The Effects of Pregnancy: A Systematic Review of Adolescent Pregnancy in Ghana, Liberia, and Nigeria

There is a high incidence of adolescent pregnancy in West Africa. The objective of this study is to highlight the health impacts of adolescent pregnancy through a systematic review. A search was conducted in the electronic databases of Google, Google Scholar, SCOPUS, EBSCO, CINAHL, Web of Science, African Journals Online (AJOL), and the Demographic Health Surveys (DHS) Program. The study found anemia, complications of pregnancy, obstetric and gynecological risks, unsafe abortions, and psychological effects to adversely impact the health of adolescent girls in Ghana, Liberia, and Nigeria. Pregnancy could be deleterious to the health and well-being of adolescent girls in various forms. In addition, adolescent pregnancy could expose adolescent girls to gender-based violence, exclusions, and inequities, be detrimental to upholding women’s sexual and reproductive health rights, and could also have implications for Sustainable Development Goal 3. Targeted interventions to prevent pregnancy in young women and mitigate these effects by stakeholders are encouraged.


Introduction
The adolescence (10)(11)(12)(13)(14)(15)(16)(17)(18)(19) years are a transitional period between childhood and adulthood [1]. There are about 1.2 billion adolescents globally with over 50% of them from Asia. Sub-Saharan Africa has the largest proportion of their general population [2]. For this group of young people to grow and make meaningful contributions to society, their fundamental human rights must be ensured and they must be well-educated. The provision of jobs, inclusiveness, and important issues relating to their health should effectively be dealt with [3]. Adolescents are faced with myriad health challenges with an increased risk depending on which part of the world they find themselves in [4]. Sexual and reproductive health and rights among adolescents have been an ongoing global health concern given the fact that they are regarded as critical for the progress of society.
The issue of adolescent health as a global health challenge is due to the complexity of meeting sexual and reproductive health needs and the provision of antenatal care (ANC) services to adolescents. It requires a multi-sectoral and collaborative approach to prevent of unwanted pregnancies and alleviate the negative consequences of adolescent pregnancy [5]. The World Health Organization (WHO) issued 18 guidelines in 2011 seeking to prevent adolescent pregnancies and improve reproductive health in Low-and Middle-Income Countries (LMICs) [6]. In spite of this and other local interventions, pregnancies among young girls in LMICs are unacceptably high. According to the World Health Organization (WHO), about 21 million girls (15)(16)(17)(18)(19) years become mothers and a further 2 million younger than 15 years old give birth annually across the world, with most of them occurring in LMICs, specifically countries in South Asia and Sub-Saharan Africa. Further, three million pregnancies are unsafely terminated which can negatively impact the health of these girls [7]. Adolescent pregnancy in West Africa, as in other regions of the developing world, teenage pregnancy. Search terms such as outcomes, risks, impacts, effects, consequences, and associated factors were also used.

Selection Criteria
A broad search framework was constructed and implemented for a thorough online search of applicable studies. The inclusion criteria applied for the purposes of gathering literature for the review were publications and articles published from the year 2016, post-Millennium Development Goals (MDGs), to 2021 were considered. Abstracts were screened, and a full text was retrieved and assessed for eligibility. Publications that discussed adolescent pregnancies in the selected countries were reviewed. Reports and publications by organizations (governmental and non-governmental bodies) on the impacts of adolescent pregnancy in the selected West African nations were evaluated for inclusion. Publications in the English language relating to the search terms relevant for the review and analyzed the effects of pregnancy in adolescent women between the ages of 10-19 years, determined to be useful for the review, were used. Publications were excluded from the review if they lacked relevant data on pregnant adolescents aged 10-19 years. Studies on adolescent pregnancy conducted outside of the region were not considered for the review.

Data Extraction and Quality Assessment
The Joanna Briggs appraisal tool was independently used by two reviewers to ascertain their quality for inclusion or exclusion. The tool is a checklist made up of a set of eleven questions [17]. Where there was a disagreement or due to inadequate information, the full text of the disputed abstract was obtained, and a third reviewer mediated following a discussion on the issue for a consensus to be reached. Studies that reported different outcomes from the same study sample were excluded for the likelihood of publication bias. The latest and final reports of the relevant Demographic and Health Surveys were included. For a possible publication bias, some articles were excluded from the final synthesis of the review [18][19][20].

Data Synthesis
A narrative synthesis was chosen to carefully select the clearest reported outcomes that were directly relevant to the review question and were grouped under common themes suitable to the objective of the study. The narrative synthesis complied with the recommended criteria in the performance of a rigorous synthesis without meta-analysis (SWiM) [21]. This provides a clear guide for reporting on the evaluation of studies using alternative synthesis approaches to a meta-analysis of effect estimates. It allowed for the extracted data to be summarized, structured, and described independently of the reviewers, and a consensus formed over disputed results. The effects of pregnancy on girls were combined and homogenously grouped as anemia, complications of pregnancy and obstetric and gynecological effects, unsafe abortions, psychological effects based on conceptual appropriateness, methods employed, and how unbiased they were in terms of designing, conducting, and analyzing the studies.

Results
The 28 studies included in the review were conducted in Ghana, Liberia, and Nigeria in the West African sub-region, and were used after they were blindly reviewed by two independent reviewers and a third reviewer whenever there was no consensus between independent reviewers. Figure 1 illustrates the screening steps for inclusion and exclusion. Three studies that reported different outcomes from the same study were excluded from the final synthesis of results for possible publication bias.

Characteristics of Included Studies
As shown in Table 1, most of the studies used were qualitative, cross-sectional studies, and surveys (five each). Three of the surveys were demographic and health surveys (final reports) and two were national surveys. There were three retrospective studies. Two of the studies used descriptive, prospective, and longitudinal designs. One of the two longitudinal studies used Adolescent Birth Outcomes, Ghana (ANBOG). There was one randomized control trial, exploratory, observational, and mixed study design (qualitative and quantitative) studies each for the reviews.  Figure 1 illustrates the screening steps for inclusion and exclusion. Three studies that reported different outcomes from the same study were excluded from the final synthesis of results for possible publication bias.

Characteristics of Included Studies
As shown in Table 1, most of the studies used were qualitative, cross-sectional studies, and surveys (five each). Three of the surveys were demographic and health surveys Participants in the studies used had at least a sample size of 17 [22] and the highest sample size was 26,055 [23]. These studies were carried out in both rural and urban settings, and were institution-based and community-based. A total of 47,479 adolescent girls eligible for the studies were pregnant either during or before the studies were undertaken. Their ages ranged from 11 years (youngest) to 24 years (oldest) and included educated and noneducated, and married and unmarried. Some key informants comprising parents, teachers, adolescent mothers and partners, and health care providers participated in some of the qualitative studies used, providing useful and relevant information on how pregnancy impacts the health of adolescent girls.
It is worthy of note that none of the studies included in this review included studies on vulnerable adolescent groups, such as the disabled or those living with non-communicable diseases (NCDs) or victims of pandemics, such as HIV/AIDS or Ebola, which have devastated the sub-region. There was no study found to have investigated COVID-19-positive pregnant adolescent girls in the selected countries in West Africa. Detailed characteristics of all included studies are summarized in Table 1. As summarized in Table 2, this review found four main themes on how pregnancy affects the health and well-being of adolescent girls in West Africa. They are anemia, complications of pregnancy, obstetric and gynecological effects, unsafe abortions, and psychological effects.

Anaemia
Anemia as determined by the six studies is a common complication that occurs among pregnant adolescents in these countries. Higher anemia among adolescents [24], iron deficiency anemia common among pregnant teenagers [25], the presence of morbidity in the form of anemia [26], and adolescent expectant mothers more likely to be anemic [27] were the findings under this theme.

Pregnancy-Related Complications and Obstetric and Gynecological Effects
The various unpleasant health effects during pregnancy in adolescent girls, categorized as complications of pregnancy, and obstetric and gynecological effects, are immature pelvic structures of pregnant teenagers that could cause cephalo-pelvic disproportion which could injure pelvic structures, thereby causing postpartum bleeding [44], hypertensive disorders of pregnancy and obstructed labor among teenagers [24], the likelihood of fistula experience and postpartum hemorrhage [43], and cesarean sections as a result of the mother's medical conditions [14].

Unsafe Abortions
Abortions under unsafe circumstances were found to be a common health hazard for teenage mothers largely due to the illegality of abortion in the sub-region. Most abortions by adolescents were unsafely terminated [45], more adolescents indulged in unsafe abortions [32], abortions by adolescents were performed under unsafe circumstances [29], methods for abortions were obtained from non-formal providers [35], and crude methods such as insertion of objects into the vagina, a heavy message and the drinking of a herbal concoction were used [34].

Psychological Effects
The mental health and psychological effects related impact of adolescent pregnancy findings reported by the studies are sadness and an unhappy mood [37], moderate to severe depression, and major psychosocial effects due to pregnancy [28,31], such as feelings of fear, anger, shyness, and being miserable [30] were described. Findings of pregnancy-related stress [24], suicidal thoughts, ideations and feelings of rejection [33], fear, self-condemnation, guilt [22], and poorer coping ability and attitude toward pregnancy [41] were also found through this review. Lastly, three of the studies included in the review measured other outcomes different from the themes above. They reported not encouraging eating habits of pregnant adolescent women [27] and experiences of physical violence by pregnant adolescent girls [23,39].

Discussion
This systematic review was conducted to identify the adolescent maternal health impacts of pregnancy in three West African states. It found pregnant adolescent mothers to be anemic; they overly become exposed to pregnancy-related complications, they suffer from obstetric and gynecological effects, and they indulge in unsafe abortions, as well face pregnancy-related psychosocial stresses. These deleterious adverse health outcomes could have implications for women's sexual and reproductive health and rights, as well as the attainment of SDG 3. All the studies that reported these deleterious medical effects that accompany adolescent pregnancy were conducted recently (post-MGDs), which is consistent with a study on the global burden of diseases that found adverse adolescent maternal outcomes as a substantial burden of adolescent morbidity and mortality in the Global South [4]. This review reported the health impacts of adolescent pregnancy from studies published in the last six years preceding this review, about six years into the start of the SDGs, and also in an era (twenty-first century) where the advancement in medical care is complemented by sophisticated information communication technology (ICT) driving the quality and efficacy of health care, bringing about an increment in quality and longer life span since the turn of the century [10]. However, over 70% of women of reproductive age face restrictive abortion laws in West Africa, where about 85% of abortions are performed in an unsafe manner [13]. The emergence and diffusion of Islam and Christianity together with traditional African religious beliefs in these countries make it challenging for the implementation of such scientific interventions, such as abortion care [46]. Some attitudes of healthcare providers influenced by religion, access and stigma, and victimization discourage women from patronizing the limited available safe abortion care services [47]. This forces many adolescent girls in the region to be in need of such services, as found through this study to engage in deadly abortion practices, where over 90% of the countries have prohibitive abortion rules [13]. Unsurprisingly, maternal mortality and morbidity indices in the selected countries are worrying [48]. These findings by this study are consistent with [49] stating that adolescent women are categorized within a special risk group of expectant mothers and routine antenatal care might not be enough to avert complications. What perhaps is not clear is the association of inadequate dietary intake, unhealthy eating habits, and intimate partner violence with adolescent pregnancy since only a couple of studies reported these outcomes. Young maternal age is found to be at an increased health risk during pregnancy [44]. Risks of complications and injuries such as obstetric fistulas, abortions, and even death could be a consequence of pregnancy in young women (10)(11)(12)(13)(14)(15)(16)(17)(18)(19) [12]. The adverse health outcomes emanating from adolescent pregnancy are considered a public health hazard contributing significantly to maternal and child morbidity and mortality, and have been reported widely [8]. The health effects, as stated above, could manifest from the period of conception and may last a lifetime.
As has been revealed through this study, pregnancy could severely and adversely impact the health of girls in West Africa. One such adverse health outcome is anemia. Pregnancy during this period can contribute substantially to making them anemic without effective interventions. Anemia during pregnancy is due to physiological changes resulting in hemodilution and the increased requirements of iron [50]. A cross-sectional retrospective quantitative study found 68.9% of parturient adolescents to be anemic [51]. Cognitive performance is thought to be affected by anemia, in particular iron deficiency anemia. Iron deficiency anemia is a common phenomenon in adolescent pregnancy and iron treatment is required for a positive maternal outcome [52]. Anemic pregnant adolescents are found to have a postpartum hemorrhage, preeclampsia, and heart failure. The underlying factors for these adverse maternal outcomes are adolescent pregnancy itself [53], thus emphasizing the need to deal with the root cause which is adolescent pregnancy. Pregnancy-related complications, and obstetric and gynecological effects are also known to cause various degrees of harm to the health of adolescents. Pregnancy-induced hypertension and cesarean sections are commonly associated with adolescent pregnancy [54]. This is considered not only risky for adolescent childbearing but a risk factor for later pregnancies as well [45]. The development of obstetric fistulas among adolescent mothers accounted for up to 86% of treated cases with the majority of them from Sub-Saharan Africa in a clinical review study [55].
Another serious health impact is mental state disturbances. Postpartum depression in adolescent mothers has been reported [56]. In a systematic review in Sub-Saharan Africa and globally of adolescent girls and young women's psychosocial experiences post-abortion, the prevalence of shame and abandonment was reportedly experienced by adolescents of all ages [57]. This population subgroup at this critical developmental stage is noted for its fragility in terms of mental health stability [56] and, therefore, pregnancy should be avoided if undesired, especially among the younger adolescents who are less than fifteen years old and who are known to suffer gravely to prevent it from becoming a precursor to mental health disorders. Reduced uptake and the use of contraception and reproductive health-related services among adolescents is a painful reality. The goal of SDG 3, target 3.7, for wider coverage of sexual and reproductive healthcare services for adolescents, truly deserves some more attention as contraception usage is regarded as the surest way of preventing unintended pregnancy in this population sub-group [32]. This is even more so as low coverage and patronage of this essential service is noted as a major determining factor in the incidence of adolescent pregnancy [11]. Restrictions on reproductive services to adolescents could be infringing on international conventions that are seeking to abolish all forms of discrimination, inequalities, and abusive practices against women [58]. International treaties such as The Convention on the Elimination of All Forms of Discrimination Against Women (CEDAW) and The African Charter on the Human and Peoples' Rights and Rights of Women of Africa (Maputo Protocol) are some specific treaties adopted to ensure the protection of women's sexual and reproductive rights. CEDAW, also referred to as the international bill of rights of women, calls on countries to guarantee adolescents access to reproductive health services and family planning. Similarly, the Maputo Protocol aims to guarantee sexual and reproductive health including safe abortion care (Article 14). Early marriages (under 18 years) which contribute to adolescent pregnancy are discouraged by the protocol. It further calls upon duty bearers in Article 14 to ensure a woman's right to health, including respecting and promoting their sexual and reproductive health [59]. This suggests that much more needs to be performed to promote the uptake and usage of contraception by adolescents. Key to the expansion of coverage and uptake of contraception is education and information dissemination. Adopting and comprehensively implementing the WHO's guidelines on adolescent sexual and reproductive health and rights [6] can help push the wheels of progress to attain the above target 3.7 of SDG 3, as sexual and reproductive health and right is a critical tool for fulfilling developmental goals [58]. Ensuring universal coverage of sexual and reproductive healthcare, as far as the adolescent girl population in these countries and to a large extend West Africa is concerned, could help build their capacity to take charge of their sexual live and significantly consolidate gains in the realization of SDG 3 [60]. HRBA to sexual reproductive health services and rights could promote increased access and uptake in women, particularly adolescents [58].
The study has some strengths and limitations. The study identified adverse adolescent maternal outcomes attributable to pregnancy in Ghana, Liberia, and Nigeria in West Africa through a comprehensive search and the religious application of the PRISMA 2020 guidelines [16]. The inclusion of DHS improves the quality of the review as it provides reliable and timely information on population and health in developing countries. However, the main sources of data were scientific databases and DHS; therefore, there is a possibility of missing out on some studies during the search process as they might not have published their findings in journals in these databases as adolescent pregnancy is a multidisciplinary topic. Some included studies had small sample sizes. Only studies in the English language published from 2016 to 2021 were used for this study. Contrary to the initial plan, metaanalyses are not performed as a result of a lack of reported statistically estimated effect sizes by most of the studies, thus making the study lack statistical power. In addition, there are no studies from all the West African countries which could limit this review's generalization.

Conclusions
In conclusion, the review identified anemia, complications of pregnancy, obstetric and gynecological effects, unsafe abortions, and mental health-related effects as negatively impacting the health and well-being of adolescent girls which could substantially contribute to maternal and child morbidity and mortality. As women suffer these ailments, and some sadly lose their lives rather prematurely through pregnancy as a result of restrictions on sexual and reproductive health and rights and safe abortion care which might be required exclusively by women, could suggest the need to prioritize HRBA to sexual and reproductive health issues in Ghana, Liberia, and Nigeria in West Africa. This unfortunate situation seems to infringe on their rights to health and ripples to hinder their full participation, and could expose adolescent girls to gender-based violence (GBV), exclusions, and inequities. Sexual reproductive health and rights services for adolescents should be scaled up across these countries and the entirety of the sub-region to help accelerate the attainment of SDG 3. Women's rights to exclusive services, such as safe abortion care, should be regarded as a safe scientific intervention to promote health and well-being and, therefore, legal instruments, religion, and culture should not be used to discourage the provision and accessibility of such services.
Funding: There was no funding source for this study.
Institutional Review Board Statement: This study was approved by the Human Research Ethics Committee of Thammasat University (Science), Thailand (HREC-TUSc) (COE No. 020/2564).