Effect of COVID-19 lock down on teenage pregnancies in Northern Uganda: an interrupted time series analysis

Pregnancy and childbirth complications are the leading cause of death among girls aged 15–19 years globally, with LMICs accounting for 99% of global maternal deaths of women aged 15–49 years [1]. Although the rates of adolescent pregnancy have decreased in recent years around the world [2], the emergency of the COVID-19 pandemic and its effects, like lockdown, have increased the rates of teenage pregnancy. The prolonged school closure brought by the lockdown had a significant impact on the past trends in teenage pregnancies in many countries in Africa. Lockdown-related school closures frequently have a significant detrimental effect on the sexual and reproductive health and rights of adolescent girls [3, 4]. Nevertheless, when it comes to preventing teenage pregnancies, the most successful intervention initiatives have consistently gone beyond solely addressing reproductive health. These programs encompass broader aspects such as educational opportunities and vocational skills, primarily offered within school settings. During the COVID-19 period, the inactive school environment led to a significant increase in teenage pregnancies. Future research is needed to understand the risk factors for teenage pregnancy during the lockdown and their prevalence to inform interventions. In Uganda, prior to the pandemic, the prevalence of teenage pregnancies had remained stagnant since 2006, as reported in the UDHS and by UNPA [5]. The highest recorded rate was observed in 2000/2001 at 31%. However, in the subsequent years, there was a gradual decline of 6% to reach 25% in 2006, followed by a further 1% decrease in 2011 [6]. Nevertheless, the rate saw a slight increase of 1% in 2016, making it the highest in East Africa. Despite the overall stagnation with the outbreak of the COVID-19 pandemic, experts worry about the potential change in trend from stagnation to an increasing trend due to the effect of the lockdown [7]. The impact of the lockdown and its effects, like prolonged school closure, on teenage pregnancy needs to be evaluated. School closures during the 2014 Ebola outbreak in west African countries increased teenage pregnancy trends [4]. In Uganda, there is a paucity of data to understand the effects of the COVID-19 lockdown on teenage pregnancy. Therefore, in this study, we used an interrupted time series analysis and estimated the effects of the lockdown on teenage pregnancy during the COVID-19 pandemic period in Pakwach District, northern Uganda. We compared the trend in teenage pregnancy before and during COVID-19 in Pakwach District, Northern Uganda.

As shown in Table 2 below, the starting level of teenage pregnancy rate was estimated at 155 pregnancies per month, and the rate appears to significantly decrease every month prior to March 2020 by − 0.203 pregnancies. [95% CI: − 4.335 to 4.218]. pregnancy, in the first month after the institution of the COVID-19 lockdown (March 20th, 2020), there appeared to be an increase in the teenage pregnancy rate of 13.9 pregnancies [95% CI: − 33.6 to 61.5], which corresponds to an increase in the monthly trend (relative to the period before the COVID-19 lockdown trend) of 1.53 girls per month [95% CI: − 4.2 to 7.2]. After the institution of COVID-19 lockdowns, the monthly trend of teenage pregnancies in Pakwach district (relative to the period before the COVID-19 lockdown trend) increased by 1.53 pregnancies per month [95% CI: − 3.4 to 6.0].

In Fig. 1, from the result of the ordinary logistic regression plot, we see that the lockdown period is associated with an increase in the number of teenage pregnancies. Before the lockdown, the trend was decreasing. After the institution of the lockdown, the trend started to increase relative to the declining trend we saw before the lockdown. As shown in Table 2 below, the starting level of teenage pregnancy rate was estimated at 155 pregnancies per month, and the rate appears to significantly decrease every month prior to March 2020 by − 0.203 pregnancies [95% CI: − 4.335 to 4.218]. However, in the first month after the institution of the COVID-19 lockdown (March 20th, 2020), there appeared to be an increase in the teenage pregnancy rate of 13.9 pregnancies [95% CI: − 33.6 to 61.5], which corresponds to an increase in the monthly trend (relative to the period before the COVID-19 lockdown trend) of 1.53 girls per month [95% CI: − 4.2 to 7.2]. After the institution of COVID-19 lockdowns, the monthly trend of teenage pregnancies in Pakwach district (relative to the period before the COVID-19 lockdown trend) increased by 1.53 pregnancies per month [95% CI: − 3.4 to 6.0].

In Fig. 1, from the result of the ordinary logistic regression plot, we see that the lockdown period is associated with an increase in the number of teenage pregnancies. Before the lockdown, the trend was decreasing. After the institution of the lockdown, the trend started to increase relative to the declining trend we saw before the lockdown.

Generally, in Pakwach District, teenage pregnancy rates are higher (22.4%), as reflected in the Uganda Demographic Health Survey 2016 [8], Although this is the aggregate statistic for all the West Nile districts and not only for Pakwach district, it is still very high. However, during the COVID-19 period, we witnessed an increasing trend, as captured in our data.

The starting level of the teenage pregnancy trend in the district was estimated at 155 pregnancies per month. It was significantly decreasing every month before the lockdown. However, after the institution of the lockdown, this trend started increasing in the first month after the lockdown and continued monthly at a rate of 1.53 girls relative to the period before COVID-19. The increase we saw could have been because of the lockdown environment that exposed adolescent girls to many risk factors associated with pregnancy while at home. These findings agree with that of another report published by Plan International during the 2014 Ebola outbreak in West Africa where lockdown was instituted as a public health measure [9]. Additionally, it also agrees with Zulaika and others in Kenya, who also found school-age girls suffering from the effect of covenant-19 containment to have 2 times the risk of becoming pregnant [10].

This new trend corresponds to an 8% increase in teenage pregnancies in the district, and we think that factors like prolonged school closure, sexual abuse, limited access to contraceptives and others imposed by the lockdown environment on teenage girls could explain this increase. Our finding in this analysis is similar to studies conducted in West Africa during the Ebola outbreak in 2014, where a lockdown instituted to prevent Ebola led to increased teenage pregnancy rates and a shift in the trend of teenage pregnancy in school-going adolescents due to prolonged school closures [9].

Data elsewhere in Uganda also indicate that the teenage pregnancy rate in girls aged 10–19 years during the COVID-19 lockdown plummeted [11]. Even though factors that contributed to the high increase are yet to be investigated, in the population of Pakwach, the lockdown contributed an 8% increase, which we attributed to the lockdown environments and other factors.

In conclusion, almost no studies have utilized interrupted time series analysis to compare teenage pregnancy trends and rates in Uganda before, and this study is the first of its kind that we think can be used as a benchmark for many intervention studies in this area of teenage pregnancy. But all in all, we found this design very valuable in evaluating teenage pregnancy interventions, trends, and rates, and therefore we do recommend it for future studies in this area.