city of Lusaka, and 42.5% in the Southern Province. In the United Republic of Tanzania, higher teenage childbearing rates are observed in Katavi (45%), Tabora (43%), Dodoma (39%), Morogoro (39%), and Mara (37%) regions [8]. Teenage childbearing rates are lowest in Mjini Magharibi (5%) on the island of Zanzibar and Kilimanjaro (6%) in northeastern mainland Tanzania. In general, the teenage pregnancy rate in Tanzania increased by four percentage points from 23% in 2010 to 27% in 2016, and the adolescent fertility rate increased from 116 to 132 births per 1,000 women aged 15–19 years in the same period. By the end of 2016, one in every four adolescent girls aged 15–19 years in Tanzania had begun childbearing. Adolescents in rural areas are more likely to begin childbearing (32%) than those living in urban areas (19%). The reason for these regional differences in adolescent pregnancy rates lie in the contributing factors.

The factors contributing to high rates of adolescent pregnancy have been described previously [9–12], and are shared among regions. In Tanzania and East Africa at large, the main driving factors are a lack of appropriate and adequate knowledge of reproductive health, poor access to sexual and reproductive health (SRH) services, poverty, and unclear policies and legal frameworks on reproductive healthcare. While the factors are well known, it is not fully understood how Tanzania is addressing them; and whether there is any success in mitigating the problem, has remained elusive. The current work attempted to find out. Possible approaches to curb the high rates of adolescent pregnancy are also discussed.

A mixed study design was employed. A cross-sectional analytical study involving 250 adolescent students from four randomly selected secondary schools was conducted in Morogoro municipality. The study area was purposely selected because it is among the areas with high adolescent pregnancy rates in Tanzania [8]. Participants were prescribed questionnaires and were required to respond to questions that aimed at testing their knowledge of sexuality issues including teenage pregnancy.

Data analysis

Obtained data were compiled and analyzed descriptively. The publicly available data from the national surveys namely, Demographic Health Surveys (DHS), Household Budget Surveys (HBS), and ‘Tanzania in Figures’ were analyzed by content analysis. As described elsewhere [13], content analysis allows for organizing and eliciting meaning from collected data, hence, concluding. DHS protocols are reviewed and validated by the Institutional Review Board (IRB) and follow a two-stage sampling stratification and observe a standardized procedure throughout the process, from sampling to data cleaning, to ensure compliance with the country’s laws and norms. The details of the DHS consent process have been stipulated previously and are available from https://www.dhsprogram.com/What-We-Do/Protecting-the-Privacy-of-DHS-Survey-Respondents.cfm.

The cross-sectional study involved 250 participants and among them, 83.6% (n = 209) were in the age group 13–18 years and the rest were 19 + years, (Table 1).

Table 1

Demographic characteristics of study participants
Variables	Response	Frequency	%
Age (Years)	13–15	62	24.80
	16–18	147	58.80
	19+	41	16.40
Sex	Female	149	59.60
Sex	Male	101	40.40
Year of study	Form I	23	9.20
	Form II	41	16.40
	Form III	60	24.00
	Form IV	69	27.06
	Form V	33	13.20
	Form VI	24	9.60

Most (96%, n = 240) respondents mentioned that adolescent pregnancy is more common in poor societies, and 74% (n = 185) cited a lack of knowledge of reproductive health, including contraceptive methods as a major contributing factor, (Fig. 1). Poor access to reproductive health services (9%) and cost of the services (7%) were other factors mentioned, in a low percentage.

The assessment of knowledge and utilization of family planning methods revealed that only 41.6% of female and 18.8% of male respondents correctly knew about the day of ovulation, (Table 2).

Table 2

Participants’ knowledge of the day of ovulation
Responses	Sex
Responses	Female	Male	Total
During menstruation	3(1.2%)	17(6.8%)	20(8%)
A week after menstruation	21(8.40%)	14(5.6%)	35(14%)
Two weeks before menstruation	104(41.6%)	47(18.8%	151(60.4%)
Every day (any day)	4(1.6%)	9(3.6%)	13(5.2%)
Don’t know	14(5.6%)	17(6.8%)	31(12.4%)
Total	149(59.60%)	101(40.40%)	250(100%)

Regarding family planning methods, more than 55% of the respondents did not any other method of contraception, apart from male condoms, (Fig. 2). Only a few, 14% mentioning oral contraceptive pills, 10% calendar method, 8% IUCD (intra-uterine contraceptive device), 7% implants, and 6% injections, knew other contraceptive methods.

From content analysis, it was revealed that girls’ enrolment declines from 50% of the total in primary education to 30% of the total students’ enrolment in colleges and universities, (Figs. 3a & b).

It was found in the current study that, there are still unacceptable high rates of adolescent pregnancy in most parts of Tanzania, and that the two major driving factors are a lack of adequate knowledge of reproductive health and poverty. About 50% of adolescent pregnancies in low- and middle-income countries are unintended and over 55% of them end up in abortions, which are often unsafe [4]. Every year, nearly four million girls aged 15–19 years undergo unsafe abortions in the world. It is worth noting that, pregnancy and childbirth complications are the leading cause of death among girls aged 15–19 years in low- and middle-income countries [14]. Generally, abortion is illegal in Tanzania; however, it can be legally obtained if it is meant to save the life of the pregnant woman. The confusing abortion policies and laws in Tanzania make many pregnant women, especially pregnant adolescent girls, turn to unsafe abortions that are associated with serious health complications. Abortions and miscarriages account for 14% of maternal deaths in Tanzania [15]. In a situation like this, empowering girls with formal and sexuality education is of paramount importance.

Adolescents need and have the right to access a skills-based education including sexuality education that empowers and helps them make conscious and healthy choices about relationships. In Europe, sexuality education started first in Sweden more than half a century ago (1955) and spread to other Western European countries between 1970 and 1980 [16]. It became a school curriculum subject in most parts of Europe in the 1990s and early 2000s. In contrast, most countries in the developing regions, particularly sub-Saharan Africa have not introduced sexuality education in their schools’ curricula; they remain conceived that sexuality education encourages children to practice sexual activities. It is mainly due to this reason that the region has higher rates of adolescent childbirths (101 births per 1000 women) than anywhere else on earth [3, 17]. A body of research [18–20] attempted to describe the state and importance of sexuality education in Tanzania. In the study about teaching school-based sexuality education in Tanzania, Mkumbo [20] emphasized the need for facilitating teachers with the knowledge and skills required to teach sexuality education. The current study thus underscores the importance of introducing compulsory, more focused, age-appropriate, and culturally acceptable sexuality education in Tanzania’s school curricula.

Low socio-economic family status has been established as a factor contributing to adolescent pregnancy [12, 13]. Adolescent girls from poor families are twice as much vulnerable to early sexual activities and marriage, as their counterparts from wealthy families. Generally, Tanzania is considered to be on the track toward achieving the SDG (Sustainable Development Goal) for poverty reduction. Nevertheless, the in-country produced data may be hard to comprehend. A conclusion drawn from Tanzania’s Household Budget Surveys (HBS) which are conducted every five years was that basic needs poverty declined from 28.2% in 2011/2012 to 26.4% in 2017/2018 [21].

Tanzania is struggling to curb the high rates of adolescent pregnancy and childbirths that are associated with not only school dropouts, but also serious health consequences. However, the strategy is unclear and as a result, most adolescents aged 15–19 years in the country have very limited knowledge of reproductive health services. The current study underscores the need for the government of the United Republic of Tanzania to introduce sexuality education as a compulsory school-based subject in primary and secondary schools’ curricula to empower youth to be able to make informed choices regarding sexual relationships.

Ethics approval and consent

A Research Ethics Committee of the University of Dar es Salaam, Mbeya College of Health and Allied Sciences approved this study.

All methods employed in this study were carried out in accordance with relevant guidelines and regulations (declaration of Helsinki). Informed consent was obtained from all study participants and/or their legal guardians.

Consent for publication

N/A.

Availability of data and materials

The datasets used and/or analysed during the current study available from the corresponding author on reasonable request.

Competing interests

The author has no competing interests to disclose.

Funding

The author has no funding source to report.

Authors' contributions

A.H.C conceived the idea, carried out the study, analyzed the data, and wrote the original manuscript.

Acknowledgement

The author thanks the heads of the schools surveyed for allowing their students to participate in the study.

Authors' information

AHC is a doctorate (Ph.D.) alumnus of the University of Tokyo, Japan, and is currently a Lecturer of Medical Physiology at the University of Dar es Salaam, Mbeya College of Health and Allied Sciences, Tanzania. His research interests include Reproductive Medicine and Cancer Biology.

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No competing interests reported.

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Sexuality education is key to addressing adolescent pregnancies in Tanzania; a cross-sectional study and content analysis of vital national reports

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Abstract

Background

Methods

Results

Conclusions

Figures

Introduction

Methods

Data analysis

Results

Discussion

Conclusions

Declarations

Authors' information

References

Additional Declarations

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