Adolescent sexual and reproductive health in sub-Saharan Africa: who is left behind?

Abstract

Adolescent sexual and reproductive health (ASRH) continues to be a major public health challenge in sub-Saharan Africa where child marriage, adolescent childbearing, HIV transmission and low coverage of modern contraceptives are common in many countries. The evidence is still limited on inequalities in ASRH by gender, education, urban-rural residence and household wealth for many critical areas of sexual initiation, fertility, marriage, HIV, condom use and use of modern contraceptives for family planning. We conducted a review of published literature, a synthesis of national representative Demographic and Health Surveys data for 33 countries in sub-Saharan Africa, and analyses of recent trends of 10 countries with surveys in around 2004, 2010 and 2015. Our analysis demonstrates major inequalities and uneven progress in many key ASRH indicators within sub-Saharan Africa. Gender gaps are large with little evidence of change in gaps in age at sexual debut and first marriage, resulting in adolescent girls remaining particularly vulnerable to poor sexual health outcomes. There are also major and persistent inequalities in ASRH indicators by education, urban-rural residence and economic status of the household which need to be addressed to make progress towards the goal of equity as part of the sustainable development goals and universal health coverage. These persistent inequalities suggest the need for multisectoral approaches, which address the structural issues underlying poor ASRH, such as education, poverty, gender-based violence and lack of economic opportunity.

Keywords: health policy; public Health.

Figure 1

Median age at first sex, age at first marriage and age at first birth in 33 countries in sub-Saharan Africa (14 countries in Eastern and Southern and 19 countries in West and Central Africa), most recent DHS 2010–2018. Dash denotes median value of countries in subregion. Dot denotes country median age at first sex, marriage or birth for both men and women aged 25–29 years (or 30–34 years for men only if the median age at first marriage was 25 years or higher). AGO, Angola; BDI, Burundi; COM, Comoros; ETH, Ethiopia; GMB, Gambia; GAB, Gabon; GHA, Ghana; LSO, Lesotho; MWI, Malawi; MOZ, Mozambique; NER, Niger; RWA, Rwanda; SEN, Senegal; TCD, Chad.

Figure 2

Median age at first sex, age at first marriage and age at first birth for girls and boys, by level of education, urban–rural residence and household wealth, 33 countries in sub-Saharan Africa (14 countries in Eastern and Southern and 19 countries in West and Central Africa), most recent DHS 2010–2018. Data extracted from STATcompiler are available and reported by wealth quintile. DHS, Demographic and Health Survey.

Figure 3

HIV prevalence (%) among girls/women and boys/men 15–24 years, by residence, education level and wealth quintile (poorest vs richest), 28 countries in sub-Saharan Africa (12 countries in Eastern and Southern and 16 countries in West and Central Africa), most recent surveys 2010–2018. Online supplementary file: study populations and data sources, definitions, online supplementary tables 1–8 and online supplementary figures 1–3. Wealth quintile is used as a stratified for consistency and comparability as HIV prevalence data extracted from reports and population-based HIV impact assessemnt (PHIA) are available and reported by wealth quintile.