The forgotten girls: the state of evidence for health interventions for pregnant adolescents and their newborns in low-income and middle-income countries.

Every year, an estimated 21 million girls aged 15-19 years become pregnant in low-income and middle-income countries (LMICs). Policy responses have focused on reducing the adolescent birth rate whereas efforts to support pregnant adolescents have developed more slowly. We did a systematic review of interventions addressing any health-related outcome for pregnant adolescents and their newborn babies in LMICs and mapped its results to a framework describing high-quality health systems for pregnant adolescents. Although we identified some promising interventions, such as micronutrient supplementation, conditional cash transfers, and well facilitated group care, most studies were at high risk of bias and there were substantial gaps in evidence. These included major gaps in delivery, abortion, and postnatal care, and mental health, violence, and substance misuse-related outcomes. We recommend that the fields of adolescent, maternal, and sexual and reproductive health collaborate to develop more adolescent-inclusive maternal health care and research, and specific interventions for pregnant adolescents. We outline steps to develop high-quality, evidence-based care for the millions of pregnant adolescents and their newborns who currently do not receive this.

Maternal healthcare coverage for first pregnancies in adolescent girls: a systematic comparison with adult mothers in household surveys across 105 countries, 2000-2019.

BACKGROUND: Effective maternal service delivery for adolescent mothers is essential in achieving the targets for maternal mortality under the Sustainable Development Goals. Yet little is known about levels of maternal service coverage in adolescents compared with adult mothers. METHOD: We used data from 283 Demographic and Health Surveys or Multiple Cluster Indicator Surveys for 105 countries between 2000 and 2019 to estimate the levels and trends of inequality in coverage of five maternal health services between adolescent girls (aged 15-19) and adult mothers (aged 20-34), including receiving four or more antenatal care visits, delivering with skilled birth attendants and receiving a postnatal check-up within 24 hours of delivery. RESULTS: We analysed data from 0.9 million adolescent girls and 2.4 million adult mothers. Using the most recent data, we found adolescent girls had poorer coverage across all indicators, with receipt of four or more antenatal care visits 6.5 (95% CI 6.3 to 6.7) percentage points lower than adult mothers, delivery with skilled birth attendants 3.6 (95% CI 3.4 to 3.8) lower and having a postnatal check-up within 24 hours of delivery 3.2 (95% CI 2.8 to 3.6) lower. The coverage was 54.2% (95% CI 53.9 to 54.5) among adolescents for four or more antenatal care visits, 69.7% (95% CI 69.4 to 70.0) for delivery with skilled birth attendants and only 30.0% (95% CI 29.3 to 30.7) for receiving a postnatal check-up within 24 hours of delivery. Country-specific coverage of the maternal services increased over time in most countries, but age-related differences persisted and even worsened in some, particularly in the Western Pacific (eg, Vietnam, Lao, Cambodia and Philippines). CONCLUSION: Even though their pregnancies are of higher risk, adolescent girls continue to lag behind adult mothers in maternal service coverage, suggesting a need for age-appropriate strategies to engage adolescents in maternal care.

The influence of gender on clinical examination skills of medical students in Jordan: a cross-sectional study.

BACKGROUND: A graduating medical doctor is expected to be competent in physical examinations across all systems. The exploration of how gender affects the development of clinical skills has not been explored in an Arab context, despite cultural restrictions that make it more difficult for students and doctors to examine the opposite sex. METHODS: A cross sectional survey was undertaken of graduating final year medical students in Northern Jordan. We asked about students' perceptions regarding factors that may impact the development of clinical skills potentially related to gender, and asked about the frequency of examinations performed during their training for intimate and general physical examinations on all patients, as well as patients of the opposite sex. We also asked about the students' confidence in performing the examinations (3-point Likert-scale). Comparison of male and female proportions was done using Chi square tests analysis. RESULTS: One hundred eighty-eight final year students from 481 students (41%) completed the survey, 99 males and 89 females. The greatest factor given for impacting a student's clinical examination of a patient of the opposite sex was cultural or religious traditions. Overall male students perform more clinical examinations than female students, with the odds of a male conducting more than 10 cardiovascular examinations on any patient compared to female students being 2.07 (1.13-3.79) and as high as 3.06 (1.53-6.18) for thyroid examinations. However, females were significantly more likely to examine male patients than vice versa (0.49 (0.27-0.88) for cardiovascular and 0.39 (0.21-0.71) for respiratory examinations). The gender division was more prominent for intimate examinations, with a lower odds of males conducting breast 0.11 (0.04-0.28) and vaginal examinations 0.22 (0.02-1.98) and more male students conducting prostate examinations OR 11.00 (1.39-87.03) and male genitalia examinations OR 16.31 (3.75-70.94). Overall a large proportion of students had never performed common intimate clinical examinations at all. CONCLUSIONS: In our context, clinical exposure to both intimate and general clinical examinations differs significantly between male and female students. A greater awareness and more research on the influence of gender on clinical skill attainment in conservative cultures is needed with appropriate adaption of clinical teaching. TRIAL REGISTRATION: Non interventional thus not required.

Contraceptive Use in Adolescent Girls and Adult Women in Low- and Middle-Income Countries.

Importance: Preventing unwanted pregnancy through adequate use of contraceptives among adolescent girls is essential for improving maternal and child health and social well-being. Objective: To estimate the levels and trends of contraceptive use in adolescent girls (age 15-19 years) compared with adult women (age 20-34 years). Design, Setting, and Participants: This survey study used data from 261 Demographic and Health Surveys or Multiple Cluster Indicator Surveys conducted in 103 low- and middle-income countries between 2000 and 2017. Modern contraceptive use in 90 countries and unmet need for family planning in 73 countries for adolescent girls and adult women were assessed at country and aggregate levels. Data analyses for this study were conducted between March 2019 and December 2019. Main Outcomes and Measures: Modern contraceptive use and unmet need for family planning, estimated between adolescent girls and adult women for absolute inequality and relative inequality (defined as the ratio in service use between adult women and adolescent girls). Inequalities by wealth and place of residence in each age group were also assessed. Results: A total of 832 673 adolescent girls and 2 156 268 adult women were included in the analysis. Adolescent girls were significantly less likely to use modern contraceptives (31.6% [95% CI, 30.3% to 32.8%] vs 43.5% [95% CI, 42.4% to 44.7%]; absolute inequality, 11.9 percentage points [PPs] [95% CI, 11.7 to 12.1 PPs]; relative inequality, 1.38 PPs [95% CI, 1.36 to 1.40 PPs]) and more likely to have an unmet need for family planning (50.8% [95% CI, 49.0% to 52.5%] vs 36.4% [95% CI, 34.9% to 35.8%]; absolute inequality, -14.4 PPs [95% CI, -15.8 to -15.0 PPs]; relative inequality, 0.72 PPs [95% CI, 0.69 to 0.75 PPs]). Contraceptive use generally improved over time (aggregate-level use of contraceptives increased from 17.8% [95% CI, 16.6% to 19.0%] in 2000-2006 to 27.2% [95% CI, 26.6% to 27.8%] in 2013-2017 for adolescents and from 30.9% [95% CI, 29.8% to 32.0%] in 2000-2006 to 40.3% [95% CI, 39.8% to 40.8%] in 2013-2017 for adult women), but inequalities between adolescents and adult women persisted. Aggregate-level prevalence of unmet need for family planning decreased only among adult women (from 45.8% [95% CI, 44.9% to 46.7%] in 2000-2006 to 38.0% [95% CI, 37.3% to 38.7%] in 2013-2017). For adolescents, the prevalence remained at approximately 52% over time. The inequality between the 2 age groups therefore significantly increased from 7.5 PPs (95% CI, 6.5 to 8.4 PPs) in 2000 to 2006 to 14.0 PPs (95% CI, 13.4 to 14.6 PPs) in 2013 to 2017. An increasing gap between adolescent girls and adult women was found in 18 countries for modern contraceptive use and in 20 countries for unmet need for family planning. In India, for example, both age groups had increased percentage of unmet need for family planning over time, from 16.2% (95% CI, 15.9% to 16.6%) in 2006 to 29.8% (95% CI, 29.6% to 30.1%) in 2015 for adult women and from 23.9% (95% CI, 23.0% to 24.9%) to 64.5% (95% CI, 63.3% to 65.7%) among adolescents. Thus, inequality increased from 7.7 PPs (95% CI, 7.2 to 8.2 PPs) in 2006 to 34.7 PPs (95% CI, 34.2 to 35.1 PPs) in 2015. Conclusions and Relevance: Despite a growing focus on contraception in the past decade with initiatives such as Family Planning 2020, adolescent girls continue to lag behind adult women in contraceptive use. There is a pressing need to develop age-appropriate strategies for increasing access and maintaining contraceptive use in sexually active adolescent girls.

Low birthweight and subsequent emotional and behavioural outcomes in 12-year-old children in Soweto, South Africa: findings from Birth to Twenty.

BACKGROUND: The fetal origins hypothesis suggests that an adverse prenatal environment, indexed by low birthweight (LBW), may increase the risk of developing later disease. Recently the hypothesis has been extended to psychological outcomes, especially depression. The aim of this analysis was to test, for the first time in a developing country setting, the association between LBW and psychological symptoms, in Soweto, South Africa. METHODS: A sample of 1029 children was drawn from Birth to Twenty, a longitudinal cohort followed from pregnancy to young adulthood. This sample completed the Youth Self Report at age 12 years, a validated psychological measure of behavioural and emotional adjustment. Scores were compared between LBW (<2500 g) and normal birthweight children using multivariate analysis with adjustment for potential birth and life events confounding factors. RESULTS: No associations were found between LBW and total [adjusted odds ratio (OR) 1.09, 95% confidence interval (CI) 0.69-1.74], internalizing (adjusted OR 0.81, 95% CI 0.52-1.28) or externalizing profiles (adjusted OR 0.81, 95% CI 0.49-1.36). The only difference detected was for the internalizing sub-profile of Somatic Complaints (adjusted OR 2.02, 95% CI 1.21-3.38), which on subgroup analysis was greatest among females. CONCLUSIONS: We found no convincing evidence of an association between LBW and emotional and behavioural outcomes in 12-year olds in this sample in urban South Africa. To our knowledge, this is the first published assessment of this association in a developing world context.