Drivers of early marriage and teenage pregnancy in Kenya and Uganda during COVlD-19 lockdown period:A systematic review

Brian Barasa MASABA,Rose MMUSI-PHETOE,Jacklyne Atieno ODHIAMBO,Bernard RONO,Jane Wamuyu KABO,Damaris MORAA,Alex RUTTO,John Kennedy MOTURI,Thomas Ong’ondo NG’AMBWA,Damaris OCHANDA,Sammy Diana MAWIA,Mary KIPMEREWO,Samuel OYUGI,Stephenie Lydia OJIAMBO

1Department of Health Studies,School of Social Sciences,College of Human Sciences,University of South Africa,Pretoria,South Africa;2School of Nursing,Great Lakes University of Kisumu,Kisumu,Kenya;3Centre of Microbiology Research,Kenya Medical Research Institute,Kisumu,Kenya;4School of Nursing,Kibabii University,Bungoma,Kenya;5School of Nursing,Kaimosi Friends University,Kaimosi,Kenya;6School of Nursing,Midwifery and Paramedical Sciences,Masinde Muliro University of Science and Technology,Kakamega,Kenya;7School of Nursing,University of Embu,Embu,Kenya;8School of Economics,University of Nairobi,Nairobi,Kenya

ABSTRACT The present study aimed to explore the drivers of early marriage and teenage pregnancy in Kenya and Uganda during COVID-19 lockdown period.A systematic review design was adopted.The major online databases utilized were PubMed,Google Scholar,Uganda and Kenya Ministry of Health repositories,ScienceDirect,and Scopus.Studies that were originating from Kenya and Uganda that were publicly available in electronic format published from March 2020 to March 2022 were used.The thematic analysis identified major concepts that were drivers to the present research problem which were as follows: (1) school closure and (2) loss of income by parents.The COVID-19 containment measures introduced in the two countries were noted as major contributing factors.During the pandemic,lockdown led to school closures which meant the teenagers being idle at home with an increased opportunity to indulge in sexual risk behaviors.Schools have been noted to be a safe place protecting this vulnerable population.However,with their prolonged closure,the teenagers were exposed to sexual predators.Parents lost income,and this might have contributed to early marriages and teenagers’dependency on their sexual partners.Based on the reviewed evidence,the present study furthers the advocacy for the reduction of early marriages and teenage pregnancy,especially in the current COVID-19 pandemic era.The study calls upon the governments to intensify efforts toward the present research problem as the COVID-19 pandemic is eroding the earlier gains made within the region.

Keywords: Adolescent,COVID-19,humans,Kenya,marriage,sexual behavior,teenage pregnancy,Uganda

INTRODUCTION

COVID-19 is an infectious disease that has spread globally,infecting over 387 million people and resulting in 5,705,754 deaths as by February 4,2022.[1,2]The disease is an ongoing global pandemic that was declared so by the World Health Organization (WHO) on March 11,2020,having spread to over 110 countries and territories.[3]Currently,Africa accounts for 2.8% of the global cases of which Uganda has reported 162,136 confirmed cases and 3549 deaths.[1,4]While Kenya has had 321,922 infections and 5604 COVID-19-related deaths since the pandemic began.[1]

To contain the COVID-19 pandemic,countries were advised to urgently implement some of the following measures by the WHO: have a lockdown in place,prohibit social gatherings within communities,maintain social distancing,and practice cough hygiene.A lockdown is defined as an emergency protocol issued by the government with the purpose of preventing people from leaving a given area.[5]In the East African region countries,Uganda,Rwanda,and Kenya were stricter in their COVID-19 measures,contrary to Burundi and Tanzania that resorted more to prayer as a cure for the epidemic.[6,7]Kenya and Uganda’s COVID-19 response strategy was somehow similar,as they reported their first cases within the same period.They had a hard lockdown on March 15,2020,and March 20,2020,respectively.Further measures were that they closed schools,did massive testing of people,contact tracing and put cases in quarantine.[6,7]While tight restrictions on movement may contribute to reduced disease transmission.[2]These COVID-19 containment measures are having far-reaching impacts on people around the world.[8]

Previous literature demonstrates that in times of humanitarian crisis (e.g.,conflict and war,famine,and disease outbreaks),women and girls are especially vulnerable because of gender inequality.[8]A case in point is the Ebola crisis in Sierra Leone in 2014-2015.[9,10]It is noted that there was a 65% increase in teenage pregnancy due to girls being out of school.[8]Since children are extremely vulnerable to the “secondary” impacts of the pandemic,with a possibility of lifetime effects,it is crucial to look into the impact of COVID-19 on children.[3]Based on this argument,the COVID-19 effects reviewed in the present study are not the direct result of the infection but instead the indirect consequences of socioeconomic disruptions in the society more so teenagers.[11]Teenage pregnancies are correlated to contextual factors,which have to do with the environments where these teenagers live.[12]These include services available to the teenagers to empower them,including learning -information and formal,health services and education,social services,and other socioeconomic factors.[12]With disruption of these services due to lockdown;the COVID-19 pandemic further indirectly exposes adolescent girls to multiplied risks of sexually transmitted infections including HIV and human papillomavirus.[13]

It should be noted that early marriage and teenage pregnancy have been a persisting public health problem even before the COVID-19 pandemic.The pandemic is currently exacerbating many of the complex factors that drive child marriage and teenage pregnancy.Child marriage -also termed “early marriage” -is broadly defined as a legal or customary union involving a boy or girl under the age of 18.[14]The world hosts in excess of 650 million girls and women who were married as child brides.[14]Global estimates further show that 12 million girls under 18 years of age are married annually.In other words,every minute,22 girls have their futures cut short as they are exposed to early marriages.[15]Although almost every country in the world has pledged to end child marriage by 2030 under target 5.3 of the Sustainable Development Goals,progress has been slow.[15]

In sub-Saharan Africa,nearly half (45%) of all pregnancies among girls aged 15-19 are unintended.[16]Projections from UNFPA/UNICEF show that the impact of COVID-19 could potentially result in an additional 13 million child marriages taking place between 2020 and 2030 that could otherwise have been averted.[17]Adolescent pregnancy already constitutes a major public health concern in Kenya;prior to COVID-19,one in five girls between 15 and 19 years was either pregnant or already a mother.[12,18]Further,a recent anecdotal Kenyan national report noted that,there was a 40%increase in teenage pregnancy 3 months after the COVID-19 lockdown was introduced.[19]While in Uganda,vulnerability of women and children due to the COVID-19 pandemic and its associated containment measures has so far been understated in the literature and policymaking.[20]

With most energies of the international health bodies geared toward the stop of COVID-19,there is fear of the adolescent girls’ health advocacy being neglected.[21]For instance,field research activity in Uganda on “child marriage in development and humanitarian contexts’’ has also been put on hold until COVID-19 movement restrictions are lifted.[22]There is a trending call to action for governments to put in measures to safeguard this vulnerable population of adverse sexual reproductive health outcomes.[13]According to Plan International Organization reports,the COVID-19 pandemic risks undoing decades of progress made against early marriage,especially in the sub-Saharan region.[23]The present systematic review identifies,evaluates,and synthesizes research results to create a summary of current evidence that can contribute to evidence-based practice.[24]It is essential as its evidence generates insights beyond those found in a single study.In the present study,the researchers integrated and evaluated evidence from two countries on the current research problem.[24]The present study aimed to explore the drivers of early marriage and teenage pregnancy in Kenya and Uganda during COVID-19 lockdown period.

METHODOLOGY

Study design

The PICoS tool was used to identify the components of study inclusion through the evaluation of “Participant,”“Phenomena of interest,” “Context,” and “Study design.”The participants were adolescents,parents,or health-care providers.A phenomenon of interest was the possible drivers of early marriage and teenage pregnancy.A COVID-19 lockdown-related teenage pregnancy in the current study was defined as any pregnancy of a girl who is 19 years and below,and the pregnancy occurred during the COVID-19 lockdown period of March 2020 to its end in the two respective countries.[25]The context of the study was in Kenya and Uganda.Study design was a systematic review of studies that were originating from the aforementioned countries that were publicly available in electronic format.The study adopted systemic review methodology that was previously presented by Liberatiet al.[24]Articles included were those published from March 2020 to May 2022 and in English language.No restrictions were put on the type of study designs adopted in the articles.This was to enable the researchers to have a large pool of articles to sample.The articles that discussed a similar research problem to the present study were included.Inaccessible articles,those outside the study area,abstracts,letters to the editor,and unpublished studies were all excluded.

Information sources

The major online databases utilized were PubMed,Google Scholar,Uganda and Kenya Ministry of Health repositories,ScienceDirect,and Scopus.MeSH terms that guided the search were as follows: “adolescent,” “COVID-19,” “female,”“humans,” “Kenya,” “marriage,” “pregnancy in adolescence,”“Pregnancy,” “sexual behavior,” “Uganda.”

Search

The search of articles commenced on January 7 and ended on May 3,2022.The researchers used the following combination of MeSH terms in the PubMed,Google Scholar,Uganda and Kenya Ministry of Health repositories,ScienceDirect,and Scopus databases: “adolescence pregnancy,” “teenage pregnancy,” “adolescence marriage,” “adolescence sexual behavior,” AND “COVID-19 Uganda,” AND “COVID-19 Kenya.”

Study selection

Mendeley Reference Manager was used to store the downloaded copies of the articles on the researchers’ personal computer.The reviewers assessed independently selected the articles in the following order: title screening,abstract screening,and finally full-text screening.Disagreements in the selection process were discussed and solved by consensus among the reviewers.

Data collection process

The reviewers were divided into two groups (A and B).The two independent groups of reviewers conducted comprehensive searches of relevant electronic databases and manual searches of relevant research bibliographies.Data were collected from the articles that were selected after full-text screening.The researchers utilized a data extraction form that identified the article’s year of publication,study setting,key objectives,study design,results,and discussion.Disagreements in the selection process were discussed and solved by consensus among the two groups of reviewers.

Quality assessment

The two aforementioned groups of reviewers (A and B) used the Critical Appraisal Skills Programme for the quality assessment of the identified articles.Each included study was scored on 14 aspects: (1) whether the study aims/objectives were clear;(2) whether the study design was appropriate for the stated aim (s);(3)whether the study sample size was justified;(4) whether the study the target/reference population was clearly defined;(5) whether the selection process was likely to select subjects/participants that were representative of the target/reference population under investigation;(6)whether the risk factor and outcome variables measured appropriate to the aims of the study;(7) whether the risk factor and outcome variables were measured correctly using instruments/measurements that had been piloted or published previously;(8) whether the methods (including statistical methods) were sufficiently described to enable them to be repeated;(9) whether the basic data were adequately described;(10) whether the response rate failed to raise concerns about nonresponse bias;(11) whether the authors’ discussions and conclusions were justified by the results;(12) whether the limitations of the study were discussed;(13) whether there were no any funding sources or conflicts of interest that may affect the authors’interpretation of the results;and (14) whether there was an ethical approval or consent of participants.[26,27]The reviewed studies were categorized as follows: those that scored 5 out of 14 points were considered of low quality;6-10 points were of moderate quality and finally high quality studies were those with a score above 10 points.Only studies with moderate and high quality were included.The first group (A) of reviewers independently assessed the quality of the included studies while the second group (B) of reviewers checked the assessed studies.Disagreements in this quality assessment were discussed and solved by consensus among the groups.

Synthesis of results

The extracted data included research designs,populations,interview methods,and main findings on the drivers of early marriage and teenage pregnancy in Kenya and Uganda during COVID-19 lockdown period.The findings were assembled and categorized based on similarity of meaning.These categories were then integrated to generate comprehensive findings.While the development of descriptive themes remains “close” to the primary studies,the analytical themes represent a stage of interpretation whereby the reviewers “go beyond” the primary studies and generate new interpretive constructs,explanations,or hypotheses.[28]The thematic analysis identified two major concepts to the present research problem.Data were subsequently presented in two thematic areas.The current study adopted PRISMA [Figure 1] reporting as demonstrated previously by Liberatiet al.[24]

RESULTS

The online search from the major databases generated 2884 of which 24 were identified as duplicates and removed.Upon the completion of the screening process of titles and abstracts,only 37 articles were identified and were included in the subsequent full-text review step.On further assessment using the inclusion criteria set,of the 37 articles,only 16 were finally selected.Table 1 demonstrates the characteristics of the articles that formed the final sample size;9 articles were from Kenya,6 from Uganda and one was a multi-site article of both countries.All the articles were published between 2020 and 2022.

Figure 1: PRISMA flow diagram of literature search and screening

The present systematic review study aimed to explore the drivers of early marriage and teenage pregnancy in Kenya and Uganda during COVID-19 lockdown period.The thematic analysis identified two major concepts to the present research problem which were discussed as follows: (1) COVID-19 lockdown and school closure and (2) loss of income by parents.

DISCUSSION

COVID-19 lockdown and school closure

As earlier defined in this study,COVID-19 lockdown-related teenage pregnancy is any pregnancy of a girl who is 19 years and below and the pregnancy occurred during the COVID-19 lockdown period of March 2020 to its end in the two respective countries.[25]There is evidence to demonstrate a rise in occurrences of teenage pregnancies within this pandemic period in the region as earlier predicted in past reports.[19]Ugandan youths in a past survey noted that their most common problem during pandemic was unwanted pregnancy (32.4%).[29]A Kenya Demographic and Health Survey (KDHS) review demonstrated a steady rise in number of pregnancies in the group of 15-19 years during the COVID-19 period compared to the pre-COVID-19 period.[11]Corroborating this,the UNICEF report shows that,in Kenya,more than 150,000 teenage girls became pregnant over a 3-month period during the economic lockdown,which amounts to a 40% jump.[14]Similarly as noted within the UNICEF report in Uganda,the number of adolescent pregnancies reportedly doubled in the Nwoya district when comparing data of January to March and April to June 2020 trends.[14]In the context of public health,teenage pregnancy presents significant health consequences to both mothers and newborns.[7]It is noted that pregnant adolescents face a higher risk of eclampsia,endometritis,and puerperal infections than women aged 20-24 years.[7]In addition,adolescent births are more likely to result in preterm births,low birth weight,and newborns with severe congenital conditions.[7]Additional consequences are as follows:unwanted pregnancy,unsafe abortion,and a higher risk of sexually transmitted infections,including HIV,during vaginal intercourse.[30]Based on the observed trends,it would not be uncommon for the society to observe an increased risk in perinatal complications and mortalities among the teenagers.A study that utilized KDHS data showed increased adolescent maternal death trends in the pandemic period.[11]

Table 1: The characteristics of the articles sampled for the present study

It is likely that,the COVID-19-pandemic measures put in place contributed to teen pregnancies.This can also imply that without “the strict COVID-19-pandemic measures” most of the teenager pregnancies recorded during the lockdown period would have been avoided.Ssali’s analysis in Uganda shows that early marriage was attributed to teenagers being out of school.[6]School closures heighten teenage pregnancies.Rafaeli and Hutchinson[31]illustrate that adolescent girls out of school in Africa are two times more likely to start childbearing earlier than those who are in school.In a mixed-methods study to understand how COVID-19 affected girls’ and young women’s relationships in Kenya,participants noted that school closures led to some girls to spend more time with their partners due to fewer obligations and increased free time.[32]On the contrary,when the teenagers are in school,they are less likely to be forced into marriage and be abused sexually.[33]During this pandemic (lockdown),however,schools are not there to protect girls.[33]Elsewhere in Zimbabwe,parents confirmed that teenage pregnancies were due to the fact of children being unoccupied while at home.[34]It is common for the pregnant teenagers to be allowed to marry instead of a return to school.Most of the sociocultural norms in many parts of sub-Saharan Africa devalue girl child education and rather favor a boy child educational training.[35]Although most countries guarantee girls’ rights to stay in school during pregnancy and to return afterward,these laws and policies are often insufficiently implemented and sometimes present different barriers.[10]Hence,pregnancy could be used as an easy excuse to terminate the educational goals of an adolescent girl in the society.

Opportunity for early sexual risk behaviors

Several studies have shown that the age at first intercourse is reducing,suggesting that today’s young adults are becoming sexually active at increasingly younger ages.[36]Lockdown measures might have given the teenagers opportunity to indulge in sexual risk behaviors at a much earlier age.In a Kenyan longitudinal study,the findings showed that one in two COVID-19 cohort girls become sexually active during follow-up period.[18]Similarly,the WHO observes that during the pandemic,consensual sex appears to have seen a sharp increase with idleness and boredom cited as the main reasons for the increased activity.[37]

Low access and uptake of sexual reproductive services

Few adolescents use contraceptives and are at risk of pregnancy.[36]To further worsen the low contraceptive uptake in this age group,during the pandemic,some sexual reproductive outreaches were closed as social gatherings and travel restrictions were in place.In Uganda,some gendered difficulties included accessing contraceptives.[38]Reproductive Health Uganda official reported that they suspended all outreaches during lockdown.[38]In support of this,a quarter of the adolescents-participants (26.9%,n=195) reported that testing and treatment services of sexually transmitted infections were not available during the lockdown.[29]On the other hand,low visits were noted within the facilities that remained open during the lockdown period.For instance,a health-care provider in Uganda noted an initial decrease in adolescent contraceptive visits at the start of the pandemic and actual visits dipped far below the number projected by the provider for April 2020.[39]It is also plausible that the fear of contracting COVID-19 may have kept young women from attending reproductive health services at outreaches since the WHO had advised against group gatherings as a preventive method to curb the COVID-19 spread.[40]The indirect costs-increased transport fares to the distant located hospitals could further make the teenagers unable to afford the services during the harsh economic period of the pandemic.However,in some Kenyan studies different patterns were noted,there was a significant increase in proportion among adolescents 10-14 years (0.5%-0.6%) and youths 20-24 years(18.3%-19.6%) seeking the family planning services in the health facilities during the pandemic.[11]Sexual reproductive health protection strategies need to be reviewed and adapted to changing risks in this vulnerable group during the pandemic.[9]It is well agreed that women should be able to access the right care at the right time to avoid delays that do put them at risk of experiencing poor health outcomes.[11]

Loss of income during COVID-19 pandemic

Families who were already vulnerable prior to the pandemic have been pushed to dire circumstances with losses in income and are unable to afford basic necessities.[7]Already before the COVID-19 pandemic,an estimated 55.1% of all Ugandans lived in poverty.[41]In Kenya,national estimates indicate that the pandemic led to loss of jobs and other sources of livelihood,and to loss of incomes for more women (20%)than men (12%).[42]It is unfortunate that most of those that have suffered the unemployment rate are the poor who work with the Small and Medium Scale Enterprises as they were the first casualties of the crises.[43]

The parents having lost jobs coupled with all children at home due to school closure might have contributed to them allowing their teenagers to marry in exchange of bride price.The WHO observes that,in times of economic hardship,families are much more likely to get their daughters married to reduce financial hardship on their own family.[37]To illustrate this,a Ugandan girl reported that she was lured by a broker and smuggled from her home to be married off with a man shortly after the schools closed;the man had promised her to pay the dowry to her family soon.[38,44]Girls shared that they were becoming more reliant on their partners’ income than they were pre-COVID-19 due to their own or their family’s pandemic-related income loss in Kenya.[32]The reliance on the partner by the girl teenager might easily influence a sexual relationship.In Uganda,some study participants reported that economic hardship caused by the lockdown had driven young women in their communities to engage in sex for money or material goods and others.[41]As noted elsewhere,the children in Zimbabwe indulged in antisocial behavior such as child prostitution in an endeavor to earn money for buying food.[34]With growing poverty,more girls are at risk of early pregnancy and marriage.[32]Similarly,in India,the risk of child marriages has heightened as a result of the pandemic’s economic fallout,as vulnerable households could be forced to adopt coping mechanisms.[45]They would need to find alternative sources of income or else reduce their expenditure by reducing the size of the family and marrying off their child.[45]

Although majority of parents noted of loss of income,some continued to work during the pandemic.This implied that their idle children at home stayed unsupervised as schools had closed during the lockdown period.In Uganda,it is noted that the lack of parental supervision placed children at risk of sexual peer-related behavior and raised the likelihood of contact with perpetrators’ sexual predators.[46]

Finally,some families send their children into early job market,which exposed them to sexual predators at the work environment.Illustrating this,study participants in Uganda mentioned that engagement of children in labor likely exposed them to sexual violence,early pregnancies,undesirable behaviors,and increased school dropout.[47]

Implications of the results for practice,policy,and future research

The current review illustrates that adolescent girls are disproportionately affected by emergencies.Priority efforts are diverted from routine health and gender-based interventions to the prevailing emergencies.Thus,the teenage are left more exposed to the epidemic effects.Based on these observations,the present review informs the policymakers to integrate interventions toward child marriages and those of existing emergencies at hand.The integrated approach should be across the emergency management continuum phases from mitigation,preparedness,response,to recovery.The researchers believe that this would enable nations to keep track toward the pledge to SDG 5.3-to end child marriage by 2030 despite the epidemics.Finally,more comparative studies are needed to detail the cases of early marriages and teenage pregnancy during the pre-and post-COVID-19 pandemic era.

Limitations

The review could not analyze studies that were purely quantitative since,in the present study,the research problem was only measured by a qualitative approach.The findings cannot also be generalized to all LMICs because of the cultural and socioeconomic diversity among these countries.

CONCLUSION

The present review demonstrates evidence of drivers of early marriages and teenage pregnancy within Kenya and Uganda during the pandemic period.The COVID-19 containment measures introduced in the two countries were noted as major contributing factors.During the pandemic,lockdown led to school closures which meant the teenagers being idle at home with an increased opportunity to indulge in sexual risk behaviors.Schools have been noted to be a safe place protecting this vulnerable population;however,with their prolonged closure,the teenagers were exposed to sexual predators.Parents lost income,and this might have contributed to early marriages and teenagers’ dependency on their sexual partners.Based on the reviewed evidence,the present study furthers the advocacy for the reduction of early marriages and teenage pregnancy,especially in the current COVID-19 pandemic era.The study calls upon the governments to intensify efforts toward the present research problem as the COVID-19 pandemic is eroding the earlier gains made.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.