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To examine whether childbearing before age 18 in Sub-Saharan Africa is associated with increased risk of maternal and child complications through a systematic literature review and meta-analysis. The literature on adolescent pregnancy and associated complications in Sub-Saharan Africa was reviewed. A systematic electronic database search in Medline and Embase identified relevant papers. Studies were eligible for inclusion if they had numeric data on maternal mortality, pre-eclampsia, eclampsia, preterm birth, low birth weight, small for gestational age, stillbirth, neonatal death or perinatal death. We included studies on adolescents aged 17 years or younger, and with a comparison group of adult women aged between 20 and 35 years. The quality of the articles was assessed. Meta-analyses were conducted when there were at least three included studies with minor clinical heterogeneity in population and outcome measures. Eighteen studies met our inclusion criteria. There were many studies from Sub-Saharan Africa with data on the age group 15-19 years old, but few studies had separate data on adolescents <18 years old. All included studies were of either moderate or low quality. Adolescents had an increased risk of low birth weight, pre-eclampsia/eclampsia, preterm birth and maternal and perinatal mortality. We found a lower, nonsignificant risk of stillbirth and for small for gestational age babies among the young mothers. In this systematic review, the findings indicate that young maternal age is associated with some unfavorable outcomes in Sub-Saharan Africa. High quality observational studies that adjust for sociodemographic factors are lacking.

Background Despite the effectiveness of Human Papillomavirus (HPV) vaccines in preventing cervical cancer, the low coverage of the vaccine remains a significant challenge, particularly in Sub-Saharan Africa, where the disease burden is high, and access to preventive services is limited. Socioeconomic determinants play a central role in shaping health behaviors and health outcomes. The uptake of the HPV vaccine is partly determined by parental decision-making, and this review aimed to examine whether socioeconomic factors are associated with awareness and acceptability of HPV vaccination among parents in sub-Saharan Africa. Methods A systematic literature review was carried out according to the Preferred Reporting Items for Systemic Reviews and Meta-analysis guidelines. The databases searched included Medline, Embase, Web of Science, and the Cochrane Library. Three independent reviewers conducted the screening, study selection, data extraction and risk of bias assessment. Meta-analyses were performed and the certainty of evidence was evaluated using the Grading of Recommendations Assessment, Development and Evaluation. Results The review included 26 articles, comprising 24 cross-sectional and two cohort studies. Seven studies examined parental awareness, 14 studies examined parental acceptability, and four studies examined both outcomes. Parents’ awareness of the HPV vaccine was associated with higher levels of education (OR = 3.81, 95% CI: 2.11–6.88, I 2  = 84%, four studies), higher income (OR = 1.96, 95% CI: 0.72–5.29, I 2  = 89%, four studies), moderate income (OR = 1.22, 95% CI: 0.67–2.23, I 2  = 74%, four studies). Parents’ acceptance of HPV vaccination was associated with higher levels of education (OR = 2.06, 95% CI: 1.35–3.15, I 2  = 77%, seven studies), higher income (OR = 2.16, 95% CI: 1.21–3.84, I 2  = 77%, five studies), moderate income (OR = 1.33, 95% CI: 0.86–2.07, I 2  = 74%, five studies) and urban residence (OR = 1.28, 95% CI: 0.84–1.96, I 2  = 64%, five studies). The certainty of evidence ranged from low to very low. Conclusions There may be a positive association between socioeconomic status, especially higher education and higher income, and parental awareness and acceptance of HPV vaccination. However the evidence is currently limited and inconsistent.

B ackground Parent-child communication about sexual issues can reduce risky sexual behaviour amongst adolescents. Risky sexual behaviour is of concern in sub-Saharan Africa where the prevalence of early pregnancy, unsafe abortion and HIV are high. Parent-child communication about sexual issues presents a feasible approach for reducing sexual risk amongst adolescents in sub-Saharan Africa but limited research exists from the region. This study from Zambia examines the sociodemographic and psychosocial factors that are associated with whether parents communicate with their daughters about sexual issues. Methods Data from a cluster randomized controlled trial examining the effect of interventions aiming to reduce teenage pregnancy and school drop out in Zambia was used. The data was collected between January–July in 2018 and consists of structured, face to face interviews with 4343 adolescent girls and 3878 parents. Cross sectional analyses examined the associations between parent-child communication about sexual issues and sociodemographic and psychosocial characteristics using univariate and multivariable logistic regression models. Results Adolescent girls who felt connected to their parents and those who perceived their parents to be comfortable in communicating about sex, were more likely to speak to their parents about sexual issues than those who did not (AOR 1.23, 95% CI 1.01–1.52; and AOR 2.94, 95% CI 2.45–3.54, respectively). Girls whose parents used fear-based communication about sexual issues, and those who perceived their parents as being opposed to education about contraception, were less likely to communicate with their parents about sex than those who did not (AOR 0.76, 95% CI 0.65–0.89; and AOR 0.76, 95% CI 0.63–0.91, respectively). Girls enrolled in school were less likely to communicate with their parents about sex than those out of school (AOR 0.56, 95% CI 0.44–0.71). Conclusion Parenting style, children’s perception of parental attitudes and parental communication styles are associated with whether parents and children communicate about sexual issues. This may imply that parents can improve the chances of communicating with their children about sex by conveying non-judgemental attitudes, using open communication styles with neutral messages and appearing comfortable whilst displaying positive attitudes towards communication around sex and contraceptive use. Trial registration ISRCTN registry: ISRCTN12727868 , (4 March 2016).

Background The Republic of Georgia implemented COVID-19-related restrictions starting on 31 March 2020, when it imposed a 1-month strict lockdown, after which the country continued with some form of restrictions for 1 year. These restrictions created barriers to healthcare access, affected healthcare services, caused severe economic degradation, and changed reproductive behavior. The aim of this study was to explore the impact of COVID-19-related restrictions on pregnancy and abortion rates in Georgia. Methods Information on pregnancy, abortion, and related variables was extracted from the Georgian Birth Registry from January 2018 through April 2022. The final study sample included 232,594 pregnancies and 86,729 abortions. We used interrupted time series analysis to study the impact of COVID-19-related restrictions. Results There were slightly decreasing trends in pregnancy and abortion rates in the pre-pandemic period (1 January 2018-31 March 2020). During the 1-month strict lockdown (1 April-30 April 2020), pregnancy and abortion rates decreased in all investigated age groups. There were no substantial differences in pregnancy or abortion rates in the pandemic period (for pregnancies: 1 April 2020-30 June 2021; for abortions: 1 April 2020-30 April 2022) compared to the pre-pandemic period. The precision of all estimates suggested that both small increases and decreases in pregnancy and abortion rates are reasonably compatible with our data. Conclusions Despite the 1-year-long COVID-19-related restrictions, our results did not indicate substantial long-term changes in pregnancy or abortion rates during the study period for any age group. This may indicate that the restrictions did not substantially influence access to contraception, abortion services, or reproductive behavior.

Maternal HIV infection is associated with increased risk of having a preterm delivery, low birth weight baby, small for gestational age baby and stillbirth. Maternal use of combination antiretroviral treatment is also associated with preterm delivery and low birth weight, although the effects vary by the type of drugs and timing of initiation. To examine time trends in adverse perinatal outcomes among HIV-positive compared with HIV-negative women. Registry-based cohort study. Northern Tanzania, 2000-2018. Mother-baby pairs of singleton deliveries (n = 41 156). Perinatal outcomes of HIV-positive women were compared with HIV-negative women during time periods representing shifts in prevention of mother-to-child transmission guidelines. Monotherapy was used as first-line therapy before 2007 while combination antiretroviral treatment was routinely used from 2007. Log binomial and quantile regression were used to analyze the data. Preterm delivery, low birth weight, perinatal death, stillbirth, low Apgar score, transfer to neonatal care unit and small for gestational age. Overall, maternal HIV infection was associated with a higher risk of low birth weight and small for gestational age. Moreover, this pattern became more pronounced over time for low birth weight, the last time period being an exception. For other outcomes we found none or only a small overall association with maternal HIV infection, although a trend towards higher risk over time in HIV-positive compared with HIV-negative women was observed for preterm delivery and perinatal death. Quantile regression showed an increase in birth weight in babies born to HIV-negative women over time and a corresponding decline in birth weight in babies born to HIV-positive women. Unfavourable trends in some of the selected perinatal outcomes were seen for HIV-positive compared with HIV-negative women. Potential side-effects of combination antiretroviral treatment in pregnancy should be further explored.

Introduction Pneumonia is a leading cause of under‐five mortality, with 30 million annual cases in India. Despite national guidelines, significant barriers to timely and appropriate care‐seeking persist. Caregivers often face financial constraints, lack of awareness, mistrust in government facilities and a preference for non‐registered medical practitioners (non‐RMPs), delaying effective treatment. This study explores care‐seeking behaviours, associated socio‐demographic factors and barriers to access to appropriate healthcare for childhood pneumonia in rural India. Methods This study is part of a broader implementation research (IR) initiative and represents its formative phase. This mixed‐methods study was conducted in Palwal district, Haryana, covering 42 villages (population: 107,440). A cross‐sectional survey identified suspected pneumonia cases among 9593 under‐five children through house‐to‐house visits using a structured checklist. Data on socio‐demographic characteristics, health insurance, care‐seeking patterns and provider preferences were collected. Directed acyclic graphs (DAGs) identified potential confounders in the association between care‐seeking behaviour and key exposure variables. Additionally, qualitative in‐depth interviews explored caregivers' perceptions, decision‐making and healthcare barriers to pneumonia management. Quantitative data were analysed using logistic regression, while qualitative data were thematically analysed using the Three Delays Model. Suspected under‐five pneumonia cases' caregivers and families were actively engaged in this formative phase to inform Phase II implementation strategies of broader IR, ensuring community‐driven and contextually relevant strategies. Results Among 231 suspected pneumonia cases, 97% of caregivers sought medical care, but 71% consulted non‐RMPs, and only 3.6% visited government facilities. Seeking appropriate care was associated with higher maternal education (AOR 6.5, 95% CI: 2.7–9.7) and higher wealth index (AOR 1.7, 95% CI: 1.0–2.6). Thematic analysis revealed delays due to symptom misinterpretation, reliance on home remedies, financial constraints, gender biases, mistrust in public healthcare services and logistical barriers. Conclusion Despite high care‐seeking rates, provider preferences, socio‐cultural factors and systemic barriers delay appropriate pneumonia treatment. Addressing these challenges requires improving awareness, enhancing public healthcare trust and strengthening frontline healthworker engagement. This study underscores the role of structured beneficiary involvement in refining pneumonia management strategies to ensure sustainable, community‐driven interventions. Patient or Public Contribution This study is part of an ongoing implementation research (IR) aimed at improving the effective coverage of childhood pneumonia management in a low‐resource setting. A structured engagement with primary caregivers of under‐five children, mothers, fathers, family members, community members and local community stakeholders/representatives, for example, local leaders, village heads and so forth, has been integrated at multiple stages to ensure the relevance and applicability of its findings. The current study is part of Phase I (formative research) of the IR, where primary caregivers and family members participated in a needs assessment, providing critical insights into the barriers and facilitators influencing care‐seeking for childhood pneumonia in a rural low‐to‐middle socio‐economic setting. Their inputs have informed the refinement of study tools and the development of mitigation strategies for the logic and implementation model. As the research progresses into Phase II (model development and implementation), the community continues to play an integral role in providing feedback on the feasibility and appropriateness of proposed strategies. This ongoing feedback loop assesses how effectively these strategies strengthen linkages between the healthcare system and the community, foster an active local needs assessment mechanism among healthcare providers and enhance demand generation for appropriate pneumonia care‐seeking. These iterative refinements ensure that the implementation strategies remain responsive to the evolving needs of the community. In the forthcoming Phase III, which will focus on scaling up the finalised implementation model, strategies will be adapted to further improve care‐seeking for under‐five children. Continuous engagement with caregivers and local community representatives, including Panchayati Raj Institution (PRI) members, will be central to refining these strategies. Additionally, during the dissemination phase, key findings will be shared with caregivers, community members and PRI representatives, facilitating discussions on study implications and informing future policy and programmatic decisions. Their ongoing involvement will help contextualise findings and enhance the long‐term sustainability of strategies aimed at improving pneumonia care‐seeking behaviours and effective management in rural India.

Background In India, despite several effective interventions being implemented, pneumonia persists as a major cause of under-five mortality. We explore barriers and facilitators to implementing a childhood pneumonia management program in a North Indian district. The study aims to inform the development of effective implementation strategies for pneumonia management in resource-constrained settings. Methods This mixed-method study was conducted during the formative phase of an ongoing pre-post quasi-experimental implementation study. Data collection followed the Consolidated Framework for Implementation Research, encompassing surveys on implementation climate and attitudes toward evidence-based-treatment for childhood pneumonia, as well as in-depth interviews to uncover implementation barriers and facilitators with healthcare staff. Additionally, a baseline cross-sectional facility inventory survey was conducted in 26 government healthcare facilities. We present descriptive statistics from the surveys along with deductive analysis findings from qualitative interviews. Results Several barriers were observed, like deficient infrastructure and limited space, privacy concerns, inadequate examination tables, disrupted medicine supply, non-maintenance of under-five children’s records, inadequate utilization of the digital portal for pneumonia case registration, lack of specific budget allocation for medicine procurement, absence of functional equipment, staff shortages, lack of training, referral linkage issues, and limited accessibility to guideline materials. The absence of incentives demotivated community healthcare workers (CHWs), while coordination issues, power dynamics, and unclear job responsibilities affected the motivation of other healthcare staff. Community reluctance to seek care from government facilities and diminishing community-level trust in CHWs posed implementation challenges. Facilitators included committed healthcare and community workers, problem-solving skills, community engagement, and untied funds from the district government. Implementation climate scores were mildly positive, yet provider attitudes towards Evidence-Based Practices Adoption were neutral. Conclusions We propose a multi-pronged approach including healthcare provider training, task sharing, budget reallocation promoting medication access, performance monitoring, digitalization of the record system, and community engagement to optimize program effectiveness. Trial registration This research was prospectively registered in the clinical trial registry CTRI202103031622 [Registered on: 01/03/2021].

Background Comprehensive sexuality education (CSE) has been introduced in many sub-Saharan African countries, but limited political interest and insufficient funding have resulted in many CSE initiatives being dependent on donor funding or non-governmental organisations (NGOs) supporting its implementation. This has created concerns about the sustainability of the programmes. The objective of this study was to explore factors affecting the sustainability of CSE delivered through a youth club organized after school hours in Zambia. Methods We interviewed teachers and community health workers (CHWs) who had implemented CSE as part of an after-school youth club set up as part of a cluster randomized controlled trial. The trial evaluated the effectiveness of economic support for adolescent girls, CSE and community dialogue meetings on adolescent childbearing. Teachers and CHWs in 63 schools were trained to facilitate the CSE youth clubs, and they were given economic incentives during the trial´s two-year intervention period to organize meetings every fortnight. Two years after the external support for the youth clubs ended, we conducted qualitative interviews with the facilitators in 15 of the 63 schools, interviews with some head teachers, and focus group discussions with guardians of adolescent girls. Results Whereas CHWs were generally supportive of teaching adolescents about contraception, some of the teachers stressed that abstinence was the most effective method to avoid pregnancy and diseases. The respondents’ diverging points of view did not affect their willingness to continue teaching CSE, including contraception. However, the youth club meetings were only continued in a few schools after the external support period ended. This was attributed to transfers of trained teachers and a lack of training among the remaining staff; lapse of moral support, resources and incentives; limited involvement of the school management in the CSE initiative; and attention shifting to other projects. Conclusion To ensure the sustainability of CSE initiatives for adolescents, emphasis should be placed on training several teachers in each school, and continued moral support and encouragement also appeared essential. Trial registration : ISRCTN (ISRCTN12727868). Plain Language Summary This study looked at the sustainability of Comprehensive Sexuality Education (CSE) in Zambia, delivered through after-school youth clubs. These clubs were part of a larger project that also provided economic support to adolescent girls and organized community meetings. The clubs were run by a teacher and a community health worker (CHW), who were trained and given financial incentives to hold meetings every two weeks. Two years after the project ended, interviews were conducted with various stakeholders. While CHWs were generally in favor of teaching about contraception, some teachers emphasized abstinence as the best way to avoid pregnancy and diseases. Despite these differing views, all were willing to continue teaching CSE, including contraception. However, only a few schools continued the youth club meetings after the project ended. This was due to trained teachers being transferred, lack of training for remaining staff, loss of support and resources, limited school management involvement in the CSE initiative, and the need to focus on other projects. To ensure the sustainability of CSE initiatives, more teachers in each school should be trained, and continued support and encouragement should be provided.

Background There is a need for empirically based research on social and ethical challenges related to informed consent processes, particularly in studies focusing on adolescent sexual and reproductive health. In a pilot study of a school-based pregnancy prevention intervention in rural Zambia, the majority of the guardians who were asked to consent to their daughters’ participation, refused. In this paper we explore the reasons behind the low participation in the pilot with particular attention to challenges related to the community engagement and informed consent process. Methods The pilot was implemented in two schools and examined the acceptability of a package of interventions including economic support to families to keep their girls in school, pocket money for girls, youth club meetings on reproductive health, and community meetings to sensitize the community. Focus group discussions (4) were conducted with girls who participated in the pilot, boys in their class and with parents. Individual semi-structured interviews (11) were conducted with teachers, peer educators and community health workers involved in the coordination of the intervention as well as with religious and traditional leaders. Data were analyzed through thematic analysis. Results The findings indicate that inadequate use of recognized community communication channels during the community engagement process and dissemination of information about the pilot resulted in limited understanding of the pilot concept by the community. This surfaced through uncertainty and fear that the intervention may result in loss of control over daughters, worries about why money was provided unconditionally to girls, and suspicion of links to satanism. The sense of insecurity appeared to be exacerbated by low literacy levels, poverty, fear of loss of bride wealth, perceived disregard for local perceptions of social status, and scanty trust in the actors implementing the pilot. Conclusions Inadequate use of locally appropriate channels in the dissemination of information created room for interpretation and facilitated development of mistrust, undermining the conditions for community engagement and actual informed consent. A key lesson learnt is the importance of taking seriously the complexity of local values and structures that may impact people’s capability to consent or not consent to a study in an informed manner.

Introduction Community-based sexual reproductive interventions are key in attaining universal health coverage for all by 2030, yet adolescents in many countries still lack health services that are responsive to their sexual reproductive health and rights’ needs. As the first step of realist evaluation, this study provides a programme theory that explains how, why and under what circumstances community-based sexual reproductive health interventions can transform (or not) ‘ordinary’ community-based health systems (CBHSs) into systems that are responsive to the sexual reproductive health of adolescents. Methods This realist approach adopted a case study design. We nested the study in the full intervention arm of the Research Initiative to Support the Empowerment of Girls trial in Zambia. Sixteen in-depth interviews were conducted with stakeholders involved in the development and/or implementation of the trial. All the interviews were recorded and analysed using NVIVO version 12.0. Thematic analysis was used guided by realist evaluation concepts. The findings were later synthesized using the Intervention−Context−Actors−Mechanism−Outcomes conceptualization tool. Using the retroduction approach, we summarized the findings into two programme theories. Results We identified two initial testable programme theories. The first theory presumes that adolescent sexual reproductive health and rights (SRHR) interventions that are supported by contextual factors, such as existing policies and guidelines related to SRHR, socio-cultural norms and CBHS structures are more likely to trigger mechanisms among the different actors that can encourage uptake of the interventions, and thus contribute to making the CBHS responsive to the SRHR needs of adolescents. The second and alternative theory suggests that SRHR interventions, if not supported by contextual factors, are less likely to transform the CBHSs in which they are implemented. At individual level the mechanisms, awareness and knowledge were expected to lead to value clarification’, which was also expected would lead to individuals developing a ‘supportive attitude towards adolescent SRHR. It was anticipated that these individual mechanisms would in turn trigger the collective mechanisms, communication, cohesion, social connection and linkages. Conclusion The two alternative programme theories describe how, why and under what circumstances SRHR interventions that target adolescents can transform ‘ordinary’ community-based health systems into systems that are responsive to adolescents.