REPEAT project: exploring and addressing repeat teenage pregnancies in Southwestern Uganda

Adolescent pregnancy is a global public health challenge with serious health, social and economic consequences (UNICEF, 2022). In 2022 13 % of adolescent girls gave birth before the age of 18 (WHO, 2024). Around 21 million girls aged 15 – 19 in developing countries become pregnant every year, with 12 million giving birth (WHO, 2024). 

Teenage pregnancies result in maternal complications like preterm delivery, low birth weight, and postpartum haemorrhage (UNICEF, 2022; Todhunter et al., 2021). Maternal conditions are the fourth leading cause of disability-adjusted life years (DALYs) and the second most common cause of adolescent mortality due to complications (UNICEF, 2022). Pregnant teenagers often drop out of school, and experience stigma, isolation and violence (UNICEF, 2022). 

Repeat adolescent pregnancy, a critical but less-addressed issue, has adverse effects on offspring and varies in prevalence across Sub-Saharan Africa with the highest prevalence recorded in Gabon (20.93 %) and the lowest in South Africa (4.82 %) (Ahinkorah et al., 2023). In Uganda, repeat pregnancy rates vary widely, with some studies reporting up to 74 % within 24 months among young women (Burke et al., 2018). Although the overall adolescent birth rate had been declining slowly in Uganda, the Covid-19 pandemic caused a sudden 25 % increase in teenage pregnancies in three Ugandan districts. In total, 67 districts reported a rise in teenage pregnancies between 2019 and 2020 (Amongin et al., 2020; UNF-PA, 2021).

Interventions targeting cognitive, behavioural, environmental and psychosocial changes have been implemented globally to combat repeat pregnancies in adolescents and young women (Manjarres-Posada et al., 2022; Hindin et al., 2016). Strategies such as cash transfers, sexual and reproductive health (SRH) education, contraceptive provision and vocational training have shown a potential to reduce the incidence of teenage pregnancies (Hindin et al., 2016). Evidence shows that interventions focusing on contraceptive uptake and immediate postpartum contraceptive selection decrease the incidence of maternal and infant mortality and repeat pregnancies, especially when contraceptives are directly distributed to adolescents and integrated into postabortion or postnatal care services (Hindin et al., 2016).

Uganda has made efforts to improve the SRH of adolescents and prevent unwanted pregnancies through various laws, policies and guidelines. These include but are not limited to the “Adolescent Health Policy Guidelines and Service Standards” (2012) (Ministry of Health, 2020) and the “Revised Guidelines for the Prevention and Management of Teenage Pregnancy in School Settings in Uganda” (2020) (Ministry of Education and Sports, 2020). However, despite these guidelines being in place, the level of implementation remains weak, deterring the uptake of essential preventive services for adolescents, particularly contraception (Perehudoff et al., 2022).

The aims of this project are:

(1) To identify risk and protective factors for repeat adolescent pregnancy in Southwestern Uganda to inform effective intervention(s).

(2) To co-create, implement and evaluate a pilot intervention aimed at increasing contraception use among adolescents after their first pregnancy.

We conducted a cross-sectional mixed-methods study involving a variety of stakeholders. The findings were presented at the research dissemination conference in Mbarara, Uganda in September 2023. Below, we highlight the methods used and provide a snapshot of the results.

A total of 115 girls with single pregnancies and 93 with repeat pregnancies participated in the study conducted in four districts of Southwestern Uganda: Mbarara, Rwampara, Isingiro and Ibanda. We used a tablet-based questionnaire to collect data on socio-demographic characteristics, sexual behaviours, SRH knowledge, pregnancy outcomes, experiences of violence and mental health. Trained research assistants – six females and two males, with prior experience interviewing adolescents in this setting – administered the questionnaires. Descriptive statistics and logistic regression were performed to analyse the responses.

The mean age of the study participants was 19.3 years. The majority (92%) had dropped out of school, having achieved primary-level education (67 %). The mean socio-economic score was significantly lower in the repeat teenage pregnancy group (3.5 vs 4.2).

The mean age of sexual debut (15.2 vs. 16.2 years) and first pregnancy (16.4 vs. 17.3 years) was lower among those with repeat pregnancy compared with those with single pregnancy. Nearly three-quarters of the participants (73.1 %) had experienced some form of violence in the past 12 months. The knowledge and sources of SRH information are described in Table 1.

In the repeat pregnancy group, 24.7 % reported abortion/miscarriage and 6.5 % reported stillbirths for their first pregnancy. The single-pregnancy group had a higher percentage of live births (92.2 % vs. 67.7 %). Most participants (78.4 %) delivered at a healthcare facility and had vaginal births. Antenatal care attendance was higher in the single pregnancy group (96.5 % vs. 82.8 %). Postnatal care within the first two months was reported by 56.3% of participants in both groups. 

Several factors were associated with repeat teenage pregnancy including risky sexual behaviour and experience of some form of violence.

We conducted 14 focus group discussions (FGDs) and 28 individual in-depth interviews (IDIs) with girls who have had experience of teenage pregnancy, adolescent boys and partners, community leaders (e.g., religious leaders, probation officers), healthcare workers (HCWs) and midwives. All interviews were conducted in person, audio recorded, and later transcribed by trained study team members. Transcripts were securely imported into a qualitative content analysis software (Dedoose) and analysed by several team members. A codebook was created collaboratively. 

Participants discussed numerous risk factors associated with adolescent pregnancy, with a particular emphasis on the lack of comprehensive SRH knowledge and access to services. Many highlighted that family planning and SRH services are primarily designed for adults, leaving a significant gap in youth-friendly services. One HCW shared a story about secretly providing SRH information to young girls to help reduce the stigma they faced when attending clinics alongside adults. While most young girls were aware of family planning services, the interviews revealed significant misconceptions. For instance, some believed that using family planning methods could lead to infertility, illness, or even death. Others feared that contraceptives could cause cancer or other severe health issues. Additionally, there was a general lack of basic SRH knowledge among many of the participants. 

“These teens do not have enough information about SRH, family planning services and what else they can do to protect themselves from getting pregnant." (FGD, HCW).

We surveyed 43 healthcare facilities of levels three and four (HC III and HC IV) in the region. Interviews were conducted with the people in charge of the healthcare facility, or their delegates, using pretested structured questionnaires. We extracted 6-month data from registers on repeat pregnancies, postabortion care and postnatal adolescent visits. A checklist was used to assess the availability of family planning consumables, services, and other medical equipment. Descriptive statistics were generated.

Adolescents accounted for 4.9% of repeat pregnancies, 16.3% of postabortion cases, and 14.8% of postnatal consultations recorded at all primary healthcare centres (PHCs). Our observations revealed a shortage of perinatal care staffing, with 79% of HC IIIs lacking adolescent peer educators (n=34) and 60.5% missing counsellors (n=26). There is a significant need for training in providing adolescent-friendly services, including postnatal and postabortion care, with over 90% of respondents indicating that this is necessary. Additionally, PHCs were found to be poorly equipped for postabortion care and intrauterine device (IUD) insertion.

Healthcare workers generally exhibited positive attitudes toward providing contraceptive services to adolescents who have previously been pregnant, as well as to offering post-pregnancy family planning without requiring parental consent. Despite these favourable views, significant concerns remain about the potential side effects of contraception for previously pregnant adolescents. Some HCWs also express apprehension about inadvertently encouraging sexual promiscuity or addressing the needs of unmarried adolescents (Figure 1).

Using the findings from our situation analysis and available global evidence, we designed and implemented an intervention aimed at increasing contraception use among adolescents after their first pregnancy.

A one-day workshop was held to reflect on the results and develop a pilot intervention. A variety of stakeholders took part in the workshop: ten healthcare providers, four adolescent girls (peer leaders), and eight researchers from Mbarara University of Science and Technology (MUST). The main discussions were around interpretations of the findings from the situation analysis that highlighted the challenges adolescent mothers face in seeking healthcare services, and what could be done to address such challenges at healthcare facilities, particularly to enhance attendance of postnatal care services and postpartum uptake of contraception. The participants also discussed the proposed components for an intervention to promote postdelivery/postabortion uptake of contraception and how the intervention could be tailored to the needs of the HCWs and adolescents from the various health facilities that were represented.

The final intervention consisted of: 1) training of HCWs in adolescent-friendly services and contraception; 2) a facilitation guide for the group session with postpartum or postabortion adolescents.

Training
The training was divided into three parts and delivered in three days. Ten HCWs were trained in four facilities as follows:

(1) The trainers’ session was a half-day activity designed to prepare and distribute roles and discuss the training objectives with an existing pool of HCWs and trainers specializing in maternal and newborn health, including adolescent health and family planning.

(2) The theory part of the training included topics on adolescent development and communication, understanding the risks of adolescent pregnancy, contraception (types, mode of action, side effects and myths), postnatal and postabortion care components, HIV/STIs prevention and management of sexual violence. 

(3) The skills-based or practical session involved participants being shown all the methods of family planning and practicing an IUD and implant insertion and removal, as well as procedures for using manual vacuum aspiration (MVA) for postabortion care using uterine and arm models.

A pre-and post-test assessment of HCW’s knowledge revealed an improvement in scores, with a mean increase from 28.9 to 35.9 (+7 rate of change). Feedback collected from the participants highlighted their appreciation for the training, describing it as "educative," "rich in content," "relevant to adolescent care," "informative," "easy to implement," and "clear." Most participants enjoyed multiple topics, especially adolescent communication, postnatal and postabortion care and contraception methods. The practical skills sessions were particularly well-received.

Implementation
The intervention was implemented at four facilities using the group session guide that had been developed and that contained theoretical materials as well as participatory exercises. The sessions were facilitated by trained HCWs and lasted approximately 1.5 hours. Baseline and end line assessments were conducted using a questionnaire to measure knowledge and uptake of contraception among girls. Data was also collected from five control facilities which already offered a adequate standard of care so as to be able to compare and understand the effectiveness of our intervention. The analysis is ongoing and the results will be presented in a peer-reviewed publication in 2025.

The study explored multiple risk and protective factors associated with repeat pregnancies among adolescents in Southwestern Uganda. It also assessed the readiness of healthcare systems to provide SRH services to adolescents. By testing a group postnatal/postabortion intervention, we hope to increase contraception use and support governmental efforts in improving SRH service provision for adolescents in Uganda. However, there is an urgent need for a more holistic and multifaceted approach towards repeat adolescent pregnancy. Healthcare systems’ interventions should be enhanced by educational, mental health and social support programmes. 

Ethical approvals were sought from the Mbarara University Research Ethics Committee (REF: MUST-2022-656) and the Uganda National Council of Science and Technology (REF: HS2972ES). The study also obtained approval from LMU in Germany (Project N: 23-0617). Written informed consent was obtained from all participants following a thorough explanation of the study.

We would like to thank all the participants for their valuable time and contribution to the study. We would particularly like to acknowledge Vivienne Kirabo, Nakitende Declan, Aheebwe Lennah, Monica Natukunda, Jamila Nsamba, Iqra Aheebwa, Timothy Taremwa, Edmand Tumwesiga, Shakirah Namatovu, Jackline Tumuhairwe, Honest Twinomujuni, Arimpa Amerias, Odmaro Ayesimira and Ronald Nuwamanya who participated in the data collection and Rinah Marlone Arinaitwe who designed the database for data collection. Our special thanks goes to Viola N. Nyakato, Rupa Ramachandran, Daniel Atwine and Sophie Lyon for their support with the study conceptualization and data analysis.