Background
Despite the numerous policy interventions aimed at preventing adolescent childbearing in many countries across the world, the prevalence of adolescent pregnancy and childbirth remains high [
1‐
3]. Adolescent childbearing has been defined as birth that occurs among adolescents aged 10-19 [
4]. In 2015, for example, approximately 19.4 million adolescent girls aged 10-19 years, gave birth, and 580,000 of them were aged 10-14 [
4]. Most of these adolescent births occur in less developed countries, especially in sub-Saharan Africa (SSA) [
5,
6]. Besides, childbearing related complications and delivery are reported to be the major cause of mortality among adolescent girls (aged 15-19) in the world [
2,
3].
In SSA, an estimated 570 adolescent girls die each year due to maternal complications compared to 22 in Europe, 61 in the Americas, 77 in the Western Pacific, 130 in Southeast Asia, and 430 in the Eastern Mediterranean [
7]. Again, children born to adolescent mothers have a higher risk of health complications and mortality than those born to older women [
5,
8]. It is also reported that adolescent girls have higher odds of complicated pregnancy outcomes than older women [
5]. In relation to this, Grønvik and FossgardSandøy [
8] reported that adolescent girls in SSA have a higher risk for prenatal and maternal mortality, low birth weight, eclampsia and preterm delivery. Other complications associated with adolescent childbearing include haemorrhage [
4], systemic infections, puerperal endometritis, and increased risk for caesarean sections [
7,
9].
Available evidence suggests that skilled birth attendance (SBA) is an important maternal health service that reduces adverse pregnancy outcomes among childbearing women and minimises post-delivery complications [
4,
10]. Therefore, increasing the proportion of skilled birth attendance is one of the surest ways of ending preventable maternal deaths in SSA and reducing the global maternal mortality rate to less than 70 per 100,000 live births by 2030 [SDG 3.1] [
4,
11]. However, the utilization of skilled deliveries remains relatively low among adolescent mothers in most sub-Saharan African countries [
12,
13] Mekonnen et al. [
14] estimated that the prevalence of skilled delivery among adolescent mothers in SSA ranged from 10% in Ethiopia to 72% in Guinea.
Previous studies have reported that skilled birth delivery in SSA is associated with factors such as age, parity, wealth quintile [
13], level of education, antenatal care attendance, access to electronic media [
15], and rural/urban residence [
15,
16]. Other factors include the distance from the health facility, male involvement, and mother’s knowledge of pregnancy risk factors [
17]. In Ghana, for example, Nuamah et al. [
13] reported that older mothers (> 34 years) had higher odds of SBA during delivery than younger women (< 24 years). In Ethiopia, women who have access to television or those attending antenatal care at least 4 times have higher odds of SBA [
15]. Similar studies conducted previously in SSA were mostly conducted among women aged 15-49 years and did not specifically focus on adolescent girls [
13,
15,
17]. However, few studies that focused on adolescent childbearing mostly investigated maternal services utilization such as SBA, antenatal care, and postnatal care [
14,
18,
19].
Considering the negative effects of early childbearing on maternal healthcare services utilization [
14,
20,
21], it is important to understand how early age at first birth affects the utilization of SBA among young women in SSA, especially because early childbearing could have long term effect on SBA use. Therefore, we estimated the prevalence of early age at first childbirth and skilled birth attendance among young women in sub-Saharan Africa and. We also investigated the relationship between them. This study’s findings will help stakeholders including health authorities to develop interventions and health programs to improve SBA among pregnant adolescent in SSA.
Discussion
The prevalence of early age at first childbirth and SBA among young women in SSA was investigated in this study. We also investigated the relationship between early age at first birth and SBA among young women in SSA. On average, 75.3% of births among young women in SSA were supervised by skilled birth attendants with Chad (38.4%) and Rwanda (93.7%) recording the lowest and highest prevalence respectively. Although the prevalence of 75.3% in SSA was higher than the average of 61% reported between 2014 and 2019 for less developed countries, it was still lower than the average of 99% in developed countries [
31]. Again, the prevalence of early age at first childbirth from this study was highest in Chad (85.7%) and lowest in Rwanda (43%). The high prevalence of early age at first birth in Chad could explain why SBA in the country is low. This could be that many of the young women whose first childbirth occurred when they were adolescents may face barriers accessing SBA . Such barriers may include cost of maternal healthcare services, stigma, and negative attitude of healthcare providers [
14,
20].
Young women in SSA who had their first birth at the age of 20-24 were 2.7 times more likely to have SBA during delivery than those who had first birth before 20 years. A similar result was reported in 2016 by the Family Health Division of Ghana Health Service, where younger adolescents (10-14 yrs) were less likely to utilize SBA than older adolescents (15-19). In contrast with previous findings in Nigeria [
32] and Mali [
33] where no statistical significance was found between adolescents’ age and maternal healthcare utilization, our finding supports results that were reported in Pakistan [
34]. The possible reason for this finding could be the fear of stigmatization, devaluation, stereotyping, and shaming young pregnant adolescents receive at health facilities [
35‐
37]. In many sub-Saharan African countries, negative social stigma and attitudes towards adolescent pregnancy are deeply rooted in cultural values making it difficult for even some trained health personnel to change them [
35,
38,
39]. This makes many young adolescents feel reluctant to access antenatal care and have SBA during delivery. Also, it is reported that women’s autonomy in healthcare decision making increases with age, which affects maternal services utilization [
20,
40‐
43].
Our findings showed that education had a significant relationship with SBA utilization. The lower the education, the less likelihood of SBA utilization and vice versa. Women with no formal education and women who lived in communities with low literacy levels had lower odds of SBA than those with secondary/higher levels of education and includes young women who lived in communities with medium or high literacy levels. This supports previous research output in Nepal [
44], Pakistan [
35], Namibia [
45], Nigeria [
46], Gambia [
47], and Ethiopia [
48‐
50]. Ameyaw et al. [
51] assert that education increases young women’s exposure to information, knowledge, occupation with high income and access to mass media, which subsequently informs their healthcare decisions and utilization of maternal health services. Young women with secondary/higher education levels may be more empowered and informed about the importance of SBA and be more willing to utilize skilled birth delivery services. However, it is argued that community literacy level leads to high uptake and sharing of accurate maternal health information that influences positive maternal healthcare decision-making among adolescents [
1].
Our study supports findings of previous studies [
52,
53] that showed that women with no mass media exposure had lower odds of SBA during delivery. Mass media, particularly radio and television stations should air health programs to educate people about the pressing health problems in the community. However, those who are exposed to these mass media outlets are more likely to be well informed about SBA services than those with no exposure. Studies have shown that access to mass media education positively affects one’s behavior towards the utilization of health services and SBA [
54].
Also, our study found that young women with two or three births in SSA had higher odds of utilizing SBA services compared with their counterparts with one birth. This finding supports previous research conducted in Pakistan and Bangladesh, where women with more than two births were more likely to utilize SBA than women one birth [
35,
55]. This could be related with the experience obtained when SBA is utilized for first and subsequent births. For instance, a woman who experienced complications during her first childbirth or had obstetric difficulty may choose to always engage the services of an SBA during subsequent deliveries [
56].
Pregnant adolescents residing in urban areas were found to have higher odds of SBA during delivery compared to those in rural areas. This finding highlights the inequalities in access to SBA among young women in SSA and supports other studies in Pakistan [
35], Namibia [
45], and Ethiopia [
48,
57], where young women in urban areas had higher odds of using SBA during delivery.The health facilities in the urban centers might be reasonable for higher utilization of SBA during delivery in SSA. Shorter distance to health facilities in urban centers and better roads and transportation networks, and an increased exposure to mass media and health information may increase the tendency for young women and adolescents to utilize SBA during delivery [
48]. In contrast, rural residents might be more influenced by traditional practices.
Furthermore, religion was found to predict the odds of SBA utilization in SSA. Muslim women had lower odds of using SBA during deliveries than Christian women. This corroborates with Ganle’s [
58] study findings in Ghana which reported that maternal health services utilization including SBA were low among Muslim women in Northern Ghana. As empirical evidence suggests, religion is a significant predictor of maternal healthcare utilization [
59,
60]. There are several factors that could possibly explain why maternal health services utilization among Muslim women is low. One of the reasons could be that religion and culture often interconnect. As argued in the literature, cultural beliefs that affect SBA and maternal healthcare utilization negatively dominate among a religious group [
61,
62].
Our findings also show that women in the poorest wealth quintile and women in communities with low socioeconomic levels had lower odds of SBA than women in the middle, richer and richest quintiles and communities with medium to high socio economic status. In contrast, a Nigerian study finding reported no statistical significance between SBA and the socio-economic/wealth quintile of married adolescents [
20]. This study's finding, therefore, corroborates with results from a cross-sectional study in Ghana where household wealth was significant in predicting SBA utilization among women [
59]. The disparities in the findings could be due to how data was collected on wealth or socioeconomic status in each study setting. This study finding re-emphasizes the need for sub-Saharan African countries to bridge economic inequality that predisposes many disadvantaged adolescents to poor maternal health outcomes, including non-use of SBA.
Strengths and limitations
One of the strengths of this study is its nationally representativeness. Nationally representative data across 29 sub-Saharan African countries were used. The findings therefore can be generalized to all young women in SSA. Again, data collection techniques and methods used followed best practices and they were used by experienced and well-trained data collectors. This led to a high response rate. Also, the study used advanced statistical models for its analysis in conformance with accepted scientific practices. However, despite these strengths, country-specific findings may not be the same as what has been found across the 29 countries. Again due to the study design, this study cannot generate causal interpretation and the findings and relationships between variables reported from this study may also differ over time.
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