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ObjectiveThis study aims to assess the feasibility of respondent-driven sampling (RDS) to recruit participants with recent abortion experiences in humanitarian contexts, and describe the composition of the study sample generated with this sampling method.DesignThis was a three-phase mixed-methods community-engaged research study employing an exploratory and explanatory sequential approach. We conducted in-depth interviews, focus group discussions, an interviewer-administered questionnaire on abortion experiences and a health facility assessment.SettingBidibidi Refugee Settlement, Uganda and Kakuma Refugee Camp, Kenya from November 2021 to December 2022.ParticipantsUsing RDS, we recruited 600 participants in Kakuma and 601 participants in Bidibidi with recent abortion experiences. In Kakuma, participants were primarily from Burundi, the Democratic Republic of the Congo and South Sudan; participants in Bidibidi were primarily from South Sudan. Most participants in both sites had completed at least some primary school and were not employed.Outcome measuresRDS recruitment dynamics: convergence and bottlenecks on key sociodemographic variables, recruitment and population homophily, reciprocity of social ties, success and experiences recruiting.ResultsThere were minor violations of RDS assumptions, particularly regarding assumptions of reciprocity of ties and seed composition independent of sample. In addition, there was a strong tendency of participants to recruit those from the same home country and living within the same camp zone. However, sample proportions for age, home country, marital status, zone of residence and student status reached equilibrium (stabilised) by around 500 participants at each site, and we were able to quickly attain the study sample size.ConclusionsWhile the true representativeness of our sample remains unknown, RDS is a practical and effective recruitment method in humanitarian contexts for sensitive topics, particularly for research questions in which no data or sampling frames exist. However, attention to representativeness and community engagement is essential to optimising its application and ensuring success.

Background Given the high burden of adverse sexual and reproductive health outcomes (SRH) and low levels of school attendance among adolescent girls in Kenya, this study sought to elucidate the association between school attendance and SRH outcomes among adolescent girls in Homa Bay and Narok counties. Methods This study uses baseline quantitative data from the mixed-methods evaluation of the In Their Hands (ITH) program which occurred between September to October 2018 in Homa Bay and Narok counties. In total, 1840 adolescent girls aged 15–19 years participated in the baseline survey, of which 1810 were included in the present analysis. Multivariable logistic regression models were used to assess the association between school attendance (in- versus out-of-school) and ever having sex, condom use during last sex, and ever pregnant, controlling for age, orphan status, income generation, religion, county, relationship status, and correct SRH knowledge. Results Across the 1810 participants included in our study, 61.3% were in-school and 38.7% were out-of-school. Compared to adolescent girls who were in-school, those out-of-school were more likely (AOR 5.74 95% CI 3.94, 8.46) to report ever having sex, less likely (AOR: 0.21, 95% CI 0.16, 0.31) to have used a condom during their last sexual intercourse, and more likely (AOR: 6.98, 95% CI 5.04, 9.74) to have ever been pregnant. Conclusions School attendance plays an integral role in adolescent girls’ SRH outcomes, and it is imperative that policy actors coordinate with the government and community to develop and implement initiatives that support adolescent girls’ school attendance and education. Plain Language Summary Adolescent girls in Kenya experience poor sexual and reproductive health outcomes (SRH) and have low levels of educational attainment. In this study, we aimed to examine if school attendance was associated with sexual and reproductive health outcomes among adolescent girls aged 15 to 19 years in Homa Bay and Narok counties in Kenya. The study used data from the evaluation of the In Their Hands (ITH) program which occurred between September to October 2018. A total of 1840 adolescent girls years participated in the baseline survey, of which 1810 were included in this study. We found that compared to adolescent girls in-school, those who were out-of-school were significantly more likely to report ever having sex, less likely to have used a condom during their last intercourse, and more likely to have ever been pregnant. This study found that attending school plays an important protective role in the SRH of adolescent girls. Therefore, it is important to develop and implement initiatives to support adolescent girls’ school attendance, and ultimately their education attainment.

Background Adolescent pregnancy remains a major challenge in both developed and developing countries. Early and unintended pregnancies among adolescents are associated with several adverse health, educational, social and economic outcomes. The aim of this study was to identify the contextual factors that influence adolescent pregnancy and early motherhood in five East African countries. Methods We use DHS data from five East African countries to examine trends and risk factors associated with adolescent pregnancy. DHS surveys collect detailed information on individual and household characteristics, sexual behavior, contraception, and related reproductive behaviors. Our analysis focuses on a weighted subsample of adolescent’s age 15–19 years (Kenya, 5820; Tanzania, 2904; Uganda, 4263; Malawi, 5263; Zambia, 3675). Multilevel logistic regression analysis was used to identify the net effects of individual, household and community level contextual variables on adolescent pregnancy after adjusting for potential confounders. Results Adolescent pregnancy and early motherhood is common in the five countries, ranging from 18% among adolescents in Kenya (2014) to 29% in Malawi (2016) and Zambia (2014). Although all five countries experienced a decline in adolescent pregnancy since 1990, the declines have been largely inconsistent. More than half of the adolescent’s most recent pregnancies and or births in these countries were unintended. The regression analysis found that educational attainment, age at first sex, household wealth, family structure and exposure to media were significantly associated with adolescent pregnancy in at least one of the five countries after adjusting for socio-demographic factors. Conclusion The study highlights the importance of considering multi-sectoral approaches to addressing adolescent pregnancy. Broader development programs that have positive impacts on girls educational and employment opportunities may potentially influence their agency and decision-making around if and when to have children. Likewise, policies and programs that promote access to and uptake of adolescent sexual and reproductive health services are required to reduce barriers to the use of adolescent Sexual and Reproductive Health (SRH) services.

Understanding what adolescents want and how preferences are likely to vary among different groups is important to make the healthcare system responsive to the needs of adolescents and to maximize service utilization. Despite this, evidence is scarce in this aspect. Therefore, this study aimed to explore preferences for accessing Sexual and Reproductive Health (SRH) services from the perspective of adolescents and health care providers in the South Ethiopia Regional State. A phenomenological qualitative study was conducted from September 04 to October 15, 2023. Seven Focus Group Discussions (FGDs) and ten Key Informant Interviews (KIIs) were conducted with purposively selected seventy-five adolescents and ten healthcare providers respectively. A semi-structured interview guide was used to explore their lived experiences. All interviews and discussions were audio-recorded. The research team transcribed the collected data verbatim and translated it into English. The data was analyzed using a thematic analysis approach. In this study, five main themes were identified. The identified main themes were preferred SRH services provider, preferred SRH services venue, preferred SRH services provision time, preferred SRH services information sources, and preferred strategies to improve access to SRH services. Regarding preferred SRH service providers, adolescents prefer males by sex, younger health care providers by age, and not neighborhood health providers by residence. Concerning preferred SRH services venue, adolescents prefer pharmacies as a venue to access condoms and emergency pills, while they prefer traditional medical centers as a source of abortion services. Besides this, schools are a preferred venue for adolescents to access SRH information. Moreover, sexual partners, close friends, and peers who experienced similar problems are the preferred sources of SRH information for adolescents. Furthermore, engagement of private health facilities, strengthening engagement of faith-based organization, and strengthening community-based SRH services provision were identified as preferred strategies to improve access to SRH services. Improving access to sexual and reproductive health services necessitates the implementation of innovative and responsive strategies that address the diverse preferences and needs of adolescents. Prioritizing adolescent engagement in healthcare is vital, as it fosters a better understanding of their unique perspectives and ultimately enhances the accessibility and utilization of these essential services.

Evidence from sub-Saharan Africa, including Kenya, shows that negative beliefs about contraceptive methods are associated with non-use. However, little is known about the relationship between contraceptive beliefs and subsequent method choice. We used data from a two-year longitudinal survey of married women aged 15-39 years at enrollment from one urban site (Nairobi) and one rural site (Homa Bay) in Kenya. Analysis entails descriptive statistics and estimation of a conditional logit analysis to examine associations between method-specific beliefs and choice of injectables, implants or pills among women who were not using any method or were pregnant at baseline (round 1) but adopted these methods at 12-month follow-up (Nairobi, n = 221; Homa Bay n = 197). Beliefs about pills, injectables and implants among non-users were generally negative. With the partial exception of the pill in Nairobi, the majority thought that each method was likely to cause serious health problems, unpleasant side effects, menstrual disruption, and would be unsafe for long-term use. In both sites, satisfied past use of a method and the perception that a method is easy to use had a major influence on method choice. Concerns about menstrual disruption and safety for long-term use were unimportant in both sites. There were some marked differences between the two sites. Beliefs about long-term fertility impairment and perceived husband approval had strong influences on choice of injectables, implants or pills in the urban site but not in the rural site. The relative importance of beliefs, some erroneous, in predisposing women to choose one method over another appears to be conditioned by the social context. There is need for family planning counseling programmes to pay attention to erroneous beliefs and misconceptions about contraceptives.

Long acting reversible and permanent contraception (LARPs) offer promising opportunities for addressing the high and growing unmet need for modern contraception and helps to reduce unintended pregnancies and abortion rates in sub-Saharan Africa (SSA). This study examines the contextual factors that influence the use of long acting reversible and permanent contraception among married and fecund women in Ethiopia. We use data from the 2016 Ethiopian Demographic and Health Survey to examine the contextual factors that influence choice of long acting reversible and permanent contraception among married, non-pregnant and fecund women. The DHS collects detailed information on individual and household characteristics, contraception, and related reproductive behaviors from women of reproductive age. In addition, we created cluster level variables by aggregating individual level data to the cluster level. Analysis was done using a two-level multilevel logistic regression with data from 6994 married (weighted = 7352) women residing in 642 clusters (communities). In 2016, 12% of married, non-pregnant and 'fecund' women were using long-acting reversible and permanent methods of contraception in Ethiopia. A higher proportion of women with secondary and above education (17.6%), urban residents (19.7%), in the richest wealth quintile (18.3%) and in paid employment (18.3%) were using LARP methods compared to their counterparts. Regression analysis showed that community level variables such as women's empowerment, access to family planning information and services, region of residence and knowledge of methods were significantly associated with use of LARP methods. Age, wealth status, employment status and women's fertility preferences were among the individual and household level variables associated with choice of LARP methods. With regards to age, the odds of using LARP methods was significantly lower among adolescents (OR, 0.53; 95% CI, 0.32-0.85) and women over the age of 40 (OR, 0.63; 95% CI, 0.44-0.90) compared to women in their 20's. The findings of this study indicate that the demand for long-acting reversible and permanent contraception is influenced not only by women's individual and household characteristics but also by the community's level of women's empowerment, socio-economic development, as well as access and exposure to family planning information and services. Thus, improving knowledge of long-acting reversible and permanent methods, improving women's decision making autonomy and upgrading the capacity and skills of health workers particularly the midlevel providers and community health extension workers on the provision of LARP methods and rights-based approach is important to improve the uptake of LARP methods.

Low birth weight (LBW) is the principal risk factor for neonatal and infant mortality in developing countries. This study examines the effects of unwanted pregnancy, prenatal depression and social support on the risk of low birth weight in rural southwestern Ethiopia. We hypothesized that unwanted pregnancy and prenatal depression increase the risk of low birth weight, while social support mediates this association. Data for the study comes from a prospective study in which women were followed from pregnancy through to delivery. Six hundred twenty two women were followed and 537 birth weights were measured within 72 hours. Multivariable log binomial regression was used to model the risk of low birth weight. The mean birth weight was 2989 grams (SD ± 504 grams), and the incidence of LBW was 17.88%. The mean birth weight of babies after unwanted pregnancy was 114 g lower compared to births from intended pregnancy. Similarly, mean birth weight for babies among women with symptoms of antenatal depression was 116 grams lower. Results of unadjusted log-binomial regression showed that unwanted pregnancy, prenatal depression and social support were associated with LBW. The relationship between antenatal depressive symptoms and LBW was mediated by the presence of social support, while the association between LBW and unwanted pregnancy remained after multivariable adjustment. The incidence of low birth weight is high in the study area. Poverty, nonuse of antenatal care, low social support and unwanted pregnancy contribute to this high incidence of low birth weight. Hence, identifying women's pregnancy intention during antenatal care visits, and providing appropriate counseling and social support will help improve birth outcomes.

Background In Ghana, while coverage of demand for family planning satisfied by modern methods (mDFPS) has increased, substantial inequalities persist across demographic and geographic factors. This study aims to assess mDFPS trends from 2013 to 2022, with a focus on inequalities related to residence, education, and wealth, and identifying the determinants of mDFPS. Methods Using data from Performance Monitoring Action (PMA) (2013–2017) and Ghana Demographic and Health Survey (DHS) (2022), an evaluation of the trends of demand for family planning satisfied by modern methods (mDFPS) was assessed from 2013 to 2022 with the corresponding annual average rate of change. Absolute complex measures of inequalities (SII and WMADM) were used to identify wealth, education and regional related inequalities in mDFPS coverage. A binary logistic regression was used to assess factors influencing mDFPS. Findings The coverage of women with a demand for family planning satisfied with modern methods increased from 33.0% to 49.5% between 2013 to 2022. An overall 3.8% annual increase in mDFPS was observed from 2013 to 2022. A decreasing trend in wealth, education and regional inequalities were observed over the years. However, women with no education and those from the Northern region of Ghana have consistently had the lowest mDFPS coverage over the years, and they continue to lag. Women aged 20–35 have a 28% increase in odds [95%CI:1.01–1.63; p  = 0.038] of family planning satisfaction by modern methods compared to those aged 15–19. Mothers currently working have a 27% increased odds of family planning satisfaction by modern methods compared to those who are not working [95%CI: 1.07–1.51; P  = 0.007]. Furthermore, women who are married or co-habiting have a 33% decrease in odds of family planning satisfaction by modern methods compared to those who are single [95%CI: 0.56–0.84; P  < 0.001]. Conclusion Reductions in educational and wealth-related inequalities in mDFPS coverage have been observed over time; however, persistent challenges emphasize the need for targeted interventions. Prioritizing equitable access for poorer, less educated women and addressing regional disparities, particularly in the Northern region of Ghana, are crucial to achieving inclusive family planning services.

Background Early adolescence is a critical window for intervention when it is possible to lay a foundation for a safe transition to adulthood, before negative outcomes occur. The Adolescent Girls Initiative–Kenya randomized trial tested the effects of combinations of interventions for young adolescent girls in two sites – the Kibera informal settlement in Nairobi and rural Wajir County in the Northeastern region. Methods The interventions included community dialogues on the role and value of girls (violence prevention), a conditional cash transfer (education), weekly group meetings for girls with health and life skills training (health), and training and incentives for financial literacy and savings activities (wealth creation). Participants were randomized to one of four study arms: 1) violence prevention only, 2) violence prevention and education, 3) violence prevention, education and health or 4) violence prevention, education, health and wealth creation. An intent-to-treat (ITT) analysis was conducted using longitudinal data to estimate the impact of each combination of interventions and various sensitivity analyses conducted addressing potential attrition bias and multiple hypothesis testing concerns. Results In Kibera, the education conditional cash transfer had small effects on grade attainment but larger impacts on completion of primary school and the transition to secondary school in the most comprehensive arm; the health intervention improved sexual and reproductive health knowledge and condom self-efficacy; and the wealth intervention improved financial literacy and savings behavior. In Wajir, the education conditional cash transfer increased school enrollment and grade attainment, and the wealth intervention improved savings behavior. Conclusions The results indicate that when trying to improve a range of outcomes related to adolescent wellbeing for young girls, a multisectoral intervention with components addressing household economic constraints is a promising approach. Trial registration Trial Registry: ISRCTN, ISRCTN77455458 . Registered 24/12/2015 - Retrospectively registered.

The vast majority of adolescent births occur in low- and middle-income countries and are associated with negative outcomes for both the mother and her child. A multitude of risk factors may explain why few programs have been successful in delaying childbearing and suggest that multisectoral interventions may be necessary. This study examines the longer-term impact of a two-year (2015-17) multisectoral program on early sexual debut and fertility in an urban informal settlement in Kenya. The study used a randomized trial design, longitudinally following 2,075 girls 11-14 years old in 2015 until 2019. The interventions included community dialogues on unequal gender norms and their consequences (violence prevention), a conditional cash transfer (education), health and life skills training (health), and financial literacy training and savings activities (wealth). Girls were randomized to one of four study arms: 1) violence prevention only (V-only); 2) V-only and education (VE); 3) VE and health (VEH); or 4) all four interventions (VEHW). We used ANCOVA to estimate intent-to-treat (ITT) impacts of each study arm and of pooled study arms VE, VEH, and VEHW relative to the V-only arm, on primary outcomes of fertility and herpes simplex virus-2 (HSV-2) infection, and secondary outcomes of education, health knowledge, and wealth creation. Post-hoc analysis was carried out on older girls who were 13-14-years-old at baseline. In 2018, in the VEHW arm, in-depth qualitative evaluation were carried out with adolescent girls, their parents, school staff, mentors, community conversation facilitators, and community gatekeepers. The trial is registered at ISRCTN: ISRCTN77455458. At endline in the V-only study arm, 21.0 percent of girls reported having had sex, 7.7 percent having ever been pregnant and 6.6 percent having ever given birth, with higher rates for the older subsample at 32.5 percent, 11.8 percent, and 10.1 percent, respectively. In the full sample, ever having given birth was reduced by 2.3 percentage points (pp) in the VE and VEHW study arms, significant at 10 percent. For the older subsample there were larger and significant reductions in the percent ever having had sex (8.2 pp), HSV-2 prevalence (7.5 pp) and HSV-2 incidence (5.6 pp) in the VE arm. Two years after the end of the interventions, girls continued to have increased schooling, sexual and reproductive health knowledge, and improved financial savings behaviors. Qualitatively, respondents reported that girls were likely to have sex as a result of child sexual exploitation, peer pressure or influence from the media, as well as for sexual adventure and as a mark of maturity. This study demonstrates that multisectoral cash plus interventions targeting the community and household level, combined with interventions in the education, health, and wealth-creation sectors that directly target individual girls in early adolescence, generate protective factors against early pregnancy during adolescence. Such interventions, therefore, potentially have beneficial impacts on the longer-term health and economic outcomes of girls residing in impoverished settings. ISRCTN registry: ISRCTN77455458; https://doi.org/10.1186/ISRCTN77455458.