Adolescent childbearing trends and sub-national variations in Ethiopia: a pooled analysis of data from six surveys

Adolescence is the period of transition from childhood to adulthood where major physical, behavioral, social changes occur in the lives of young people. The physical, cognitive, emotional and social transformations that individuals undergo during adolescence form the foundations of their health and well-being later in life [1]. Unfortunately, the picture is bleak for more than half of the world’s adolescents, from ages 10 to 19 years, who live in poor countries [2]. Approximately one in ten babies are born to adolescent mothers globally, with more than 95% of those births occurring in low- and middle-income countries [3].

The consequences of adolescent pregnancy and childbirth are well understood and raise fundamental concerns about the health and social development of young mothers and their children [4]. Indeed, adolescent pregnancy is dangerous, with serious long-term and wide-ranging consequences – from health complications to broader economic concerns [5]. Pregnancy is the leading cause of death for adolescent girls in developing countries, with teen mothers being twice as likely to die from pregnancy-related complications as mothers in their 20s [6]. By impacting education, employment and economic opportunities, pregnancy during adolescence can also have lasting socio-economic consequences, which, in turn, contribute to poorer health outcomes, gender inequity and poverty of adolescent mothers and their families and communities [7, 8].

There are an estimated 6 million adolescent girls in Ethiopia today [9], making the country home to the second largest adolescent population in Africa. As in most sub-Saharan African countries, Ethiopian adolescents are exposed to early marriage, pregnancy and childbirth, which are detrimental to their health and social development and to those of their offspring. The fertility rate of Ethiopian adolescents, aged 15–19 years, is estimated at 79 births per 1000 [10], a rate higher than the world’s average of 46 per 1000 but lower than Africa’s average of 98 per 1000 [11]. Cognizant of this, the government of Ethiopia through its health sector transformation plan [12] and national reproductive health strategy [13] has identified adolescent pregnancy and childbirth as important public health concerns and devised a strategy to address the reproductive health and well-being of Ethiopia’s adolescents.

Understanding the magnitude, trends and determinants of adolescent childbearing can motivate policy and programmatic responses and help monitor progress toward reducing their incidences [14]. There is, however, a general dearth of studies on adolescents’ reproductive and fertility behaviors in Ethiopia, partly because most previous studies have predominantly focused on the fertility behaviors of all women of reproductive age (15–49 years), with little focus on age-disaggregated analysis to address the specific issues that are pertinent to adolescent girls. Furthermore, the few previous studies examining adolescents in Ethiopia have focused on determinants and short-term trends in adolescent childbearing experiences [15‐17], as well as the transition to marriage and first sex [18, 19]. Unlike previous studies, our study pooled data from six nationwide surveys that were conducted during the period from 2000 to 2016 and provides a comprehensive and up-to-date analysis of annual trends, determinants and sub-national variations in relation to adolescent childbearing experiences in Ethiopia.

This study was set out to examine trends, sub-national variations and determinants of early childbearing in Ethiopia. The analysis was based on nationally representative data from six rounds of surveys. The findings suggest that early childbearing, as measured by the cumulative probability of having a first birth before the age of 20 years, declined by approximately two-fifths from 57.6% for the 1971–1981 cohort to 35.3% for the 2000–2005 cohort. The decline was much more apparent in the recent period, especially for the cohort of women who reached puberty during 2000–2005, who in turn were in the age range of 20–26 years in 2016. This recent trend is plausible given that Ethiopia has made significant progress on many frontiers in the past two decades or so that are less conducive to adolescent motherhood. Important achievements that could affect early childbearing include the expansion of female education, community mobilization efforts and the promotion of collective community efficacy against harmful traditional practices, including marriage of girls and teenage pregnancy and childbearing, as well as enactment of the criminal code that prohibits marriage before the age of 18 years for girls [22]. In addition, the unprecedented improved population access to information and services on reproductive health and other health services through the health extension program and the stipulation of a number of policies and strategies on adolescents and youths should be emphasized. Undoubtedly, the synergies of these favorable social changes have contributed to the decline in early childbearing among Ethiopian adolescents in the recent period.

Previous studies in Ethiopia did not employ a similar cohort approach to track annual trends, as presented in this study, nor did they use the most recent surveys data in their analyses. This paper is thus a more distinctive and current reflection of past and present trends in adolescent childbearing in the country. Comparison of our findings with the few published studies from Ethiopia is not warranted due to methodological differences as well as the amount and nature of data used in our analyses. Nevertheless, there are indications from previous studies in Ethiopia of a decline in adolescent childbearing since the 1970s [15, 16].

Despite the recorded decline, however, adolescent motherhood is still fairly common in Ethiopia. Girls who reached puberty during the years from 2000 to 2005 had a 35% cumulative probability of becoming a teenage mother before their 20th birthday, and approximately one-fifth (19%) had already become teenage mothers before the age of 18 years. In comparison to most sub-Saharan Africa countries, however, Ethiopia can be considered among the countries with a relatively lower rate of adolescent childbearing. For example, UNFPA reported that among 30 sub-Saharan Africa countries in which 20% or more of women gave birth before 18 years of age, Ethiopia was among the five countries with relatively low rates of early childbearing, at less than 22%. In contrast, in most sub-Saharan countries, more than 25% of the female population has been reported to have given birth before 18 years of age; five of these countries have rates exceeding 40% [23]. Previous studies have also shown that in most regions of Sub-Saharan Africa, adolescent childbearing has declined at a moderate pace over the past few decades; however, only a few countries in the region have recorded faster declines in adolescent fertility [24, 25].

Marriage determines fertility levels and patterns in societies in which most childbearing occurs within marriage [26]. Our analyses confirmed that the prevalence of marriage during adolescence and variation in age of entry into marriage were by far the most important predictors of early childbearing in Ethiopia. The risk of early childbearing decreased by 95% if women remained unmarried until their 20th birthday vis-à-vis those who married before the age of 18 years. This result clearly underscores that adolescent pregnancy and birth in Ethiopia occur largely within the context of marriage and that out-of-wedlock childbearing can be considered uncommon among the adolescents in the country. Other studies have reported similar findings for the relationship between early marriage and early childbearing [27, 28]. Furthermore, we showed that in addition to the virtual absence of marriage during the adolescent period, the age of entry into marriage appeared to significantly alter the likelihood of early childbearing. Marrying at the legal age of 18 years can reduce the risk of early childbearing by 60% in comparison to marrying before the age of 18 years. A shift of the age at marriage to 19 years reduced the risk of early childbearing by 78%. These interesting findings are central to explaining the recorded trends in early childbearing in the past four decades in the country. Analysis of the cohort data on the prevalence and age pattern of marriage among adolescents divulged significant declining trends over the past four decades that are compatible to the recorded parallel decline in early childbearing in the country. In the past four decades, the cumulative probability of early marriage (i.e., before the legal age of 18 years) declined by approximately half, from 55.3 to 28.7%.

In 2005, Ethiopia adopted a criminal law that enforces the minimum legal age of marriage for women to 18 years [29]. The code also allows the termination of pregnancy under special conditions, including when the pregnancy is a result of rape, when it endangers the life of the mother or the child or if the pregnant woman is physically or mentally unfit to raise a child, including unwanted pregnancy in teenagers. The Ethiopian Women Lawyers Association, in collaboration with the Ministry of Justice and local and international NGOs and community-based organizations, campaigns for communities, local governments and religious institutions to observe the legal age of 18 for marriage. They also provide legal literacy training on the issue of early marriage. Communities have been reached through the educational efforts of health workers, women’s associations, teachers and religious leaders. Legislative bodies and other influential groups in communities have been sensitized to enact and implement laws that protect women and girls from early marriage and other harmful traditional practices [22]. Nevertheless, a common criticism of the marriage law has been the lack of strong and wider implementation and enforcement, especially in rural parts of the country where early marriage and childbearing are common and where more than three-quarters of the population resides. One study that focused on early marriage concluded that knowledge of and respect for the marriage law is limited among many rural communities in Ethiopia [22]. Despite the law, the analysis presented in this paper also signals a fairly high incidence of early marriage in the recent cohort, with the cumulative probability of marrying before the age of 18 years estimated at 28.7% from 2000 to 2005. Based on this study, it is also unknown if and how the marriage law has impacted the recorded decline in early childbearing in recent years. Most importantly, our analyses underscore that a mere shift of the legal age at marriage to 18 years could significantly reduce the risk of early childbearing by 60%, which reinforces the significant relevance of the wider application of the marriage law for the health and wellbeing of adolescents in the country. Our study corroborates a previous study conducted in 12 sub-Saharan African countries that showed a lower prevalence of teenage childbearing in countries with a consistent minimum marriage age law of 18 years compared with countries without consistent laws [30].

In agreement with previous studies in Ethiopia [15‐17] and elsewhere [25, 27, 28], we observed a lower risk of early childbearing with an increase in women’s education. We found a 50 and 82% lower risk of early childbearing among women with elementary and secondary or higher education, respectively, compared with women with no education. Other studies of sub-Saharan Africa reported similar results. For example, Gupta et al. (2003) concluded that the education of girls from about the secondary level onwards is a key instrument for raising the age at first birth in sub-Saharan Africa but suggest that increases in schooling at lower levels alone bear only marginal effects on prospects for fertility decline among adolescents [31]. The relationship between education and adolescent fertility could be mediated by several factors. Girls with a higher education level have a lower probability of having a child before their 20th birthday mainly because of an older age at marriage. Education presents girls with more incentive to avoid early childbearing because they can achieve greater exposure and access to sexual reproductive information and receptivity to birth control [32]. Additionally, education often empowers girls with improved skills in family communication about sexual and reproductive health and other social issues, as well as their level of control within the family [33]. In recent decades, the participation of Ethiopian adolescents in primary or secondary education has improved remarkably from less than 40% in 2000 [34] to 90% in 2016 [21]. It is therefore plausible that the increase in women’s education in the past two decades in Ethiopia has inhibited adolescent fertility mainly through delayed marriage but also, to some extent, through improved female empowerment to make decisions concerning their sexual and reproductive health.

Contraceptive use among married adolescents in Ethiopia has increased substantially over the past few decades, from a low of 2% in 1990 [35] to 34% in 2016 [21]. However, contraceptive use did not emerge as a significant inhibitory factor for delaying first birth until the age of 20 years among married adolescents in our analysis. In contrast to expectations, it appears that married adolescents who practiced contraceptive use before the age of 20 years were 25% more likely than those who did not to have had early childbearing. This finding should be interpreted with caution, as it represents a reverse causation and suggests that married adolescents are more likely to use contraceptives in order to space subsequent pregnancies than to delay first birth until the age of 20 years. The observed lower adoption of contraception before first birth by married adolescents is not unique to this paper, and a recent study examining the reproductive behaviors of adolescents in rural Ethiopia observed lower contraceptive use before first birth than after first birth [36]. This finding is further corroborated by studies conducted in sub-Saharan Africa and South Asia, suggesting that married adolescents are typically under pressure from their husbands, their in-laws and their communities to begin childbearing immediately after marriage [37, 38]. For married teens, it is often important to prove their fertility as soon as they are married [37], and this reality has been reflected in DHS surveys that found married teens are not only less likely to use contraception to delay first birth but also have a reduced unmet need for contraception [38]. In most of these societies, infertility is deeply feared by most married women [39] because it can result in divorce and abuse by their husbands.

This paper has strengths that merit discussion. First, this study was based on six nationally representative surveys that were collected over the past 16 years and that can easily be compared over time and provide a large data set to allow robust statistical analyses. The three rounds of the DHS and three rounds of the PMA surveys are similar in the following aspects: the surveys used a similar sample design; sampling was performed by the same agency – the Ethiopia Statistical Agency; and similar questions were used in all rounds of the surveys for all variables studied in this paper. Second, we employed a robust approach to explore annual trends in adolescent childbearing and marriage experiences that, to our knowledge, have not been previously used in the Ethiopian context. This method permits a better understanding of how these important events have been changing over time. Third, we estimated cumulative probabilities instead of percentages to overcome the problem of censoring of adolescents who have not yet experienced events such as childbirth or marriage. Indeed, the percentage of adolescents aged 15 to 19 years who have had a live birth is affected by censoring because those girls without a live birth still face the risk of pregnancy before they reach age 20 years.

Despite the aforementioned strengths, this paper has limitations that should be mentioned. First, recall bias on the age and timing of first birth, first marriage and first contraceptive use may have been present in the data and cannot be discounted. The recall biases for these events may have been higher among older women because these events were more likely to have occurred many years ago. However, we do not feel that these biases significantly affected the present findings and conclusions of this study because the directions of the potential biases are unknown and are more likely to be random. Second, due to the obvious cross-sectional nature of the DHS and PMA surveys, causal relationships between events could not be assumed, and it was impossible to establish a temporal sequencing of events.

This study provides compelling evidence for a substantial reduction in early childbearing over the past four decades in Ethiopia, which was driven largely by a parallel and significant reduction in the prevalence of early marriage during the same period. However, a fairly large portion of Ethiopian adolescents are still suffering from early childbearing; and the situation appears to be more dismal in some regions compared with others.

Childbearing occurs predominantly within the milieu of marriage in Ethiopia, and as a result, the prevalence of marriage and the age of entry into marriage during the period of adolescence are by far the most important determinants of early childbearing in the country. Our analysis underscores that postponing marriage to the legal age of 18 years and beyond can substantially reduce the risk of early childbearing. Thus, a further decline in early childbearing could be achieved by enforcing the Ethiopian law on the minimum marriage age, which entails a continued education of the general public and communities about the law, involving community leaders, legislative bodies and local governments to seriously observe its implementation. Our analysis also confirms the potential of female education, especially secondary or higher levels of education, to curb the incidence of early childbearing among Ethiopian adolescents. Thus, further expansion of female education from the secondary level onwards and a reduced school dropout rate of girls will have a greater role in future prospects of fertility decline among adolescents in the country.

Married adolescents often find it difficult, if not impossible, to delay the first birth until the age of 20 years due to the social pressure supporting childbirth shortly after marriage. Despite the challenges, married adolescents and their partners should be provided with the necessary information and services to help them delay early childbearing. Family planning programmers must devise ways to reach out to newly married adolescents with the necessary information and services before they initiate childbearing. Priority interventions to address early childbearing in the country should also focus on dispelling community norms and attitudes that encourage early childbearing among married adolescents.

Finally, the pervasive sub-national variations in adolescent fertility, which is largely due to differences in the incidence of early marriage, calls for region-specific interventions to address the socio-economic and cultural factors that are pertinent to the regions.