Review Article :
Mohammed Tanko Naziru, Fred
Yao Gbagbo, Evans Kofi Agbenoand Easmon Otupiri Introduction: Ghana developed her adolescent reproductive health
policy in october 2000 to guide implementation of adolescent reproductive
health and related services. Despite a comprehensive policy implementation
strategy, the burden of adolescent pregnancies in rural Ghana remains a public
health challenge since little is known about the core predictors. This study
therefore explores socio-demographic and economic predictors of the pregnancies
in Amenfi West district. Methods: The study design was a community based case-control
study involving 80 cases and 220 controls. Data was collected using structured
questionnaires and analyzed by Stata
version 11 to examine associations between predictors of pregnancy
and background characteristics of adolescents. Results: Findings show that, being in school, coming from a
wealthy household, contraceptive use, parental monitoring and relationship
counselling offered significant protection against adolescent pregnancy
(p<0.05). However, factors such as violent parental attitudes towards
boy/girlfriend relationships, demanding financial support from adolescents for
housekeeping and peer pressure from ever been pregnant friends predisposes
adolescents to pregnancy. Conclusion: Advocacy for increased social/parental support for
adolescents, education on modern contraception and availability of services are
keys to preventing adolescent-pregnancies in rural communities. The adolescent period occurs
between the ages of 10-19years [1]. It is a period characterized by various
psychological, social and biological transformation which exposes adolescents
to the innate desire to experiment, natural tendency including violating
parental advices and the pseudo-feeling of maturity thereby risking unplanned
pregnancy [2,3]. Globally, about sixteen million adolescents deliver each year
with over 10,000 adolescent girls in the United States of America having their
first unprotected sexual
exposure at age fifteen [4]. These statistics are worse in low- and
middle-income countries as 95% of the teenage births occur in these countries
[5]. In sub-Saharan Africa, adolescent birth rate is about 140 per 1000
adolescent with various country variations [6]. Despite the formulation of a
national adolescent reproductive health policy in 2000 to address adolescent
sexual reproductive health and related issues in Ghana, not much has been
achieved in addressing adolescent pregnancies particularly in rural Ghana. In
2008, the adolescent birth rate stood at 13% and averagely one in ten
adolescents began childbearing in the urban areas, whereas a double of this
exists in rural communities [7]. Teenagers residing in rural
areas (17%), those living in the Brong Ahafo, Central, and Volta regions
(21-22%), those with no education (23%), and those in the second wealth
quintile (21%) tend to start childbearing earlier than other teenagers [8]. In
the Western region, the trend is a reflection of the national burden with
Amenfi West being a high contributing district [9]. Western region recorded
10.1% of adolescent pregnancy for those between the ages of 15-19 and as much
as 12.7% of that same age group had started childbearing [10]. The drivers of
this phenomenon in rural Ghana have not been fully explored. This study
therefore aims to explore the socio-demographic
and economic predictors of the pregnancies in Amenfi West district to
contribute to empirical knowledge for programming. Amenfi West (formerly Wassa
Amenfi West) District forms part of twenty two Districts in the Western Region
of Ghana with Asankrangwa being its administrative capital. It is located
between Latitude 400N and 500 40N and Longitudes 10 45W and 20 10W. The
District shares boundaries with Aowin district to the west, to the east with
Amenfi east district, to the north with Bibiani-Anhwiaso-Bekwai district and to
the South with Amenfi Central District. The current population of the Amenfi
West District is projected at 186,257 at a growth rate of 3.2% per annum which
is the regions growth rate. The district has many rural communities with a
total population density of 53.76 people per sq.km. The district has four
sub-districts with twenty widely scattered health facilities (i.e two
hospitals, two health centers, three clinics and thirteen CHPS compounds). The study design was an
unmatched case control with cases as adolescent girls who are currently
pregnant or had been pregnant for the past two years before the interview,
whilst the controls include adolescent girls who have never been pregnant. Data
were collected using tructured questionnaires in ten rural communities within
each of the three different sub-districts in Amenfi west district of Ghana.
Three trained multi-lingual (English, Twi, Hausa, and Ga) field assistants
administered the questionnaires to eligible participants or their guardians (in
the case of minors) who consented to be part of the study. Respondents who did not
understand English were interviewed in their local languages of proficiency.
Simple random sampling was applied to select three sub-districts out of the
four sub-districts in the Amenfi west district. Each sub-district had ten
communities randomly selected for the study with this method, the names of all
communities in the each of the sub-districts was written on pieces of paper and
folded. The folded papers was kept in a box and well shaken to adequately mix
them up, i.e. communities from one sub-district at a time. A volunteer was
called to pick one folded paper at a time (thirty times in all) and the names
of those communities picked constituted the chosen communities for the study.
The selection was done without replacement. An unmatched case-control study
design was used in the ratio of 1 case: 3 controls. Cases were any adolescent
girl between the ages of 10 to 19 as per WHO definition living in the selected
communities who is pregnant at the time of the interview or had been pregnant
for the first time during the two years preceding the study. These criteria
were used to minimize recall bias. Controls were chosen from the same
neighborhood/community and consisted of any adolescent girl who had never been
pregnant. The cases were identified through the help of community based
volunteers who have personal knowledge of the pregnancy history of adolescents
in their communities. In the case of the neighborhood controls, they were
sampled in alternate houses and where there was more than one eligible control
in a house, only one was chosen based on simple random sampling. A contraceptive
prevalence rate among 15-19year old of 19% was used as the percentage of
the controls with the exposure [11]. The EpiInfo version 7 statistical tool
calculated total of 275 as the sample size (69 cases and 206 controls).Making
an allowance of 10% for non- response approximated the sample size to 320
i.e.80 cases and 240 controls. The sample size calculated was subsequently
distributed according to the following percentages based on the population
sizes of the three sub-districts selected: 40% to Asankragua sub-district (32
cases, 96 controls), 35% to Samreboi sub-district (28 cases, 84 controls) and
25% to Asankra Bremang sub-district (20 cases, 60 controls). Twenty of the
questionnaires were pre-tested among residents of a nearby community in the
adjoining district (Amenfi Central) to help correct potential difficulties with
the usage of the tool. The data were stored electronically on two different
laptops and analyzed using Stata version 11 (Stata IC version 11, College
Station, Texas, USA). As part of the ethical
considerations, ethical clearance was sought from the Kwame Nkrumah University
of Science and Technology Ethics Review Board and subsequently permission was
obtained from the Amenfi west district assembly and health directorate. Written
and verbal informed consent was obtained from the parents/guardians of the
pregnant teenagers/mothers and verbal consent from the teenage mothers below 16
years of age respectively. All participants agree to publishing the research
findings but anonymously. A total number of 320
respondents were sampled in the ratio of 80 cases to 240 controls. After
cleaning, 300 responses (80 cases, 220 controls) were analyzed and presented with
a response rate of 88.2%.There were few non-responses under some of the
variables which did not reduce the power to detect the differences if existed. Prevalence
of adolescent pregnancy shows that for the year 2014, seven hundred and
thirty one (731) pregnant adolescents were registered (32 early teens and 699
late teens) at antennal care services across the district. Four thousand and
ten (4010) ANC registrants were recorded over the same period. The prevalence
of adolescent pregnancy in Amenfi West for 2014 based on health facility
records was 18%. Table 1 presents the socio-demographic and economic
characteristics of respondents. More than half (60.7%) of the respondents were
in the age group 16-19years while a little over two-thirds of them(71%) had Junior
High School education or higher. Majority (64.9%) of the adolescents
interviewed were currently schooling while the rest were engaged in one
occupation or the other. Most of the study participants were Christians (68.3%)
and involved in various marital relationships (83.9%). For the respondents who
were in sexual unions (married/cohabiting), majority (64.3%) were in the age
group 15-19 years, a quarter (25.5%) of the girls interviewed had their male
guardians/parents who had not pursued any formal education while a little over
a third (36.9%) of their female guardians/parents were not formally schooled. Table 1:
Socio-demographic and economic characteristics of respondents. With regards to socioeconomic
characteristics of respondents using they or their guardians possession of
certain household items, about 23.2% of them had Digital Versatile Disc (DVD)
players, 21.1% had bicycle, 68.2% had mobile phones, 11.8% had motor
bicycles whiles only 5.2% had tap/well water within the household compound.
Majority of them (89.0%) conceded the items asked about were of value to them.
On the ability of respondents to afford certain essential items, 27.6% of them
had registered with the NHIA and could afford paying for healthcare. Almost
equal numbers (21%) had regular school supplies and were satisfied with the
amount of clothing they had. The school supplies were mainly stationery and
fees. Majority of respondents had their male and female guardians being farmers
i.e. 72.91% and 71.33% respectively. Very few of the guardians were engaged
with the civil/public services i.e.7.36% for the male and 2.00% for the female
guardians. Among the male guardians, 0.67% was unemployed while the females had
a 1.67% unemployment rate. There were no significant
statistical differences between the cases (adolescents that are currently
pregnant or had been pregnant two years preceding this study) and controls
(adolescents that had never been pregnant) with respect to their level of
education (p=0.291), religion (p=0.061), and marital status (p=0.321). The
cases and controls however differed significantly with respect to the age of
study participants (p<0.001), occupation of respondents (<0.001), male
guardian level of education (p=0.030) and female guardian level of education
(p=0.024). With regards to relationship between socioeconomic status and
adolescent pregnancy, there were no significant statistical differences between
the cases and controls with respect to their male and female guardians
occupations (p-value=0.277 and 0.474 respectively). There were however
statistically significant differences between the study groups with respect to
their socio-economic status (p<0.001). Those who possessed at least a
minimum of five household items and could afford at least two essential services
rendered were categorized to be in the high socio-economic ladder. The items
asked about were electricity, motor bicycle, television, bicycle, electric
iron, mobile phone, refrigerator, DVD Player and tap/well within compound. The
affordability of the following services was questioned: travelling fares,
electricity and hospital bills, regular supplies of school items and satisfied
amount of clothes (Table 2). Examining
the adolescent-parent
relationship and peer influence on the prevalence of adolescents pregnancy,
it was observed that majority (56.7%) of adolescent girls were staying with
both parents while approximately half of them had ever had sex education
discussions with parents. Most (84.7%) of the study participants had never
discussed contraceptives with guardians although 15%of their guardians
patronized alcohol/abused drugs. Most (58%) of the adolescent could not discuss
their relationships with their parents. Half (53.3%) of them had parents with
violent attitudes towards boyfriend/girlfriend relationships. Just
a few of respondents (4%) however felt pressured by guardians to contribute
towards house upkeep financially or materially. About a third (27.4%) of the
respondents in the study had more than three friends with just 1%having none. About
three-fifths (58.7%) of the study population never had a pregnant peer and
87.7%of their peers would be sad if they (the respondents) were to be pregnant.
A third (31.4%) conceded that their friends opinion moderately influences their
sexual lives. Ten percent (10%) of respondents had ever discussed
contraceptives with their friends and that about five percent (5.1%) of them
would advise their friends to go for an abortion in the event of getting
pregnant. A
regression analysis of responsible parenthood on the prevalence of adolescent
pregnancy in the study area shows significant differences between those who
were staying with both parents and those who are not with respect to getting
pregnant. In Model 1, those staying with both parents were approximately fifty
percent less likely to get pregnant when compared with those not staying with
both parent (OR=0.53, 95% CI: 0.31-0.88, p value <0.05). In Model 2, this
effect was lost completely. Similarly, both parents discussion on sex and
contraception offered protection against adolescent pregnancy. Discussion on
sex minimized the risk of a respondent significantly. (OR=0.44, 95% CI:
0.26-0.27, p value <0.05). Adjusting
for other covariates, this protection offered by discussion of sex
and contraceptives was lost.
Monitoring of adolescent childrens where-about in the study area was
observed as a significant parental concern as this offered protection to the
adolescent whose guardians were concerned by reducing their likelihood of
getting pregnant (OR= O.37, 95% CI: 0.19-0.77, p-value <0.01; AOR=0.36, 95%
CI: 0.17-0.75; p-value <0.01). Violent
parental attitude was found to be associated with adolescent pregnancy by
increasing the odds to about twice in the unadjusted model and almost three
times in the adjusted model. The odds of becoming pregnant in Model 1 were 2.32
(95% CI: 1.28-4.21, p-value <0.001). In Model 2, the odds increased to 2.93
(95% CI: 1.49-5.83, p-value <0.001). The ability of adolescents to confide
in guardians about relationships was found to be statistically significant both
at the bivariate and multivariate levels with the crude and adjusted odd ratios
being almost same. Significance differences were also observed between feelings
of being pressured by parents towards house upkeep financially and adolescent
pregnancy in this study. Such pressure was found to predispose the adolescent
to getting pregnant by as much as six times compared with those not pressured
(OR=5.94, 95% CI: 1.74-20.33, p value <0.005). After adjusting for other
covariates at the multivariate level, the effect remained similar (AOR =4.91, 95%
CI: 1.06-22.86, p-value of <0.05) (Table
3). When
the effects of other variables were held constant, reaction of friends still
remained statistically significant in its association with adolescent pregnancy
(AOR=0.17, 95% CI: 0.10-0.28, p-value <0.001). Who had never had pregnant
friend(s) had significantly lower odds of getting pregnant (OR=0.44; 95% CI:
0.25-0.78, p-value <0.01). After adjusting for other covariates, the effect
remained the same with the association still being statistically significant.
(AOR=0.44, 95% CI: 0.25-0.76, p-value <0.01) (Table4). Discussion Global
statistics on adolescent
pregnancy shows a huge public health challenge with a devastating
consequence of increased maternal and infant mortalities particularly in rural
settings of which Ghana is not an exception [5,10]. With a national prevalence
of 14.0%adolescents residing in rural areas in Ghana, have a prevalence of 17%which
is consistent with the finding in this study (17%versus 18%). There exist some
relationships between predictors of socio-demographic and socio-economic
characteristics on adolescent pregnancy as evident in this study that there was
a higher odd to get pregnant within the late adolescent period. This finding is
consistent with the situation in the United States where majority of the teen
pregnancies were in the late adolescence period [12]. Being
a student (currently schooling) showed high significance in the study with
protection against the odds of getting pregnant by as much as hundred times.
Education is known to increase the adolescence awareness about sexuality and
avoidance of risky
sexual behavior. As part of the consequences of adolescent pregnancy
however is high school dropout rates, hence 6 (7.50%) of the cases in the study
were school dropouts. The association between education and age at first
pregnancy may be due to the possible delay of sexual activity by those still in
academic pursuit or as a result of those getting pregnant, dropping out of the
educational system before getting to secondary school level. This result
supports findings from studies on the relationship between educational
attainment and teenage
pregnancy [13]. The
statistical insignificance shown by the level of education attained by the
respondents in the study could be due to the fact that the study being an
unmatched case-control might have recruited more controls that are still in the
lower age limits and are still attending the basic school. The education level
of both guardians showed an association with adolescent pregnancy in the study.
Mothers education level showed stronger protective association than the fathers.
The finding relating female guardian education level is consistent with the
findings of a similar study which showed that the education level of the adolescents
mother is a predictor of adolescent pregnancy such that the higher the level,
the lower the pregnancy rates [14]. This finding could also be attributed to
the fact that the female adolescent in the rural areas of Ghana naturally spend
much of her time with her mother and may therefore find it more comfortable
discussing issues about her sexuality with the mother more than the father. Early
sexual unions emanating from cohabitation for economic reasons is increasingly
gaining acceptance in the study area thereby predisposing adolescents to early
pregnancy in the study area. In another study, a strong association between
marital status/cohabitation and adolescent pregnancy was established [15].
About 63%of the cases were either married or cohabiting while none of the
controls was in any form of sexual union. In such unions, there were early
exposure to sex and hence pregnancy. In many countries, girls are married at a
very young age while in others it is the age at the time of first intercourse
where honor is given to young motherhood. Reasons why parents endorse such
early marriages or sexual unions are varied. Inabilities to pay school fees by
parents, avoidance
of promiscuity, Sexually Transmitted Infections (STIs), and parents desire
to obtain dowries have been cited to be among the key reasons. Again such early
marriages are more common among adolescents with low levels of education [16]. The
availability of household items of various kinds in the study area showed some
association with adolescent pregnancy. Items such as television, electricity
and ownership of motor bicycle were very significant predictors of pregnancy as
most adolescent girls end up being sexually exploited whilst searching for
these items predominantly from the opposite sex. The ability of the adolescents
guardian to afford the payment of health services, travelling fares, and
regular school supplies and clothes also showed a very strong association as a
predictor of adolescent pregnancy in this study. Adolescent girls as observed
in the study area have the desire to possess material things to enhance their
look. In all these essential services/items, lesser percentages of the cases
could afford them compared to the controls i.e. travelling fares (20.00% Vs 38.18%),
health services (70.00% Vs 80.91%) regular school supplies (31.25% Vs 70.45%)
and sufficient clothes (30.00% Vs 71.36%). They
will therefore go at all lengths in search of these hence are likely to be
exposed to sexual relationships resulting to unplanned
pregnancy. When the respondents were categorized into high and low
socioeconomic classes, there was a strong association between socio-economic
status and adolescent pregnancy with p-value of <0.001.Those in the high
socio-economic stratum were protected and had lower odds of getting
pregnant when compared with those in the lower socioeconomic class. This was
consistent with a study which reported that teenage pregnancy is more common
among girls who were less educated and had poor economic back grounds [17]. A
similar reflection was seen in another study conducted in the United Kingdom
where there was an increased sexual activity marked teenage pregnancy among
girls who are living in economically deprived areas and families [18]. The
adolescent-parent relationship was also observed as a predictor to adolescent
pregnancy. In this study, staying with both parents was seen to be protective
against adolescent pregnancy. About 61%of the controls were staying with both parents
while less than half 45%of the cases were staying with both parents. The
presence of both parents has been shown to be a factor in minimizing adolescent
pregnancy with significant statistical difference among the cases compared with
the controls. Having both parents around offers a high probability of warmth
and proper monitoring being given to the adolescent. The adolescent female is
likely to have most of her social and psychological/emotional needs catered
for. This supports findings of a related study which observed that there is a
strong negative impact of absence of one parent at home on early
sexual initiation and adolescent pregnancy [19]. A
little above half of the controls in this study had parents giving them sex
education 129(58.64%) as compared with 31(38.75%) of the cases which showed a
statistically significant difference in minimizing the odds of getting pregnant
among the controls. This is in contravention with the societal perception that
it could make adolescents who are not sexually active, start sexual
experimentation and hence increase teenage pregnancy. The opposite however has
been shown to be true in New York where sex
education was not provided to the teens and as such was associated with
highest rates of teen pregnancy [20]. The situation where parents concentrate
on moral education and not sex education and more sadly even seeing sex
education as a taboo needs some advocacy efforts to address this in rural Ghana
since evidence has shown that parent-child
communication that involves sex education and to large extent discussions on
contraception are known to reduce teen pregnancy [21]. In
this study, adolescent girls discussions with parents on contraceptives showed
significant statistical difference between the cases and the controls.
Adolescents who held such discussions were approximately 60% less likely to be
pregnant compared with those who did not have. For example, in a multinational
study across four countries to look at parental roles in adolescent sexual
activity and contraceptive use, parent-child communication about sex-related
matters was positively associated with contraceptive use for Ghanaian and
Ugandan females and males but there was no association found between parents
providing information about contraception and adolescents contraceptive use
[22]. This is quite significant amidst
the fact that it offered significant protection against pregnancy among the
controls when compared with the cases. In another related study, the protective
factors against pregnancy among others was parental supervision (OR =0.88, 95%
CI: 0.81, 0.94) with the risk factor being if adolescent ever used drugs (OR
=2.85, 95% CI: 2.57, 3.15)
[23]. The
attitude of parent/guardians towards boy/girlfriend relationship was also seen
to have a significant predisposition to adolescent pregnancy. Adolescents who
regarded their parents attitudes as being violent were at higher odds of
getting pregnant. Adolescents who had ever suffered any violence (physical,
verbal, etc.) are at higher odds of pregnancy (1.69 times) [24]. Such violent
attitudes are likely to make adolescents recoil and find it difficult to open
up to parents with their most sensitive
sexual problems but rather result to their peers who inappropriately
advises them compared to those who could confide in their parents/guardians to
get matured good advices on sexuality and pregnancy prevention. In this study,
parental demand for material and/or financial support from adolescent daughters
tends to expose them to risky sexual behaviors hence pregnancy. In a similar
study, adolescents girls whose parents never pressured them financially were
significantly less likely to become pregnant compared to those constantly under
pressure to support their parents financially since they are likely to resort
to boyfriends and/or older men (economic and age disproportionateness) for
transactional sex to help bridge such financial gaps [25]. Because of their
vulnerability, they are likely to be unable to negotiate for safer sex hence
end up with unwanted pregnancies and Sexually
Transmitted Infections (STIs). Peer
influence on adolescent pregnancy cannot be overemphasized as adolescence is a
period when peer influence is greatest. The observation in this study that
about 60%of respondents among the cases have ever had a pregnant friend
confirms some other research findings that adolescents, whose friends were
sexually experienced, had higher odds of sexual debut [26]. The odds of
pregnancy were higher among adolescents who believed they will gain respect by
engaging in sex and by extension getting pregnant. The influence of peers
offered protection against pregnancy by as almost 50%in this study. Having a
pregnant peer significantly predisposed one to also getting pregnant. Although
peer knowledge on contraceptives is believed to be misguided and inaccurate
most times it is therefore recommended that exploring the use of peer educators
as a source of information for contraceptive use could be useful predictor of
preventing adolescent pregnancy in rural communities [27]. Additionally,
advocacy for increased social/parental support for adolescents contraception
use will also be helpful in complementing public health workers efforts in
rural Ghana. Ethical approval:
Ethical
clearance was obtained from the Kwame Nkrumah University of Science and
Technology Ethics Review Board. Permission was also obtained from the Amenfi
West District Assembly and Health Directorate. Informed
consent for participation and publication: Written and verbal informed
consent was obtained from the parents/ guardians of the pregnant teenagers/
mothers and verbal consent from the teenage mothers below 16 years of age
respectively. All participants agree to publishing the research findings
anonymously. Authors
contributions: MTN
conceptualized, designed the study and analyzed the data. EKA supervised the
field work, EO reviewed the data analysis and provided technical advice and FYG
drafted the full study report. All authors discussed the report, edited it
together and approved the manuscript for final submission. The
authors are grateful to the respondents and the Amenfi West District Health
Management Team for approving the study and for their corporations during data
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Yao Gbagbo, Department of Health Administration and Education, Faculty of
Science Education, University of
Education, Winneba, Ghana,
Tel:
+233(0)243335708, Email: gbagbofredyao2002@yahoo.co.uk Naziru
TM, Gbagbo YF, Agbeno KE and Otupiri E. Review of socio-demographic and
economic predictors of adolescent pregnancies in rural Ghana (2019) Nursing and
Health Care 4: 38-43. Socio-demographic, Socio-economic, Predictors,
Adolescent-pregnancy, Ghana.Review of Socio-Demographic and Economic Predictors of Adolescent Pregnancies in Rural Ghana
Full-Text
Abstract
Introduction
Method
Results
Relationship between socio-demographics and adolescent pregnancy
Table3: Regression of
responsible parenthood on the prevalence of adolescent pregnancy.
Peer
influence is a significant predictor of adolescent pregnancy in the study area.
There was a significant association between ones friend ever been pregnant and
the adolescent herself getting pregnant; an adolescent who had had a pregnant
peer was seven times more likelihood to get pregnant at the bivariate level
(OR=7.31, 95% CI: 4.08-13.11, p value <0.001). After adjusting for other
covariates, the predisposing effect still remained significant statistically.
The reaction of friends if one was pregnant was also seen to be associated with
adolescent pregnancy. It is seen to offer protection as a respondent whose
friend would be sad were she to be pregnant was significantly less likely to
get pregnant compared with those whose friend would be happy (OR=0.08, 95% CI:
0.04-0.18, p-value <0.001). 
Table 4: Regression of peer
influence on the prevalence of adolescent pregnancy.Acknowledgement
References
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Citation
Keywords
