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The views expressed in this presentation are the views of the author and do not necessarily reflect the

views or policies of the Asian

Development Bank Institute (ADBI), the Asian Development Bank (ADB), its Board of Directors, or the governments they represent. ADBI
does not guarantee the accuracy of the data included in this paper and accepts no responsibility for any consequences of their use. Terminology
used may not necessarily be consistent with ADB official terms.

Comprehensive Understanding
of Risk and Protective Factors
for Adolescent Pregnancy
in Low- and Middle- Income

Ji-Eun Lee, Ph.D.

Chung, H. W., Kim, E. M., & Lee, J. E. (2018). Comprehensive understanding of risk
and protective factors related to adolescent pregnancy in low-and middle-income
countries: A systematic review. Journal of Adolescence, 69, 180-188.


“When a girl becomes pregnant, her present and future change

radically, and rarely for the better. Her education may end, her job
prospects evaporate, and her vulnerabilities to poverty, exclusion
and dependency multiply (UNFPA 2013:ii).”

• 20,000 girls giving birth every day

• Missed educational and other
• 70,000 adolescent deaths annually
from complications from pregnancy and
• 3.2 million unsafe abortions among
adolescents each year
• Perpetration of poverty and exclusion
• Basic human rights denied
• Girls’ potential going unfulfilled

Direct quotation from UNFPA 2013:iv, Photo from UNFPA 2014:7 3


• The study objective: to provide a comprehensive view of

factors associated with adolescent pregnancy in low-
and middle- income countries by synthesizing as many
related studies as possible. (Systematic review)

• What is the systematic review?

“A systematic review is a review of a clearly formulated
question that uses systematic and explicit methods to
identify, select, and critically appraise relevant research,
and to collect and analyze data from the studies that are
included in the review.” (Moher et al. 2009:264)


• We developed a framework of multilevel approach to

gain a comprehensive understanding of adolescent
pregnancy based on Bronfenbrenner(1994)’s ecological
model of human development (Figure 1).
• This model suggested that “human and the environment
interact with each other and each is affected by the other.”

a person’s profile that
both active and passive directly tells his/her
behavior of adolescents current situation (e.g., age,
(e.g., sexual risk behavior, education, economic status)
substance use, abuse)

Figure 1. Multilevel approach to adolescent pregnancy. 6


• Four electronic databases widely used in medical science

and social science were searched: POPLINE, PubMed,
Web of Science, and PsycINFO.
• Search terms were chosen by reviewing references of
literature regarding adolescent pregnancy and
childbearing to include as many related studies as
possible (Table 1).
Table 1 Search Terms.
Column 1 Column 2 (Individually combined with)
Title: (pregnant* OR childbearing* OR bi
Title: (adolescent* OR teen* OR “youn
rth* OR childbirth* OR delivery OR deliv
g maternal” OR “young women” OR “y
eries OR mortality OR morbidity OR ferti
oung mother*” OR early OR girl* OR “
lity OR “reproductive health” OR mother
young people”)
* OR marriage OR *married)
Note: We used quotation marks (“ ”) in order to find the exact words or phase. 7
• In order to select articles eligible for our systematic review,
the inclusion criteria were used (Table 2). Based on these
criteria, titles and abstracts were screened.
• Risk of bias assessment was conducted using various
tools depending on the study design.

Table 2. Inclusion Criteria.

Criterion Inclusion
Year 2000 – 2015
Language English
Geographic area Low- and middle- income countries (based on
classification of the World Bank)
Outcome measured Factors related to adolescent pregnancy or childbearing
Study population Study group includes adolescents aged between 10-19
Study type Qualitative, quantitative or mixed method

Figure 3. Flow of search process. 9

• Country: Asia (7), Africa (11), Latin America (9), Europe (1), others
as a group (39)
• Research methods: Analytical cross-sectional (35), qualitative
(5), case-control (7), cohort (3), randomized controlled trials (2), panel
(1), cross-sectional survey (9), descriptive (3), mixed method (2)
• Study population:
– Many studies included adolescents aged from 10 to 19 years, but
the most commonly used age group was between 15-19 years old.
– Some studies included young people aged 20-24 years or adults
aged over 25 years for one of the following reasons:
1) to compare adolescents and adults; 2) to examine adults who
gave birth during their adolescence; and 3) to compare both groups
and separate the result of adolescents from that of adults.

Risk factors Protective factors
Age Older age, younger age (for unwanted or
unintended pregnancy)
Education No formal education, long-term school Higher level of
absences, school failure, attending educational attainment,
public school (vs. private school) being a student
Economic Low economic status, poverty, smaller Higher levels of family
status income, income inequality income
Marital married in adolescence, not being
status married (for unintended or unplanned
Psycholog Depression, low self-esteem, higher
ical status locus of control
Religion No religion (vs. Catholic), Muslim (vs. Religiously affiliated,
Protestant) protestants (vs. Catholics)
Attitudes Having strong gender bias, concerns Think important to
about the side-effects of contraceptive protect self against
methods pregnancy 12
Risk factors Protective factors
Sexual risk Early sexual debut, having many lifetime
behavior sexual partners,
having first partner who is older than the
girl, ever engaging in transactional sex
Contracepti No use or inconsistent use of Consistent condom
on* contraceptive method, use, using condom
ever used a contraceptive method or at first sex
family planning**
Substance Alcohol, smoking, drug use, etc.
Abuse Sexual or physical abuse during
childhood to adolescence,
coerced sex by boyfriend, forced first sex

*Studies have showed mixed results.

**The author has presented several reasons for the results: the study has not
considered sub-factors related to contraceptive use; adolescents are likely to start
using the method after experiencing pregnancy; and they might misuse the method
(Were, 2007, p. 336).
Risk factors Protective factors
Living Living without both parents, Father is present in the
arrangement not living with father, being household
raised by single parent
Family Having divorced or separated
disruption parents, have siblings of
different fathers
Parent’s Authoritarian or permissive Supportive or affectionate
discipline parenting parents
Communicati Lack of discussion regarding Communication between
on sexual issues with parents, no parents and children
guidance on sex
Education Educated parents, higher
level of parental schooling
Pregnancy Having family members who
experience had pregnancy before age 20

Risk factors Protective factors
Pressure Peer or partner’s pressure
to have sex

Friends’ Having friends with health-

(perceived) risk behaviors, beliefs that
behaviors most friends are pregnant

Peer Frequent dialogue about Talk about sex with peers,

communicati sex with boyfriend, get sex spending time with peers
on* information from peers, or communicate with

*Studies have showed mixed results.
Risk factors Protective factors
Group Unsupervised activities after School activities,
activities school, less participated community group
extra activities at school meetings

Sex Lack of or low-quality sex youth forums where

education, education at school, adolescents discuss and
information lack of access to health learn about sex
Residence* Urban (vs. peri-urban, rural), Rural
Neighborho Poor community Better perceived physical
od environment, community environment
violence, fear of being
robbed or attacked

*Studies have showed mixed results.
Risk factors Protective factors
Income inequality, Strict laws setting the minimum-
low human development index, age-of-marriage at 18,
low Municipal development index, population reduction policies,
low social responsibility index, education subsidy program,
government's safe sex programs free education by government)
did not target adolescents


1) Several factors showed inconsistent association with

teenage pregnancy.

For example:
Contraceptive use
Contraceptive Rural-urban Peer
Rural-urbanuseresidence residence communication
(not significant) substance use, orphan-hood, and income

 We need to consider specific context or detail

background of adolescents in order to answer
complicated and inconsistent relationships between
various factors and adolescent pregnancy.

 Adolescents living in urban Ghana are more likely to be

pregnant than those in the peri-urban or rural area (Agyei
et al., 2000). Ghana

 Another study in Kenya has found that living in the rural

area reduces the likelihood of pregnancy (Magadi &
Agwandaf, 2009; Maswikwa et al., 2015). Kenya

 However, other studies have shown the opposite result

that rural residence is positively associated with teenage
pregnancy (Alemayehu et al., 2010; Choe et al., 2001).
Ethiopia, Indonesia/Nepal


 Having time with friends who performed risk behaviours

and provided information about sex and
contraceptives—“sexual intercourse was an expression
of love and not using condoms was an expression of
fidelity (Mkhwanazi, 2010, p. 351)”—has increased the
likelihood of teenage pregnancy (e.g., Mkhwanazi, 2010).
South Africa

 Some studies have found that adolescents who spend

time with peers or discuss sexual matters with peers
are less likely to get pregnant (Lipovsek et al., 2002;
Magadi & Agwandaf, 2009). Bolivia, Kenya

2) Only few studies have examined complex interactions
among these factors.

For example:

Low economic Adolescent

status pregnancy

Low self-esteem?
Vulnerable to sexual
Mediating factor
Transactional sex?

 It is essential to examine the complex interaction of

several factors that affect teenage pregnancy.
3) Characterization of teenage pregnancy matters.
Results are different depending on how the author
defines/identifies teenage pregnancy.

unplanned unwanted unintended

 In order to enhance our understanding of adolescents’

pregnancy, it is crucial to assess the type of pregnancy
among adolescents (Christofides et al., 2014).


Age is positively associated with adolescent pregnancy

(e.g., Alemayehu, Haider, & Habte, 2010; Calvert et al.,
2013). Ethiopia, Tanzania
Cross-sectional survey in Ghana and South Africa have
shown similar findings that pregnant girls are older than
non-pregnant girls (Agyei, Biritwum, Ashitey, & Hill, 2000).
However, when it comes to unwanted or unintended
pregnancy, younger adolescents have shown a higher
likelihood of being pregnant than older adolescents or
adults (e.g., Amoran, 2012). Nigeria

Agyei, W. K. A., Biritwum, R. B., Ashitey, A. G., & Hill, R. B. (2000). Sexual behaviour and contraception among unmarried
adolescents and young adults in greater Accra and Eastern regions of Ghana. Journal of Biosocial Science, 32(4), 495–512.

Alemayehu, T., Haider, J., & Habte, D. (2010). Determinants of adolescent fertility in Ethiopia. Ethiopian Journal of Health
Development, 24(1), 30–38.

Amoran, O. E. (2012). A comparative analysis of predictors of teenage pregnancy and its prevention in a rural town in
Western Nigeria. International Journal for Equity in Health, 11.

Bronfenbrenner, U. (1994). Ecological models of human development. Readings on the development of children, 2(1), 37-

Calvert, C., Baisley, K., Doyle, A. M., Maganja, K., Changalucha, J., Watson-Jones, D., & Ross, D. A. (2013). Risk factors
for unplanned pregnancy among young women in Tanzania. Journal of Family Planning and Reproductive Health Care,
39(4), 1–12.

Choe, M. K., Thapa, S., & Achmad, S. I. (2001). Surveys show persistence of teenage marriage and childbearing in
Indonesia and Nepal. Asia-Pacific Population and Policy, (58), 1–4.

Chung, H. W., Kim, E. M., & Lee, J. E. (2018). Comprehensive understanding of risk and protective factors related to
adolescent pregnancy in low-and middle-income countries: A systematic review. Journal of adolescence, 69, 180-188.

Lipovsek, V., Karim, A. M., Gutiérrez, E. Z., Magnani, R. J., & Castro Gomez, M. C. (2002). Correlates of adolescent
pregnancy in La Paz, Bolivia: Findings from a quantitative-qualitative study. Adolescence, 37(146), 335–352.

Magadi, M. A., & Agwandaf, A. O. (2009). Determinants of transitions to first sexual intercourse, marriage and pregnancy
among female adolescents: Evidence from South Nyanza, Kenya. Journal of Biosocial Science, 41(3), 409–427.

Mkhwanazi, N. (2010). Understanding teenage pregnancy in a post-apartheid South African township. Culture, Health and
Sexuality, 12(4), 347–358.

UNFPA (2013). The state of world population 2013. Retrieved from United Nations Population Fund, New York:

UNFPA (2014) Girlhood, not motherhood: Preventing adolescent pregnancy. Retrieved from United Nations Population
Fund, New York: