Drivers of adolescent pregnancy decline in five adolescent sexual and reproductive health and rights exemplar countries: a quantitative decomposition analysis.

Abstract

In 2023, there were 9·9 million births among adolescents aged 15-19 years in low-income and middle-income countries, with an estimated half of those births unintended. Cameroon, Ghana, Malawi, Nepal, and Rwanda stand out as exemplar countries experiencing some of the largest declines in adolescent fertility (ie, the demographic concept of livebirths per woman) globally between 2000 and 2023 relative to countries with similar socioeconomic change during this period. We aimed to examine how these five countries reduced adolescent pregnancy by decomposing declines into key determinants. Our analysis leveraged all Demographic and Health Surveys and Multiple Indicator Cluster Surveys available for the five countries between 2000 and 2023. We implemented an Oaxaca-Blinder decomposition analysis of pregnancy among adolescents aged 15-19 years, comparing the earliest and latest years of available data on adolescent pregnancy and influential factors thereof. We implemented an array of sensitivity analyses to assess the robustness of the results of our analysis to different population strata and model specifications. The largest driver associated with decreases in adolescent pregnancy in all countries was a substantial decline in the adolescent marriage rate, which dropped by between 4·3 and 12·2 percentage points. The second largest factor was increased educational attainment among adolescents, with gains between 1·5 and 3·0 more years of education. Although unmet need for contraceptive use exhibited a statistically significant association with adolescent pregnancy, it was not attributed a large contribution as it did not change substantially during the period of focus. These changes coincide with major policy developments surrounding adolescent marriage and education in the five countries: the legal age of marriage increased, and exemptions were removed to facilitate stronger enforcement of laws; policies making education free (or of low cost) and compulsory were also implemented. Underpinning the policy changes were broad shifts in underlying social norms on gender and other changes to the enabling environment for the policies to have their intended impact. Gates Ventures.