Adolescent pregnancy is a major global health issue that contributes to maternal and newborn mortality. It is estimated that 21 million girls aged 15–19 years become pregnant, 12 million give birth, and 777,000 girls give birth below the age of 15 each year in low- and middle-income countries [1–3]. According to the world health organization (WHO), adolescent pregnancy is defined as “pregnancy in a woman aged 10–19 years [4]. Pregnancy during adolescence increases the risk of complications during pregnancy and childbirth such as eclampsia, puerperal endometritis, and infection, which are the leading causes of death in 15–19-year-old girls (WHO, 2016). Moreover, in the developing world, at least 10 million unintended pregnancies occur annually [1]. This could lead to unsafe induced abortion, which is another cause of maternal death, with an estimated 6,230,000 deaths, the highest occurring in East Africa [5]. Additionally, adolescent pregnancy increases the risk of stillbirth, low birth weight, and newborn deaths [4].
In Tanzania, a significant number of adolescent girls become sexually active at the age of 15, and 60% of women have had sex before the age of 18 [6]. By 2016, one in four adolescents aged 15–19 began childbearing [7]. The adolescent fertility rate increased from 116 to 132 between 2010 and 2015/16, the 17th highest in Africa [8]. Until the recent policy change, pregnant girls attending school were compelled to withdraw from school between 2003 and 2011 in Tanzania, and 55,000 children were withdrawn from school due to pregnancy [8]. Dropping out from school makes it difficult for girls to get a job, and consequently, many fall into a cycle of multigenerational poverty. Thus, interventions for reducing unintended adolescent pregnancies are of substantial benefit to adolescents, their following generations, and society as a whole.
A systematic review of 254,350 participants concerning adolescent pregnancy in Africa identified several factors associated with an increased risk of adolescent pregnancy as potential targets for intervention. These included residing in rural areas, being married, not attending school, having no maternal education, lack of father's education, and lack of parent-to-adolescent communication on sexual and reproductive health (SRH) issues [9]. McCleary-Sills et al. (2013) conducted action research on adolescent pregnancy and reported four major risk factors that undermined girls' ability to protect their health and well-being, including poverty that pushed them into having sex to meet basic needs, sexual expectations of older men and boys, age, rape, and coercive sex (including sexual abuse from an early age), and unintended pregnancy [10]. On the other hand, a study conducted in Tanzania showed that personal, cultural, and religious lenses affected healthcare professionals’ decisions about whether to provide contraception to adolescent girls [11]. Prevention of unwanted pregnancy needs collaborative efforts, and healthcare providers need knowledge about reproductive health rights for girls and boys and should adhere to this by providing youth-friendly reproductive healthcare. While girls require proper knowledge about pregnancy and its consequences, boys need to know what issues girls face when they unintentionally become pregnant [12].
To the best of our knowledge, there are no sex education classes in Tanzania, and life skills teachers often lack special training on sexual and reproductive health [13, 14]. Moreover, “abstinence-only” sex education is often the only content at school and provides Tanzanian adolescents with insufficient information on how to prevent unwanted pregnancy [15]. Even at home, cultural norms and traditional values make it difficult for parents and children to discuss sexuality [16]. Several studies in Africa have reported that parents hesitated to talk about sexuality with their children because of feelings of inadequate knowledge [17–19]. Discussions between parents and their children also turned out to be not knowledge-providing but prohibitive and one-sided [20, 21]. Therefore, there is an urgent need for third parties to provide proper and adequate knowledge and comprehensive sexuality education messages [22, 23].
In response to this need, Madeni et al. (2011) developed and conducted a reproductive health education awareness program in Tanzania using a picture drama of a girl who experienced adolescent pregnancy [24]. The study showed significant beneficial effects of this program on adolescent boys’ and girls’ knowledge, attitudes, and reproductive health behavior. A subsequent study in rural Tanzania showed less successful results with the same intervention and measurements [25]. In both studies, the authors discussed the difference in responses to the program due to lower levels of educational attainment and culture in rural villages and concluded that revisions must be made to the existing program for adolescents living in rural areas, by considering their specific culture, practices, and learning needs. In addition, both studies measured the learning effects immediately after the program. Therefore, the long-term effect, that is, the effect after a year, needs to be analyzed.
As a next step, the Japan international cooperation agency (JICA) Partnership Project, “Adolescent education project to prevent social isolation due to unwanted pregnancy and school dropouts,” was launched in rural Tanzania in 2017 by a Japanese Non-Profit Organization (NPO), Class for Everyone, in collaboration with a local Non-Governmental Organization (NGO), the New Rural Children Foundation. The project added role-play in their teaching and asked students how they felt when they played roles in the story and how they could have behaved to prevent unwanted pregnancy, aiming to use more experiential learning to address the rural culture. They included more open discussions among students under the guidance of a third party, the local NGO. This project followed up with the students for one year and evaluated the differences in reproductive attitudes, behavior, and logical thinking. Therefore, in this quasi-experimental study, the aim was to investigate the effects of reproductive health education on the attitudes and behavior toward reproductive health among adolescent girls and boys in rural Tanzania.