Interventions to prevent unintended pregnancies among adolescents: A rapid overview of systematic reviews

doi:10.21203/rs.3.rs-2568862/v1

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Interventions to prevent unintended pregnancies among adolescents: A rapid overview of systematic reviews

https://doi.org/10.21203/rs.3.rs-2568862/v1

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published 19 Oct, 2023

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Risks associated with unintended pregnancy include unsafe abortions, poor maternal health-seeking behaviour, poor mental health and potentially, maternal and infant deaths. Adolescent girls faced with an unintended pregnancy are particularly vulnerable as they are at higher risk of eclampsia, premature onset of labour, and increased neonatal morbidity and mortality. Unintended pregnancy, with the right combination of interventions, can be avoided. Evidence-based decision-making and the need for a robust appraisal of the evidence have resulted in many systematic reviews. This review of systematic reviews focuses on adolescent pregnancy prevention and will seek to facilitate evidence-based decision-making. Two review authors independently extracted data and assessed the methodological quality of each review according to the AMSTAR 2 criteria. We identified three systematic reviews from low- and middle-income countries (LMICs) and high-income counties (HICs) and included all socioeconomic groups. We used vote counting and individual narrative review summaries to present the results. Overall, skill-building, peer-led and abstinence programmes were generally effective. Interventions focused on information only, counselling and interactive sessions provided mixed results.

In contrast, exposure to parenting and delaying sexual debut interventions were generally ineffective. Adolescent pregnancy prevention interventions that deploy school-based primary prevention strategies, i.e., strategies that prevent unintended pregnancies in the first place, may effectively reduce teenage pregnancy rates, improve contraceptive use, attitudes and knowledge, and delay sexual debut. However, the included studies have methodological issues, and our ability to generalise the result is limited.

The adolescent population (aged 10–19 years old) in sub-Saharan Africa is growing (Bakilana, 2015). Child mortality on the continent is declining faster than fertility which has increased the relative proportion of the adolescent population (Masquelier et al., 2021). Consequently, many countries enter a new demographic era that allows them to leverage this youthful population to ensure a favourable population structure for social and economic gains(Cardona et al., 2020). For countries to reap these social and economic benefits, targeted investments in adolescents’ health, education, and well-being must be sustained. However, approximately 12 million adolescent girls fall pregnant in the developing world, and nearly 10 million are unintended (Darroch, 2016).

The potential consequences of unintended adolescent pregnancies are well known. They include adverse developmental, economic and health outcomes such as child undernutrition, increased risk of school dropout rates and decreased educational attainment. (Fielding & Williams, 1991; Wemakor et al., 2018) Adolescents are more likely to be discriminated against when seeking information and services related to sexual and reproductive health because they may feel embarrassed or encounter judgmental providers and be stigmatised. (Biddlecom et al., 2007; Santhya & Jejeebhoy, 2015) In contexts where contraceptive and abortion services are unavailable, difficult to access or illegal, this can result in women opting for and receiving sub-standard or unsafe services. These risks are heightened for adolescent girls and can lead to long-term adverse health impacts and death (Crowley et al., 2019).

Early childbearing is also associated with risks for adolescent girls who continue the pregnancy. Compared to older mothers, adolescent mothers are far more likely to deliver prematurely, suffer complications during labour, and give birth to a low-birth-weight baby (Azevedo et al., 2015). Moreover, children born to adolescent mothers are far more likely to be stunted, wasted or underweight (Wemakor et al., 2018).

Pregnant adolescents and adolescent mothers drop out of school at much higher rates than their non-pregnant peers, even in countries with policies encouraging pregnant adolescents to remain in education (Stoner et al., 2019). A lack of education limits the economic and social opportunities available to girls and increases their dependency on others and, in turn, their vulnerability. Adolescent pregnancy is a public health problem. Sustainable development goal (SDG) 3.7.2, which focuses on the adolescent birth rate, acknowledges this and tasks the global community to address this issue. In sub-Saharan Africa (SSA), approximately one in five teenage girls becomes pregnant (Kassa et al., 2018). Although the overall adolescent birth rate trends downwards, the region is still lagging (Nations & Affairs, 2019).

The COVID-19 pandemic has exacerbated this public health problem by interrupting access to essential health services (Kassa et al., 2018). In addition to health services being interrupted, other essential services, such as schools, were also affected. There is an evidence base for the protective effect schooling has on adolescent girls, as it decreases their likelihood of both becoming a child bride and falling pregnant (Adu Boahen & Yamauchi, 2017; Malhotra & Elnakib, 2021; Rasmussen et al., 2019). Access to adolescent-friendly sexual and reproductive health services is critical for girls who find themselves pregnant. Despite this, many girls have been unable to attend school and access sexual and reproductive health services due to national lockdowns and severe restrictions on movement, which have significantly increased their chances of getting pregnant. (Malhotra & Elnakib, 2021). As national governments seek not only to address the virus but also the consequences of the virus, such as an increase in child marriages, school dropouts and pregnancy, policymakers want to understand better what interventions work and how applicable these interventions are to their context (Meherali et al., 2021; Zulaika et al., 2022).

Description of the condition

Unintended pregnancy is defined as a pregnancy that is either unwanted, such as a pregnancy that occurs when no children are desired, or a pregnancy that is mistimed, such as pregnancies that occur earlier than desired (Santelli et al., 2003). Approximately 40% of all global pregnancies are unintended, and a quarter of these occur in sub-Saharan Africa (Bain et al., 2020). Amongst adolescent girls, the issue is particularly acute, with at least 10 million 15–19 year-old girls in the developing world having to deal with unintended pregnancy (Darroch, 2016). Unintended pregnancies tend to occur when adolescent girls or their partners do not use family planning methods, use them incorrectly or inconsistently or are coerced into sex. Unintended pregnancy is not a static concept since pregnancy can start by being intended and then become unintended because of circumstances in which the adolescent finds herself. Many factors influence the different pathways that lead to an unintended pregnancy. This includes but is not limited to a lack of SRH knowledge, access to adolescent-friendly SRH services and lack of resources to access services (Yakubu & Salisu, 2018). The inability to openly discuss and make contraceptive decisions has also been cited as a barrier for adolescent girls, particularly girls with older partners (Kassa et al., 2018).

Unintended pregnancy is associated with an increased risk of unsafe abortions, poor maternal health-seeking behaviour, poor mental health and potentially maternal and infant deaths (Barton et al., 2017; Hubacher et al., 2008; Wado et al., 2013). A recent study compared children’s morality rates amongst first-time mothers aged < 16 years, 16–17 years and 18–19 years and found they were about 2–4 times, 1.5–2 times and 1.2–1.5 times higher, respectively than among children of mothers aged 23–25 (Noori et al., 2022).

Adolescent girls faced with an unintended pregnancy are particularly vulnerable as they are at higher risk of eclampsia, premature onset of labour, as well as increased neonatal morbidity and mortality. Complications like pregnancy-induced hypertension (11.4% vs 2.2%, p < 0.01), pre-eclamptic toxaemia (4.3% vs 0.6%, p < 0.01), eclampsia (4.9% vs 0.6%, p < 0.01) and premature onset of labour (26.1% vs 14.6%, p < 0.01) occurred more commonly in teenagers compared to women aged 20–30 years old (Kumar et al., 2007). Unintended pregnancy, with the right combination of interventions, can be avoided. The right interventions must first address the economic, socio-cultural and environmental factors that place adolescents in a position to deal with an unintended pregnancy. It is also necessary to implement these interventions within a context that ensures girls can access essential health services but also addresses individual-level factors like education and self-esteem for girls to take control of their sexuality and utilise the services available to them.

Description of the intervention

For this study, we define intervention(s) as any activities that target adolescents and are undertaken to prevent unintended pregnancies amongst adolescent girls. Pregnancies can be prevented by encouraging adolescents to delay their sexual debut, countering child marriage practices, increasing uptake and continued use of contraception, and educating girls and boys on the risks associated with unintended pregnancies (Oringanje et al., 2016a). Drawing from the literature on evidence-based guidelines for preventing adolescent pregnancies (Taylor & James, 2011), we identify three pregnancy prevention strategies as follows.

Primary prevention strategies: Include strategies that prevent unintended pregnancies in the first place. Examples are a supportive family environment, comprehensive sexuality education, contraception, and prevention and detection of sexual and gender-based violence.
Secondary management strategies: Early pregnancy diagnosis and counselling on pregnancy options, including access to safe abortion care.
Tertiary management strategies: Prevention of adverse events associated with unintended pregnancy, for example, treatment of incomplete abortion; access to services for psychosocial trauma; and services for antenatal care and maternity services to prevent maternal morbidity and mortality.

How the intervention might work

Communities that tend to be the most successful adopt a multifaceted approach, i.e. implement prevention programmes that operate at the primary, secondary and tertiary levels. These programmes seek to not only focus on sex and the potential consequence of engaging in unsafe sex but also address contextual factors such as social norms, empowerment, skill training and personal development. Moreover, the target group should not be limited to adolescent girls but also include adolescent boys, parents, teachers and community leaders (Oringanje et al., 2016a). For this review, we focus on primary prevention strategies. For example, school-based programmes delivered via the school platform mainly focus on psychosocial risk and protective factors that involve sexuality. These primary prevention strategies aim to improve adolescent girls’ and boys’ knowledge and awareness of their sexual reproductive health and reduce unintended pregnancies (Taylor et al., 2014).

Leveraging the school platform to deliver interventions helps ensure that students have a safe space to learn about their sexuality, pregnancy prevention and the transmission of sexually transmitted diseases, and where to access SRH services. Moreover, school-based programmes allow adolescents to engage with these topics in a socially acceptable forum. Delivering sex education via schools ensures that more adolescents are reached before their sexual debut (Mantell et al., 2006).

Although clinic and community-based (i.e. establishing health clubs to educate on SRH and facilitate referrals to clinics, mobile health clinics for youth and SRH services within youth centres) tend to incorporate elements of educational programmes, unlike school-based interventions, these sessions can also be delivered separately as a stand-alone intervention both within the clinic or outside on the broader community. These types of interventions also seek to promote access to family planning services for adolescents, improve adolescents’ knowledge of methods and dispel misconceptions (Ross et al., 2007). Community contraceptive-promoting activities can also seek to shift social norms within the community that inhibit the uptake of methods which also facilitates the acceptability of sex educational programmes at school, the creation of adolescent-friendly services and the promotion and distribution of methods (Ross et al., 2007).

Youth development interventions not only focus on the sexual health needs of the target population but also address these needs within a programme that tries to tackle other cross-cutting issues through skill building and mentorship. The success of these programmes is contingent upon the involvement of various stakeholders such as schools, religious groups, health officials, and adolescents. In addition, implementors must ensure the intervention is practical, culturally apt and evidence-based (Oringanje et al., 2016b).

Why it is essential to do this review

Evidence-based decision-making and the need for a robust appraisal of the evidence have resulted in many systematic reviews. Systematic reviews are a valuable tool for summarising a large body of evidence, and this is reflected in the statistics that approximately 22 new systematic reviews are published daily (Hasanpoor et al., 2019). However, a large number of systematic reviews leads policymakers and other decision-makers to find themselves unable to call upon a single document that robustly apprises the current state of the evidence. Currently, many systematic reviews focus on adolescent pregnancy prevention. A decision-maker who wants to understand better what interventions they can implement to curb adolescent pregnancy rates would have to review multiple different systematic reviews. A systematic review like this one aims to focus more broadly on an outcome, such as unintended adolescent pregnancy, and identify potentially effective interventions (Aromataris et al., 2015). Thus, this review of systematic reviews focuses on unintentional adolescent pregnancy prevention and will seek to facilitate evidence-based decision-making.

Objectives

To synthesise existing and emerging systematic reviews on interventions to prevent unintended adolescent pregnancy.

Specific objective

To understand barriers to and enablers of interventions focused on adolescent pregnancy prevention.
To identify the best practices and interventions to combat unintended adolescent pregnancy.

The study’s method of synthesis was adopted from the provisional recommendations from the Cochrane Rapid Reviews Methods Group (Garritty et al., 2021). This methodology is the Cochrane provisional recommendation for conducting a rapid review of systematic reviews. In addition, we also reviewed two papers that provided reporting guidelines for overviews of reviews (Gates et al., 2022; Pollock et al., 2019). The study is registered with PROSPERO, registration number CRD42021266470.

PICOST matrix

Population: Adolescent girls 15–19 years of age.
Intervention: Any primary prevention strategy that may lead to a reduction of unintended adolescent pregnancies.
Study setting: All global studies focus on adolescent pregnancy prevention.
Comparator: No intervention targeting to reduce unintended adolescent pregnancy over and above the ones listed under interventions.
Outcomes: The outcomes include

o Primary outcome: Unintended adolescent pregnancy.

o Secondary outcomes:

Use of contraception
Change in knowledge of contraceptive effectiveness or effective method use
Change in attitude towards contraception use
Study design: The study only included completed systematic reviews.
Time: The time frame spanned systematic reviews conducted between January 2015 to June 2021,

Search methods for identification of studies

We searched for published resources in selected databases and selected systematic studies published in English from January 2015 to June 2021 (see Table 5). The databases searched include Cochrane Library, PubMed and Epistemonikos. Medical subject headings and keywords used include “unintended pregnancy” and “adolescents” or include “unintended pregnancy” and “teenage” or “unwanted pregnancy among adolescents” or “mistimed pregnancy among adolescents” or “unwanted pregnancy among teenagers” or “mistimed pregnancy among teenagers” or “unwanted childbearing among teenagers” or “mistimed childbearing among teenagers” or “unwanted childbearing among adolescents” or “mistimed childbearing among adolescents” from January 2015 to June 2021.

We conducted an updated search of the three databases (Cochrane Library, PubMed, and Epistemonikos) for the period between November 2021 and October 2022. We found no new systematic reviews focused on school-based intervention to reduce unintended pregnancy amongst adolescent girls.

Searching other resources:

Not applicable

Data Collection And Analysis

Selection of studies

We adopted a 2-step screening process. In the first step, two authors, i.e. (SM and MC) (TK and CC), independently screened the abstract of the studies retrieved from the electronic databases. After that, a full text of eligible studies was obtained for further review and the final selection of eligible studies for analysis. All the articles that did not meet the inclusion criteria were eliminated, and the reviewer indicated the reasons for elimination. Any disagreement that surfaced during the review was solved by a third party (either LA or LN) after thorough discussions were done on the issue.

Data extraction and management

Using a modified COCHRANE collaboration data extraction form (Cochrane Collaboration, 2022), we extracted and entered data from all study articles that met the inclusion criteria. The form also guided reviewers on extracting and recording data for uniformity. The following details were extracted from the included systematic reviews:

Name of the first author

Publication year

Location of the study

Data collection period

Adolescent pregnancy preventions interventions and

Analysis methods

Assessment of methodological quality of included reviews

We assessed the methodological quality of each systematic review using AMSTAR 2: “A Measurement Tool to Assess Reviews 2” (Shea et al., 2017). The AMSTAR 2 is a critical appraisal tool with 16 criteria to evaluate the quality of randomised controlled trials’ systematic reviews. For this review, we grouped the bottom (scores 0 to 4), middle lower (scores 5 to 8), middle-upper (scores 9 to 12), and upper (13–16) quartiles. Two review authors independently performed quality assessments (SM and MC), and discussion between review authors resolved disagreements.

Data synthesis

We organised the results according to (i) the type of adolescent pregnancy prevention intervention(s) and (ii) the type of outcomes being assessed. We only included studies that reported our primary outcome of interest, unintended adolescent pregnancy. Having viewed the outcomes reported, we categorised them into five groups: unintended adolescent pregnancy rates, improved contraception use; improved knowledge; improved attitude towards contraception use, and delayed sexual debut. We used vote counting and individual narrative review summaries to present the results. We reported all outcomes reported by the studies within the relevant category (not preferencing one outcome over a similar or overlapping one). We then reported results as the number of outcomes favouring the intervention out of the total number of outcomes, based on the direction of effect and not necessarily statistical significance as suggested by the Cochrane Handbook for Systematic Reviews of Intervention.

Our initial electronic database search generated 4,626 titles. After searching and removing duplicates, 4,508 titles remained. During the first round of screening, we excluded 4,481 titles and reviewed the remaining 27 titles in more detail. Of the 27, 24 were excluded for reasons elaborated in Table 1 in the annexes and three studies were included in the overview of systematic reviews; (Lopez et al., (2016); Mason Jones et al., (2016); Oringanje et al., (2016)). Figure 1 below elaborates on the study screening and selection process.

Table 1

List of Excluded Articles (after the title and abstract or full-text review)
Reviews	Reasons for exclusion
Ampt et al., 2018	Wrong study population
Aventin et al., 2021	No numerical data reported on the primary outcome
Biddlecom 2007	No numerical data reported on the main outcome
Fielding and Williams, 1991	No numerical data reported on the primary outcome
Kassa et al., 2018	Does not report data on any of the pre-specified outcomes
Laurenzi et al., 2020	Interventions do not focus on pregnancy prevention
Morales-Alemán and Scarinci 2016	No numerical data reported on the primary outcome
Munakamp et al., 2018	Interventions do not focus on pregnancy prevention
Pradhan et al., 2015	Interventions do not focus on pregnancy prevention
Rizvi et al., 2020	Interventions do not focus on pregnancy prevention
Roberts et al., 2021	Interventions do not focus on pregnancy prevention
Ross et al., 2007	Not a systematic review
Vanderkruik et al., 2021	Interventions do not focus on pregnancy prevention
Yakubu 2018	Interventions do not focus on pregnancy prevention
Arnold 2020	Insufficient information on provided on the methods
Evans 2020	data were not reported on an individual study basis
Gavin et al., 2015	No numerical data reported on the primary outcome
Maravilla et al., 2016	No numerical data reported on the primary outcome/ wrong study population
McQueston et al., 2013	no numerical data reported
Nkhoma et al., 2020	no numerical data was reported or the data reported were incomplete in that tests of significance were reported without numerical outcome data
Salam et al., 2016	Data were not reported on an individual study basis
Taylor et al., 2014	Not a systematic review
Tolli 2012	Data were not reported on an individual study basis
Whitaker et al., 2016	Does not report data on any of the pre-specified outcomes

Summaries of individual reviews

Lopez et. al., (2016)

Lopez et al. (2016) stated that the aim was to ‘identify school-based interventions that improved contraceptive use among adolescents. Lopez et al. (2016) searched five databases. They also searched trial registries for recent trials. The study included twenty-one trials, but only the five studies that measured unintended pregnancy were included in this review. All five studies were cluster randomised control trials based in schools. The students were aged between 13 to 18 years. Four out of five of the studies took place in the global north: two in the United States (Coyle 2006; Kirby 1997) (cited inLopez et al., 2016) and two in the United Kingdom (Wight 2002; Stephenson 2008 cited in Lopez et al., 2016). Taylor’s 2014 South African study is the only exception. One study evaluated the effect of a school-based intervention that combined active learning, information provision, and skill development to reduce unsafe sexual behaviour and unwanted pregnancies and improve the quality of sexual relationships (Wight 2002, cited in Lopez et al., 2016). Another study looked at skills-based HIV, sexually transmitted Infections (STI), and pregnancy prevention curricula. It compared this to standard school-based activities related to the prevention of HIV, STI, and pregnancy implemented by presenters from community-based agencies (Coyle, 2006, cited in Lopez et al., 2016). Another study addressed unwanted teen pregnancies holistically and looked at an interactive programme that addressed choice, body development, contraception and parenthood (Taylor, 2014, cited in Lopez et al., 2016).

Two studies looked at peer-led interventions. The first peer-led interventions evaluated the impact of HIV (AIDS) and pregnancy prevention with activities that focused on delaying intercourse and increasing contraception (Kirby, 1997, cited in Lopez et al., 2016). The second assessed a school-based peer-led sex education programme that focused on improving the quality of sexual relationships, STI and pregnancy prevention (Stephenson, 2008, cited in Lopez et al., 2016).

Mason Jones et al., (2016)

Mason Jones stated the aim was ‘to evaluate the effects of school-based sexual and reproductive health programmes on sexually transmitted infections (such as HIV, herpes simplex virus, and syphilis), and pregnancy among adolescents. Mason Jones et al. (2016) searched six bibliographic and two conference databases. The study included twenty-one trials, but only the six studies that measured unintended pregnancy were included in this review. All six studies were cluster randomised control trials based in schools. The students were aged between 13 to 18 years of age. Three studies were in sub-Saharan Africa (Duflo 2015; Ross 2017; Cowan 2010 cited in Mason-Jones et al. 2016). Two in Europe (Henderson 2007; Stevenson 2008 cited in Mason‐Jones et al., 2016) and one in Latin America (Cabezón 2005 cited in Mason‐Jones et al., 2016).

Teachers delivered interventions in four studies. The first, Cabezón (2016) (2016, cited inMason-Jones et al., 2016) evaluated the Teen STAR programme, stressing abstinence, fertility awareness, and the psychological and personal aspects of sexuality. Contraceptive use was not recommended. The second, Henderson (2007) (cited in Mason‐Jones et al., 2016), looked at the effect of a teacher-based programme that advised students to delay sexual intercourse and encouraged condom use. The third was Duflo’s 2015 (cited inMason‐Jones et al., 2016) trial that evaluated a teacher-delivered programme promoting abstinence until marriage. Ross (2007) (2007, cited inMason‐Jones et al., 2016) reviewed a teacher and peer assistant-led programme that aimed to provide knowledge and skills to delay sexual debut, reduce sexual risk-taking and increase appropriate use of health services.

Peer educators delivered two studies. Cowan (2007) (2007 cited in Mason-Jones et al., 2016) was delivered by professional peer educators whose HIV prevention activities adapted the ‘MEMAkwa Vijana’ programme, which included modules focused on self-awareness, communication, self-belief, and gender. This was delivered alongside programmes aimed at improving communication between parents and children and increasing support for adolescent reproductive health. Stephenson (2008) (2008 cited inMason‐Jones et al., 2016) trial looked at trained peer educators that delivered sessions that focused on sexual communication and condom use, knowledge about pregnancy, STIs (including HIV), contraception, and local sexual health services.

Oringanje et al., (2016)

The Oringanje et al. (2016) review aimed to assess the effects of primary prevention interventions on unintended adolescent pregnancies. Oringanje et al. (2016) searched ten electronic databases and three trial registers. The review contained fifty-three studies, but only eight that measured unintended pregnancy were included. Four were randomised control trials, and the remaining four were cluster randomised control trials. The study participants were aged between 12 to 19 years old. Five studies were in the USA (Herceg-Brown 1986; Morrison-Beedy 2013; Philliber 2002; Howard 1990; Kirby 1997 cited in Oringanje et al., 2016 ). For the remaining studies, Cabezon (2005) took place in Chile, Wight (2002) in Scotland, and Bonnell (2013) in England (cited in Oringanje et al., 2016).

All eight studies took a holistic approach to preventing unintended pregnancy. Four studies took place within the school setting (Howard 1990; Kirby 1997; Stephenson 2008; Cabezón 2005 cited in Oringanje et al., 2016). Cabezon (2005), Howard (1990) and Kirby (1997) (cited in Oringanje et al., 2016) all delivered in-person sessions on health/STI education, skills building and contraceptive education. Similarly, Wight (2002) (cited in Oringanje et al., 2016) delivered health/sex education, skills-building and contraceptive education. However, in this case, it was primarily delivered through interactive video.

Summary across reviews

The included reviews reported results from 19 studies, of which four were included in more than one review (Cabezón 2005; Kirby 1997; Stephenson 2008; Wight 2002) (cited in Lopez et al., 2016; Mason-Jones et al., 2016; Oringanje et al., 2016a). We did not remove the duplicates for this review but included them as individual trials. We had the following study designs: fifteen cluster randomised controlled trials and four individual randomised controlled trials.

Population and settings

The primary target audience for all of the studies included in the selected systematic reviews was adolescents. The age group started at 12–13 years of age, and the overall upper limit was 19 years in Morrison-Beedy 2013 (Oringanje et al., 2016a)). Three studies included male participants (Philliber 2002; Kirby 1997; Wight 2002) (cited in Lopez et al., 2016; Oringanje et al., 2016a). One study was unspecific (Howard (1990) cited in Mason-Jones et al., 2016, Oringanje et al., 2016). Sixteen out of 19 trials were in a school setting, and one was community-based. The setting was unclear for two studies included in this review (Morrison-Beedy 2013; Philliber 2002 cited in Oringanje et al., 2016). Eight trials were USA based. Two trials were based in Chile, England, Scotland and the UK and one in Kenya, South Africa, Tanzania and Zimbabwe. Thirteen studies were conducted in high-, three in middle and three in low-income countries. Of the 19 studies included in the three reviews, four were conducted between 1986-97, ten were between 2002-08, and five were conducted between 2008-15. All of the included reviews are at least seven years old, and 74% were performed at least ten years ago.

Teenage Pregnancy Prevention Interventions

We reviewed the nineteen studies and attempted to identify groups using the review author’s description. All interventions included sex education; therefore, studies were grouped based on additional intervention characteristics. We identified eight different adolescent pregnancy prevention intervention types or groups. All reviews did not contribute data to all categories but did contribute to at least one group.

i. Skills building

Interventions that provide instruction, practice, or other activities are designed to help the target audience build and enhance their skills. i.e. teachers deliver better SRH classes or academic tuition for adolescents

Two reviews (Lopez et al., 2016; Oringanje et al., 2016) reported data from five different studies (Coyle, 2006; Howard, 1990; Kirby, 1997; Wight, 2002; Philliber, 2002).

Wight (2002) (cited in Oringanje et al., 2016) identified teachers’ lack of sex education training as a barrier to the effective delivery of sex education classes. This paper investigated whether a teacher training intervention primarily delivered through an interactive video that combined active learning, information provision, and skill development would improve adolescent SRH outcomes. Coyle (2006) (cited in Lopez et al., 2016) compared the effects of skills-based HIV, STD, and pregnancy prevention curriculum plus service-learning activities implemented 2 or 3 times per week for 5 to 7 weeks against usual activities related to the prevention of HIV, STI, and pregnancy. Howard (1990) (cited in Oringanje et al., 2016) also looked at a skill-building health/STD and contraceptive education intervention. Kirby (1997) (cited in Oringanje et al., 2016) reviewed a classroom-based intervention that included health education, skills-building, and contraceptive education in addition to the standard sexuality curriculum. The team compared the impact of who delivered the sessions; teachers and young people. Philliber (2002) (cited in Oringanje et al., 2016) looked at the impact of a wide range of skill-building activities, including but not limited to job clubs, academic skills, art and other recreational activities, as well as counselling, contraceptive education and access.

ii. Interactive

Interventions are based on a principle of student engagement, which requires a balance between student and teacher voices. Students and teachers are equally engaged in learning.

One review (Lopez et al., 2016) reported data from one study (Taylor, 2014).

Taylor’s (2014) (cited in Lopez et al., 2016) intervention addressed concepts such as choice, body development and contraception using an interactive format.

iii. Peer-led

Interventions that use a method of teaching or facilitating health promotion that asks people to share specific health messages with members of their community

Three reviews (Lopez et al., 2016; Mason Jones et al., 2016; Oringanje et al., 2016) reported data from three different studies (Cowan, 2010; Kirby, 1997; Stephenson, 2008).

Cowan (2010) (cited in Mason Jones et al., 2016) evaluated ‘professional peer educators’ (PPEs) - i.e. school leavers who were selected, trained, supervised and worked in the community for 8 to 10 months on SRH with adolescents. Kirby’s (1997) (cited in Oringanje et al., 2016) was a peer-led HIV/AIDS and pregnancy prevention intervention with interactive activities that sought to delay intercourse and increase condom use. Stephenson (2008) (cited in Lopez et al., 2016) reviewed a school-based peer-led sex education project that included sexual communication, condom use, HIV/STI, and different types of contraception, including emergency contraception and local sexual health services.

iv. Delaying sexual debut

Interventions seek to influence the timing or assist young people in delaying sexual initiation.

One review (Mason Jones et al., 2016) reported data from two different studies (Henderson 2007; Ross 2007).

Henderson’s (2007) SHARE (Sexual Health and Relationships: Safe, Happy and Responsible) programme (cited in Mason Jones et al., 2016) trained class teachers on how to promote delayed sexual debut until they were ready and always use a condom until they planned to have children. Ross (2007) (cited in Mason Jones et al., 2016) examined teachers with peer assistants. The aim was to provide knowledge and skills to delay sexual debut, reduce sexual risk-taking and increase the appropriate use of health services.

v. Abstinence

Interventions that actively discourage sex before marriage

Two reviews (Oringanje et al., 2016; Mason Jones et al., 2016) reported data from two studies (Duflo, 2015; Cabezon, 2005).

Duflo (2015) (cited in Mason Jones et al., 2016) trained class teachers to deliver abstinence-focused sex education. Cabezon (2005) (cited in Mason Jones et al., 2016 and Oringanje et al., 2016) examined an intervention that delivered a 45-minute class per week for a year on health education and skills-building but focused on abstinence and did not recommend contraceptive use.

vi. Counselling

Interventions that use talking therapy with a trained professional to help clients address their sexual and reproductive health needs.

One review (Oringanje et al., 2016) reported data from one study (Herceg-Brown, 1986).

Herceg-Brown (1986) (cited in Oringanje et al., 2016) reviewed two different types of interventions. The first was a family support group (regular clinic services plus 50 minutes of family or individualised counselling services on sex and contraceptive education for six weeks). This was compared to a periodic support group plus staff support through two to six telephone calls every four to six weeks after the initial clinic visit to monitor teenagers’ adjustment to contraceptives received at the clinic.

vii. Exposure to parental responsibilities

Interventions that expose adolescents to the realities of being a parent, i.e. childrearing

One review (Oringanje et al., (2016)) reported data from one study (Bonell, 2013).

Bonell (2013) (cited in Oringanje et al., 2016) reviewed a study that delivered weekly three-hour sessions in preschool nurseries to develop an awareness of the responsibilities involved in parenting and build self-awareness and confidence to reduce the risk of teenage pregnancy.

Duration, frequency and intensity of adolescent pregnancy prevention interventions

The duration of all included adolescent pregnancy prevention interventions was described for all 19 studies. The frequency, however, was only described for eight studies.

Comparisons

The types of stated comparisons were i) no intervention; i) usual sex education/standard curriculum; iii) compulsory life skills programme, iv) youth programme, and v) general health promotion. In one study, the control intervention was not adequately described (Kirby, 1997, cited in Oringanje et al., 2016).

Outcomes

The primary outcomes from the included reviews are summarised in Table 2. Only outcomes that presented numerical data were selected.

Table 2

AMSTAR 2 framework review results
	Lopez (2016)	Mason Jones (2016)	Oringanje (2016)
1. Did the research questions and inclusion criteria for the review include the components of PICO?	3	3	4
2. Did the review report explicitly state that the review methods were established before the conduct of the review, and did the report justify any significant deviations from the protocol?	1	1	1
3. Did the review authors explain their selection of the study designs for inclusion in the review?	0	0	1
4. Did the review authors use a comprehensive literature search strategy?	0.5	1	1
5. Did the review authors perform study selection in duplicate?	1	1	1
6. Did the review authors perform data extraction in duplicate?	1	1	1
7. Did the review authors provide a list of excluded studies and justify the exclusions?	1	1	1
8. Did the review authors describe the included studies in adequate detail?	1	1	1
9. Did the review authors use a satisfactory technique for assessing the risk of bias (RoB) in individual studies included in the review?	1	1	1
10. Did the review authors report on the sources of funding for the studies included in the review?	0	0	0
11. If meta-analysis was performed, did the review authors use appropriate methods for the statistical combination of results?	N/A	1	0.5
12. If a meta-analysis was performed, did the review authors assess the potential impact of RoB in individual studies on the results of the meta-analysis or other evidence synthesis?	N/A	1	1
13. Did the review authors consider RoB in individual studies when interpreting/ discussing the review results?	1	1	1
14. Did the review authors provide a satisfactory explanation for and discussion of any heterogeneity observed in the results?	N/A	1	1
15. If they performed quantitative synthesis, did the review authors conduct an adequate investigation of publication bias (small study bias) and discuss its likely impact on the review results?	0	0	1
16. Did the review authors report any potential sources of conflict of interest, including any funding they received for conducting the review?	1	1	1
Total	11.5	15	17.5

Lopez et. al., (2016)

Two of the five included studies looked at adolescent pregnancy rates. Both interventions focused on skill-building. The remaining three studies examined self-reported ‘ever pregnant’ or caused a pregnancy. Two of these studies focused on peer-led interventions. One of these peer-led interventions also looked at abortion rates to deduce pregnancy rates. The third was an interactive programme that focused on choice and body development. Self-reported unwanted pregnancy was another outcome also measured in two studies that looked at peer-led and skill-based interventions separately.

Mason Jones et al., (2016)

All six papers included in this review looked at pregnancy prevalence or current pregnancy. Two papers investigated abstinence, two looked at peer-led interventions, and two focused on delaying sexual debut. Another outcome this review explored was ‘has been pregnant’. Two papers looking at delaying and peer-led intervention also measured this.

Oringanje et al., (2016)

All eight papers included in this review measured unintended pregnancy. Three articles looked at skill-building and rates of unintended pregnancy. The remaining five papers individually looked at the effect of the following interventions on unintended pregnancy: exposure to parenting, counselling, standard sex education, abstinence and peer-led sessions. Two papers (one peer-led and the other skill-based) also looked at childbirth as an outcome of interest.

The Methodological Quality Of Included Reviews

Quality of included reviews

The “A MeaSurement Tool to Assess Systematic Reviews 2” (AMSTAR 2) scores for the individual reviews are presented in Table 3 (Shea et al., 2017). Although the AMSTAR 2 tool is not meant to provide an overall score, we can use it to appraise our confidence in the review results. One review scored high with no or one non-critical weakness (Oringanje et al., (2016)). The remaining two reviews scored moderately (Lopez et al., (2016); Mason Jones et al., (2016)) with one or more non-critical weaknesses. All three reviews included explicit statements that review methods were established before the review and if there were any significant deviations from the protocol, this was highlighted and explained.

Table 3

Selected individual trials outcome counting results
Intervention	Adolescent pregnancy 5/20 Coyle, Kirby, Stephenson, Taylor, Wight, Cabezon, cowan, Henderson, Duflo, Ross, Bonell, HB, MB, Phillber, Howard	Improved contraception use 5/31 Coyle, Kirby, Stephenson, Taylor, Wright, Cowan, Henderson, Duflo, Ross, Bonell, Philleber, MB, HB,	Improved knowledge 1/4 Coyle, Stephenson, Kirby,	Improved attitude towards contraception use 3/4 Coyle, Stephenson, Taylor	Delay sexual debut among adolescents 1/11 Ross, Philleber, Howard, Kirby, Wright
Skill building Lopez (2016) Coyle 2006	1/1 outcomes from 1 study reported in 1 review favoured the intervention	2/3 outcomes from 1 study reported in 1 review favoured the intervention	1/1 outcomes from 1 study reported in 1 review favoured the intervention	0/1 outcomes from 1 study reported in 1 review favoured the intervention
Oringanje et al., (2016) Howard 1990; Kirby 1997; Wight 2002; Philliber 2002	4/4 outcomes from 4 studies reported in 1 review favoured the intervention	2/4 outcomes from 3 studies reported in 1 review favoured the intervention k-2, w-0,p,0			2/4 of outcomes from 4 studies reported in 1 review favoured the intervention
Peer-led Lopez et. al., (2016) Kirby b 1997; Stephenson 2008	2/2 outcomes from 2 studies reported in 1 review favoured the intervention	2/ 3 outcomes from 2 studies reported in 1 review favoured the intervention	1/3 outcomes from 2 studies reported in 1 review favoured the intervention	0/2 outcomes from 1 study reported in 1 review favoured the intervention
Mason-Jones 2016 Cowan 2010 Stephenson 2008	1/2 outcomes from 2 studies reported in 1 review favoured the intervention	1/4 outcomes from 2 studies reported in 1 review favoured the intervention			0/2 outcomes from 1 study reported in 1 review favoured the intervention
Oringanje et al., (2016) Kirby 1997	1/1 outcomes from 1 study reported in 1 review favoured the intervention	2/1 outcomes from 1 study reported in 1 review favoured the intervention
Interactive Lopez et. al., (2016) Taylor 2014	1/1 outcomes from 1 study reported in 1 review favoured the intervention	1/2 outcomes from 1 study reported in 1 review favoured the intervention		0/1 outcomes from 1 study reported in 1 review favoured the intervention
Delaying Mason-Jones 2016 Henderson 2007 Ross 2007	0/2 outcomes from 2 studies reported in 1 review favoured the intervention	0/4 outcomes from 2 studies reported in 1 review favoured the intervention			1/4 outcomes from 1 study reported in 1 review favoured the intervention
Abstinence Mason-Jones 2016 Duflo 2015 Cabezon 2005 Oringanje et al., (2016) Cabezon 2005	3/3 outcomes from 3 studies reported in 2 reviews favoured the intervention	0/1 outcomes from 1 study reported in 1 review favoured the intervention			1/1 outcomes from 1 study reported in 1 review favoured the intervention
Exposure to parenting Oringanje et al., (2016) Bonell 2013	1/1 outcomes from 1 study reported in 1 review favoured the intervention	0/2 outcomes from 1 study reported in 1 review favoured the intervention
Counselling Oringanje et al., (2016) Herceg-Brown 1986	1/1 outcomes from 1 study reported in 1 review favoured the intervention	1/1 outcomes from 1 study reported in 1 review favoured the intervention
Information only Oringanje et al., (2016) Morrison-Beedy 2013	1/1 outcomes from 1 study reported in 1 review favoured the intervention	0/1 outcomes from 1 study reported in 1 review favoured the intervention

Two reviews used a comprehensive literature search strategy (Oringanje et al., (2016); Mason Jones et al., (2016)). In the third review, Lopez et al. (2016) did not search the grey literature or consult with experts in the field. All three reviews provided a list of their excluded studies and justified the exclusion. Only two reviews conducted a meta-analysis (Oringanje et al., (2016); Mason Jones et al., (2016)); both of these reviews adequately justified combining the data in a meta-analysis, and appropriate weighting techniques were used and adjusted for when heterogeneity was detected. All the reviews accounted for the risk of bias in the individual studies when discussing the review results. Two reviews did not investigate publication bias, as there was an insufficient number of trials (Lopez et al., (2016); Mason Jones et al., (2016)). Lopez et al. (2016) did not conduct a meta-analysis, so there was no investigation into publication bias.

Quality of evidence in included reviews

The three reviews used the following to assess the quality of included papers. Oringanje et al. (2016) and Mason-Jones et al. (2016) reported using Schünemann’s 2011 Grading of Recommendations, Assessment, Development and Evaluations (GRADE) approach. Lopez et al. (2016) applied principles from GRADE and entered the information into a risk of bias table. Oringanje et al. (2016) used the GRADE approach to assess the evidence for a reduction in unintended pregnancies to be of moderate quality and low quality for both the contraceptive-promoting interventions (downgraded for imprecision) and for multiple interventions (downgraded for risk of bias, imprecision and inconsistency).

Using the GRADE principles, Lopez et al. (2016) concluded that the overall quality of evidence is low. Of the five trials included in this review, two were considered very low (Stephenson 2008; Taylor 2014), another two were considered low (Wight 2002; Coyle 2006), and one trial was considered moderate (Kirby 1997). Mason Jones et al. (2016) developed a risk of bias summary that assessed nine categories of bias where each paper was graded using a traffic light system. One paper (Cabezon 2005) is at a high risk of bias for six of the nine categories and an unclear risk for the remaining three categories due to inadequate description of methods. Another paper was identified as having a high risk of bias (Cowan 2010). The remaining articles were either designated as low risk of bias or did not provide sufficient information to conclude.

Effect of interventions

The results of the interventions to prevent adolescent pregnancy are presented below and in Table 4. We report all outcomes reported by the studies within the relevant category. Analyses were then reported as the number of outcomes favouring the intervention out of the total number of outcomes reported, based on the direction of effect and not statistical significance. The specific outcomes are listed in Table 5.

Table 4

Selected individual trials outcome reported results
Study ID	Adolescent pregnancy		Improved contraception use		Improved knowledge		Improved attitude towards contraception use		Delay sexual debut among adolescents
Lopez (2016)	pregnancy (self-report 17 months post-program) 0.84 (no CI reported) p 0.61 Reported adjusted OR (95% CI)	Coyle 2006	effective pregnancy prevention at the last sex. 0.77 (0.49 to 1.23) Reported adjusted OR (95% CI)	Coyle 2006			General attitudes toward condoms. -0.044 ± 0.066 Reported adjusted MD ± SE 0.5 Reported p	Coyle 2006
	Ever pregnant or caused pregnancy (reported no pregnancy at pretest) 0.82[0.34,1.99] Odds Ratio M-H, Fixed, 95% CI	Kirby 1997	Condom use at last sex. 1.00 (0.49 to 2.02) Reported adjusted OR (95% CI)	Coyle 2006	Condom knowledge 0.060 ± 0.030 P 0.04 Reported adjusted MD ± SE	Coyle 2006	A positive attitude about condom use. 1.19 (0.98 to 1.45) girls 1.09 (0.92 to 1.29) boys Reported adjusted OR (95% CI)	Stephenson 2008
	Ever had an unwanted pregnancy 0.69 (0.44 to 1.07) Reported adjusted OR (95% CI)	Stephenson 2008	Frequency of sex without condom use in the past three months. 0.38 ± 0.39 Reported adjusted MD ± SE 0.33 Reported P	Coyle 2006	knowledge of EC timing 0.93 (0.66 to 1.32) girls 1.11 (0.86 to 1.45) boys Reported adjusted OR (95% CI)	Stephenson 2008	attitudes to teen pregnancy (con scales); Reported adjusted beta ± SE 0.01 ± 0.09 p.NS	Taylor 2014
	been pregnant or caused pregnancy 0.27 ± 2.99 NS Reported adjusted beta ± SE	Taylor 2014	Condom use with last sex. 0.76[0.49,1.18] Odds Ratio M-H, Fixed, 95% CI	Kirby 1997	Knowledge of HIV and pregnancy prevention. 0.89 Intervention Reported mean change 0.53 Control Reported mean change < 0.001 Reported P	Kirby 1997
	unwanted pregnancy (self-report) 1.0 (0.6 to 1.8) Reported adjusted difference (95% CI)	Wight 2002	Contraception Use at the most recent sex 1.43 (0.94 to 2.18) girls 0.61 (0.25 to 1.46) boys Reported adjusted OR (95% CI)	Stephenson 2008
			use condoms (any); 0.98 ± 0.37 Reported adjusted beta ± SE p < 0.01	Taylor 2014
			Condom use consistency (4-point scale) -0.25 ± 0.21 Reported adjusted beta ± SE p NS	Taylor 2014
			OC use during last Sex 2.4 (-4.1 to 8.9) girls -2.5 (-8.0 to 2.9) boys Reported adjusted difference (95% CI)	Wight 2002
			Condom use with last sex. 0.76[0.49,1.18] Odds Ratio M-H, Fixed, 95% CI	Kirby 1997
			OC use with last sex. 0.57[0.36,0.91] Odds Ratio M-H, Fixed, 95% CI	Kirby 1997
			No condom during last sex 0.9 (-5.7 to 7.4) girls -1.3 (-5.9 to 3.3) boys Reported adjusted difference (95% CI)	Wight 2002
Study ID	Adolescent pregnancy		Improved contraception use		Improved knowledge		Improved attitude towards contraception use		Delay sexual debut among adolescents
Mason-Jones (2016)	pregnancy prevalence. (long-term) 0.18[0.08,0.39] Risk Ratio IV, Random, 95% CI	Cabezón 2005	Self-reported use of condoms at last sex 0.98[0.87,1.11] Women 0.99[0.94,1.04] Men Risk Ratio IV, Random, 95% CI	Cowan 2010					Self-reported sexualdebut 1.01[0.88,1.15]Women 1.03[0.91,1.17] Men Risk Ratio IV, Random, 95% CI	Cowan 2010;
	Pregnancy prevalence 0.95[0.72,1.26] IV, Random, 95% CI	Cowan 2010;	self-reported condom use at last sex 0.98[0.88,1.11] Women 1.02[0.93,1.12] Men Risk Ratio IV, Random, 95% CI	Henderson 2007					Self-reported sexualdebut 0.96[0.85,1.1] women 0.98[0.79,1.23] men Risk Ratio IV, Random, 95% CI	Henderson 2007
	Pregnancy prevalence 0.8[0.63,1.03] Risk Ratio IV, Random, 95% CI	Stephenson 2008	self-reported condom use at last sex 1.01[0.93,1.11] women 0.92[0.79,1.07] men Risk Ratio IV, Random, 95% CI	Stephenson 2008					Self-reported sexualdebut 0.84[0.73,0.97] Risk Ratio IV, Random, 95% CI	Duflo 2015;
	Pregnancy prevalence 1.03[0.75,1.4] Risk Ratio IV, Random, 95% CI	Henderson 2007	self-reported condom use at last sex 0.99[0.86,1.15] Risk Ratio IV, Random, 95% CI	Duflo 2015;					Self-reported sexualdebut 1[0.93,1.08] women 0.89[0.84,0.94] men Risk Ratio IV, Random, 95% CI	Ross 2007
	Pregnancy prevalence 0.9[0.73,1.12] Risk Ratio IV, Random, 95% CI Combined incentive-based and educational interventions	Duflo 2015	self-reported condom use at last sex 1.23[0.94,1.61] women 1.29[0.97,1.72] men Risk Ratio IV, Random, 95% CI	Ross 2007
	Pregnancy prevalence 1.06[0.83,1.37] Risk Ratio IV, Random, 95% CI	Ross 2007
Study ID	Adolescent pregnancy		Improved contraception use		Improved knowledge		Improved attitude towards contraception use		Delay sexual debut among adolescents
Oringanje (2016)	Unintended pregnancy 0.77[0.33,1.79] Risk Ratio M-H, Fixed, 95% CI	Bonell 2013;	Use of birth control methods 0.99[0.92,1.06] Risk Ratio M-H, Random, 95% CI	Bonell 2013;					Initiation of sexual intercourse 0.87[0.77,0.99] Risk Ratio M-H, Random, 95% CI]	Philliber 2002
	Unintended pregnancy 0.96[0.56,1.65] Risk Ratio M-H, Fixed, 95% CI	Herceg-Brown 1986;	Condom use at last sex 1.03[0.94,1.13] Risk Ratio M-H, Random, 95% CI	Philliber 2002					Initiation of sexual intercourse 0.51[0.36,0.74] Risk Ratio M-H, Random, 95% CI]	Howard 1990
	Unintended pregnancy 0.5[0.28,0.88] Risk Ratio M-H, Fixed, 95% CI	Morrison-Beedy 2013;	Condom use at last sex 0.91[0.77,1.06] M-H, Random, 95% CI	Kirby 1997					Initiation of sexual intercourse 1.01[0.8,1.29] Risk Ratio M-H, Random, 95% CI]	Kirby 1997
	Unintended pregnancy 0.59[0.37,0.94] Risk Ratio M-H, Fixed, 95% CI	Philliber 2002;	Consistent condom use 1.16[0.88,1.54]	Morrison-Beedy 2013					Initiation of sexual intercourse 0.98[0.9,1.07] Risk Ratio M-H, Random, 95% CI]	Wight 2002
	Unintended pregnancy 0.2[0.1,0.39] Risk Ratio M-H, Fixed, 95% CI	Cabezon 2005;	Consistent condom use 0.85[0.65,1.1] Risk Ratio M-H, Fixed, 95% CI	Herceg-Brown 1986
	Unintended pregnancy 0.48[0.11,2.09] Risk Ratio M-H, Fixed, 95% CI	Howard 1990	Contraceptive use at last sex 0.99[0.95,1.03] Risk Ratio M-H, Fixed, 95% CI	Bonell 2013
	Unintended pregnancy 0.78[0.51,1.2] Risk Ratio M-H, Fixed, 95% CI	Wight 2002	Hormonal contraceptives 0.67[0.48,0.94] Risk Ratio M-H, Fixed, 95% CI	Kirby 1997a
	Unintended pregnancy 0.86[0.36,2.05] Odds Ratio M-H, Fixed, 95% CI	Kirby 1997	Hormonal contraceptives 1.03[0.89,1.19] Risk Ratio M-H, Fixed, 95% CI	Wight 2002
	Childbirth 0.67[0.31,1.45] Odds Ratio M-H, Fixed, 95% CI	Philliber 2002

Table 5. Search strategy

Search databases

1. Medline PUBMED

2. Epistemonikos

3. Cochrane Library

No.	Keyword	Search strategies
1	Determinant	Determinant(s)[tw] OR Factors[tw] OR Causes*[tw]
2	Prevalence/incidence	Prevalence[tw] OR Incidence[tw] OR Frequency*[tw]
3	Adolescent	"Pregnancy in Adolescence"[Mesh] OR Adolescent[tw] OR teenage[tw] OR youthful*[tw]
4	Pregnancy	"Pregnancy, Unplanned"[Mesh] OR Unintended[tw] OR Accidental[tw] OR Unintentional[tw] AND "Pregnancy "[MESH] OR Pregnanc[tw] OR Fertilization[tw] OR Gestation[tw] OR Gravidity[tw] OR ‘pregnan near (prevent* or interrupt* or terminat*
5	Sub-saharan countries	Algeria OR Angola OR Benin OR Botswana OR "Burkina Faso" OR Burundi OR Cameroon OR "Cape Verde" OR "Cabo Verde" OR "Central African Republic" OR Chad OR Comoros OR Comores OR Comoro OR Congo OR "Congo-Brazzaville" OR "Congo Republic" OR "Republic of the Congo" "Côte d'Ivoire" OR "Democratic Republic of the Congo" OR "DR Congo" OR DRC OR "Congo-Kinshasa" OR Djibouti OR "Equatorial Guinea" OR Eritrea OR Ethiopia OR Gabon OR Gambia OR "The Gambia" OR Ghana OR Guinea OR Guinea-Bissau OR Kenya OR Lesotho OR Liberia OR Madagascar OR Malawi OR Mali OR Mauritania OR Mauritius OR Mozambique OR Namibia OR Niger OR Nigeria OR Rwanda OR "Sao Tome and Principe" OR "São Tomé and Príncipe" OR Senegal OR Seychelles OR "Sierra Leone" OR Somalia OR "South Africa" OR "South Sudan" OR Sudan OR Swaziland OR Togo OR Uganda OR "United Republic of Tanzania" OR Tanzania OR Zambia OR Zimbabwe
6	Combined terms (#1 AND #2 AND #3 AND #4 AND #5)	(((((Determinant(s)[tw] OR Factors[tw] OR Causes[tw]) AND (Prevalence[tw] OR Incidence[tw] OR Frequency[tw]))) AND ("Pregnancy in Adolescence"[Mesh] OR Adolescent[tw] OR teenage[tw] OR youthful[tw])) AND ("Pregnancy, Unplanned"[Mesh] OR Unintended[tw] OR Accidental[tw] OR Unintentional[tw] AND "Pregnancy "[MESH] OR Pregnanc[tw] OR Fertilization[tw] OR Gestation[tw] OR Gravidity[tw] OR ‘pregnan* near (prevent* or interrupt* or terminat*)) AND (Algeria OR Angola OR Benin OR Botswana OR "Burkina Faso" OR Burundi OR Cameroon OR "Cape Verde" OR "Cabo Verde" OR "Central African Republic" OR Chad OR Comoros OR Comores OR Comoro OR Congo OR "Congo-Brazzaville" OR "Congo Republic" OR "Republic of the Congo" "Côte d'Ivoire" OR "Democratic Republic of the Congo" OR "DR Congo" OR DRC OR "Congo-Kinshasa" OR Djibouti OR "Equatorial Guinea" OR Eritrea OR Ethiopia OR Gabon OR Gambia OR "The Gambia" OR Ghana OR Guinea OR Guinea-Bissau OR Kenya OR Lesotho OR Liberia OR Madagascar OR Malawi OR Mali OR Mauritania OR Mauritius OR Mozambique OR Namibia OR Niger OR Nigeria OR Rwanda OR "Sao Tome and Principe" OR "São Tomé and Príncipe" OR Senegal OR Seychelles OR "Sierra Leone" OR Somalia OR "South Africa" OR "South Sudan" OR Sudan OR Swaziland OR Togo OR Uganda OR "United Republic of Tanzania" OR Tanzania OR Zambia OR Zimbabwe)

Skill building

Interventions focused on skill-building were generally effective, improving 12 of the 18 outcomes in five studies. Two reviews (Lopez et al., (2016); Oringanje et al., (2016)) reported results from one and four studies, respectively (four cluster RCTs and one individual RCT). These papers reported that skill-building interventions improved adolescent pregnancy outcomes and attitudes toward contraception and contraceptive use.

Peer-led

Interventions focused on peer-led were generally effective, improving 10 of the 20 outcomes in five studies. Three reviews (Oringanje et al., (2016); Mason-Jones, 2016; Lopez et al., (2016) ) reported results, and two studies (Kirby, 1997; Stephenson, 2008) were included in two separate reviews. These papers reported that peer-led interventions reduced adolescent pregnancy rates, increased contraceptive use, knowledge, and attitudes towards contraception, and delayed sexual debut rates.

Interactive programmes

Interventions focused on interactive programmes generally mixed, improving only two of the four outcomes in one study. One review (Lopez et al., (2016)) reported results from one study (cluster RCT). This paper reported that interactive programme interventions improved adolescent pregnancy rates and contraceptive use but did not improve attitudes toward contraception.

Delaying sexual debut

Interventions focused on delaying sexual debut were generally ineffective, improving one out of ten outcomes in two review studies. One review (Mason Jones et al., (2016)) reported results from two studies (cluster RCTs). Only one study, Duflo (2015), measured an improvement in self-reported sexual debut rates.

Abstinence

Interventions focused on abstinence were generally effective, improving four out of five outcomes in three studies. Two reviews (Mason Jones et al., (2016); Oringanje et al., (2016)) reported results from two and one study, respectively (three cluster RCTs). One study (Cabezon, 2005) was included in two reviews. These papers reported that interventions that focused on delaying sexual debut improved adolescent pregnancy outcomes and delayed sexual debut but did not improve contraceptive use.

Exposure to parental responsibilities

Interventions focused on parenting exposure were generally ineffective, improving one out of three outcomes in one study. One review (Oringanje et al., (2016)) reported results from one study (individual RCT). This paper found that these interventions improved adolescent pregnancy rates but did not improve contraceptive use.

Counselling

Interventions focused on counselling were generally effective, improving two out of two outcomes in one study. One review (Oringanje et al., (2016)) reported results from one study (individual RCT). This paper found that interventions that provided counselling improved adolescent pregnancy outcomes and improved contraceptive use outcomes.

Information only

Interventions focused on only information were mixed, improving one out of two outcomes in one study. One review (Oringanje et al., (2016)) reported results from one study (individual RCTs). This paper said that interventions promoted improved adolescent pregnancy rates but did not improve contraceptive use.

Our search identified 19 studies from three reviews investigating the effectiveness of various sexual health programmes that seek to prevent adolescent pregnancy. The methodological quality of these three reviews was moderate to high, whereas the quality of the individual studies included in the reviews was of low to moderate quality.

Summary of main results

Although all of the interventions included sex education, we grouped the studies using other intervention characteristics, namely delivery strategy (i.e. peer-led, interactive or counselling), key message (abstinence or delaying) or skill-building. Overall, skill-building, counselling and abstinence programmes were generally effective. Interventions that focused on peer-led, information-only and interactive sessions provided mixed results. In contrast, exposure to parenting and delaying sexual debut interventions were generally ineffective. When looking at the groups of outcomes, interventions to prevent adolescent pregnancy were generally effective at adolescent pregnancy outcomes. They provided mixed results for improving contraceptive use, knowledge, and delaying sexual debut.

Overall completeness and applicability of evidence

During this review, we identified studies that fell within each of our intervention groups. However, there were only ever a few studies within each group. Although all of the studies included described the intervention, these descriptions were not detailed enough to determine the ‘dosage’ and support the comparison of the effect of differences across the studies. Most studies describe the comparison intervention but are not sufficiently detailed to determine their generalisability to other settings.

We faced challenges when categorising the different types of adolescent pregnancy prevention interventions. First, we reviewed the nineteen studies and attempted to identify groups using the review author’s description. All interventions included sex education; therefore, studies were grouped based on additional intervention characteristics. The level of detail in the descriptions varied, and due to unclear descriptions for a handful of interventions, we had to use our judgement to determine group allocation. Consequently, it is not clear how homogenous our groups are. We identified eight different adolescent pregnancy prevention intervention types or groups. All reviews did not contribute data to all categories but did contribute to at least one group.

The studies included in this review were conducted in various global north and south income settings. Thirteen studies were conducted in high-, three in middle and three in low-income countries. Of the 19 studies included in the three reviews, four were conducted between 1986-97, ten were between 2002-08, and five were conducted between 2008-15. All of the included reviews are at least seven years old, and 74% were performed at least ten years ago. Attitudes to adolescent sexual reproductive health have changed at different rates in different settings. The extent to which changes in attitudes may have influenced the effectiveness of various interventions was not explored in this study but is likely to influence outcomes.

Quality of evidence

The methodological quality of the three reviews included in this overview was moderate to high. The quality of the individual studies included in the three reviews was of low to moderate quality. Many studies had limited information on intervention fidelity, loss of follow-up or discontinuation. Most of the studies that assessed pregnancy relied upon self-reported rates as one of the assessments. Self-reported pregnancy rates are susceptible to underreporting. Although all of the included studies presented the effect size for the odds and risk ratios, it was difficult to ascertain the statistical significance for many outcomes as the 95% confidence interval crossed 1.

Potential biases in the overview process

As this is a rapid review, the search was expedited and may not have identified all potentially important data. If we had more time and resources, we would have increased the number of databases, included the use of grey literature and narrowed the scope. Thus, the review is not without bias. Two reviewers independently assessed all of the studies against the eligibility criteria. We have only included RCTs. Data were extracted from the selected studies, and we evaluated the scientific quality of the individual papers according to AMSTAR 2. The overview only included articles that reported quantitative data on the primary outcome of interest, adolescent pregnancy. Moreover, all of the outcome data are susceptible to self-reporting bias. We did not contact investigators for missing data.

The restrictive measures put in place by many countries to contain the spread of the virus could negatively affect access to essential SRH services, particularly by adolescents living in low- and middle-income countries (LMICs) and fragile settings (Bauer et al., 2021). Young people are significantly affected by the closure of social spaces, including schools, community centres, and health clinics, where many of them receive comprehensive education on SRH and services. Past epidemic outbreaks have shown that disruptions in education are incredibly harmful to young people, especially girls, in terms of lost earnings and education and increased vulnerability to gender-based violence, early marriages, unintended pregnancy, and female genital mutilation. As countries now transition from prioritising tackling the virus and re-orienting themselves towards achieving the SDGs, policymakers need access to a robust appraisal of the evidence to make evidence-based policy decisions.

Three reviews that used individual trials that were of low to moderate quality suggest that adolescent pregnancy prevention interventions that deploy school-based strategies that prevent the occurrence of pregnancies in the first place may effectively reduce unintended adolescent pregnancy rates, improve contraceptive use, attitudes and knowledge, and delay sexual debut. However, the included studies have methodological issues, and our ability to generalise the result is limited. There is a strong desire to reduce unintended adolescent pregnancy rates globally, and schools can provide a valuable platform to reach adolescents and share SRH information. Still, there is little evidence supporting curriculum-based educational programmes alone. These programmes need to be delivered alongside the provision of contraceptives and in a setting where SRH services are readily available and easily accessible. This review found that interventions focused on skill-building and counselling were generally effective at reducing unintended pregnancies. If done well, incorporating peer-led and interactive components into interventions that focus on skill building and counselling can strengthen existing programmes that seek to reduce unintended pregnancies. This review recommends leveraging the school platform and adopting interventions that concurrently deliver skill-building, counselling, contraceptive promotion, and sex education. Interventions that emphasise delayed sexual initiation or abstinence must also provide information about contraceptives.

Acknowledgements

We acknowledge the technical support of an information specialist from Cochrane in completing the protocol for this review to an acceptable standard for registration with the PROSPERO International Prospective Register of Systematic Reviews database.

Authors Contributions

Nyovani Madise (NM) and Michal G Chipeta (MC) conceptualised the review. Sahra Mohammed (SM) wrote the protocol, analysed the data and wrote the first draft of this review. Tony Kamninga (TK), Lomuthando Nthakomwa (LN), Chimwemwe Chifungo (CC), Themba Mzembe (TM), Ruth Vellemu (RV), Victor Chikwapulo (VC), Maame Peterson (MP), Leyla Abdullahi (LA), and MC developed and run the search strategy; selected studies included in the review; obtained full texts of the studies chosen; extracted data; carried out analyses and made interpretations. LA, MC, EZ and NM contributed to the analysis and interpretation of the findings and provided high-level content expertise. Kelvin Musau (KM) and Kerri Wazny (KW) contributed to the technical review of the methods and outputs from the review. All authors contributed to scientific writing and guaranteed the integrity of the work.

Declaration of conflicts of interest

Kelvin Musau and Kerri Wazny are affiliated with CIFF and disclose that their support of the manuscript was limited to project design and technical review of the methods and outputs, with no direct involvement in the data extraction and analysis.

Funding

This research was funded by the Children Investment Funds Foundation (CIFF), grant number 2007-04927.

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Interventions to prevent unintended pregnancies among adolescents: A rapid overview of systematic reviews

Status:

Journal Publication

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Abstract

Figures

Background

Description of the condition

Description of the intervention

How the intervention might work

Why it is essential to do this review

Objectives

Specific objective

Methods

PICOST matrix

o Primary outcome: Unintended adolescent pregnancy.

o Secondary outcomes:

Search methods for identification of studies

Searching other resources:

Data Collection And Analysis

Selection of studies

Data extraction and management

Assessment of methodological quality of included reviews

Data synthesis

Results

Summaries of individual reviews

Lopez et. al., (2016)

Mason Jones et al., (2016)

Oringanje et al., (2016)

Summary across reviews

Population and settings

Teenage Pregnancy Prevention Interventions

i. Skills building

ii. Interactive

iii. Peer-led

iv. Delaying sexual debut

v. Abstinence

Interventions that actively discourage sex before marriage

vi. Counselling

vii. Exposure to parental responsibilities

Duration, frequency and intensity of adolescent pregnancy prevention interventions

Comparisons

Outcomes

Lopez et. al., (2016)

Mason Jones et al., (2016)

Oringanje et al., (2016)

The Methodological Quality Of Included Reviews

Quality of included reviews

Quality of evidence in included reviews

Effect of interventions

Skill building

Peer-led

Interactive programmes

Delaying sexual debut

Abstinence

Exposure to parental responsibilities

Counselling

Information only

Discussion

Summary of main results

Overall completeness and applicability of evidence

Quality of evidence

Potential biases in the overview process

Authors’ Conclusions

Declarations

Acknowledgements

Authors Contributions

Declaration of conflicts of interest

Funding

References

Status:

Journal Publication

Version 1