Impact of COVID-19 Lockdowns on Rates of Adolescent Pregnancies: A Systematic Review

Impact of COVID-19 Lockdowns on Rates of Adolescent Pregnancies: A Systematic Review | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Impact of COVID-19 Lockdowns on Rates of Adolescent Pregnancies: A Systematic Review Lauren Hookham, Jackeline Alger, Margit Endler, Michael Enwere, and 25 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-3956706/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background: Education is known to protect adolescent girls from unplanned pregnancy. School closures were component of COVID-19 “lockdown measures”. The impact of these measures on adolescent pregnancy worldwideis unknown. Methods: We performed a systematic review to find evidence of the impact of “lockdowns” and school closures on adolescent pregnancy events during the COVID-19 pandemic. Databases including Pubmed, EMBASE, CINAHL, WHO Index Medicus, and Literatura Latinoamericana y Caribe en Ciencias de la Salud (LILACS) were searched. Studies that provided data on pregnancy rates in girls aged 10-19 before, during, and after the onset of the COVID-19 pandemic (defined as March 2020) were eligible for inclusion. Extracted data included study design, study location, age of participants, exposure period, and percentage or pregnancy rate data. Findings: On August 21 st , 2023, 3049 studies were screened, with 79 eligible for full-text review. Ten studies were included in the final review: Seven performed in Africa (Uganda, Kenya, South Africa, and Ethiopia), and three in the Americas (USA and Brazil). Adolescent pregnancy increased in six out of the seven African studies while a decrease or no change was noted in USA and Brazil.All studies were at a high risk of bias. Interpretation: Adolescent pregnancy rates during the COVID-19 pandemic may have substantially increased in sub-Saharan Africa. Data scarcity and low-quality evidence are significant limitations. The dynamic relationship between lockdown measures and adolescent pregnancies warrants ongoing multifaceted research and adaptive policies to safeguard adolescent sexual and reproductive health during health crisis. Systematic Review Registration: PROSPERO registration number CRD42022308354. Figures Figure 1 Figure 2 Background In response to the evolving COVID-19 pandemic, from March 2020 onwards, governments worldwide imposed restrictions on movement and travel both within and between countries. These non-pharmaceutical interventions or “lock-down” restrictions included stay at home orders, school closures, and curfews. School closures were a common restrictive measure to limit the spread of the virus, with over 1 billion children affected at any one time during the pandemic [ 1 ]. Lockdown restrictions caused disruption to education and access to sexual and reproductive health (SRH) services across the globe on an unprecedented scale. Loss of household heads during the pandemic further resulted in adolescent girls coerced into early marriage, and exchanging sexual services for financial support, putting them at greater risk of unintended pregnancies [ 2 , 3 ]. The epidemiological association between exposure to the pandemic-related lock-down restrictions and adolescent pregnancy is unclear. Early reports of a significant pandemic-related spike in adolescent pregnancies may be unreliable and research to clarify this issue is needed. This study aims to bridge this gap, inform policy makers, and act as a springboard for future research to protect vulnerable girls globally in future outbreaks and pandemics. Objectives We aimed to examine the relationship between non-pharmaceutical interventions (informally known as “lock-down restrictions”) imposed secondary to the COVID-19 pandemic and worldwide rates of adolescent pregnancies (10–19 years). Methods The reporting of this systematic review complies with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) [ 4 ]. Eligibility Criteria The population of interest was girls aged 10–19 years old. Studies which provided data outside of this age group, from pre-pandemic (defined as March 2020), or which did not provide data on adolescent pregnancy or fertility rates were excluded. Case reports, review articles and commentary pieces were also excluded. Information sources Electronic databases were systematically searched, including the grey literature. This included PUBMED/MEDLINE (National Library of Medicine), COCHRANE, EMBASE (Elsevier), Web of Science (Clarivate Analytics), CINAHL (EBSCO), SCOPUS (Elsevier), WHO database – COVID-19 Global literature on coronavirus disease, WHO Index Medicus, Literatura Latinoamericana y Caribe en Ciencias de la Salud (LILACS), and Google Scholar. The reference list of each included study was searched as well, with identified studies screened for relevance. Search strategy A list of search terms can be found in the Appendix, Table 1 . Preliminary searches were run by reviewers using search strings that were developed for each database. Articles in English, Spanish, and French were included in the review without formal translation being required. Articles in other languages could be included if translation could be undertaken. Selection Process References were imported into Rayyan [ 5 ] with all abstracts reviewed against inclusion and exclusion criteria to ensure that the target research topic, methodology, and population, were included in the study. Full-text articles were reviewed if it was unclear whether a study met inclusion criteria via abstract alone. Full-text copies of articles identified as potentially meeting inclusion criteria were obtained for full-text review. All references were managed in Endnote v20 [ 6 ]. Discrepancies amongst reviewers (LH, RE, AN, CR, KL, ZM, AL, SS) on inclusion or exclusion of a study were resolved by independent third reviewers (TR, KLD). Reasons for exclusion were recorded at each stage of the review. Each article was reviewed by at least two reviewers. Data collection process The data extraction form was piloted and tested by data extractors on a small subset of studies (n = 5). Authors completed data extraction independently using an Excel template [ 7 ]. Data was then compared for consensus (GM, CR, SS, LH). Data items Data extraction included study design and identifiers; participant, participant’s age, exposure (i.e., timing, duration, type of lock-down restrictions), outcome information; and information about analytical methods. Missing information was noted. Information on author’s names, study title, publication date, publication type, journal (including volume, issue, and page numbers); study design, period of study (i.e., the time frame), and geographical area or zone of interest (i.e. country and region) was also extracted. If data presented in a study were unclear, missing or presented in a form that were non-extractable or unusable, authors of these studies were contacted via e-mail for clarification. Reporting bias assessment and certainty of evidence Risk of bias tools were used depending on the type of study or data extracted. The ROBINS-E tool provides a structured approach to assessing the risk of bias in observational epidemiological studies [ 8 ]. Effect measures The effect measure was defined as the rate/frequency of adolescent pregnancy and early childbearing before and after the onset of the COVID-19 pandemic (post March 2020). This could be captured via the adolescent fertility rate, defined as births per 1,000 women aged 15–19. Data on conceptions to women aged under 18, defined as conceptions per 1,000 women aged under 18 were also eligible. Alternative outcomes which captured data on adolescent pregnancy were also included and outcome parametres documented in the data extraction form. Results Study selection Searches were performed on 4th May, 2022 with a repeat search performed on 21st August, 2023. A total of 3,049 articles were reviewed after duplicates were removed, with 2,970 being excluded on initial screening. Seventy-nine texts were eligible for full review, and 10 studies were included in the final review. Common reasons for exclusion were lack of original data inclusive of the COVID-19 pandemic era and wrong article type (i.e, commentary). The PRISMA flowchart can be seen in Fig. 1. Figure 1: PRISMA flowchart Figure legen: PRISMA flow diagram depicting the number of papers identified, screened and excluded. The characteristics of the included studies can be seen in Table 1 . The risk of bias scores for each included study can be seen in Table 2 . All studies were graded as having high risk of bias. The certainty of evidence (GRADE [ 9 ]) can be seen in Table 3 . Table 1 Characteristics of included studies Authors Study type Study Region Country Study sites Time period of study Study outcomes Age of participants Number of adolescents included Data collected Overall result Study results Shikuku et al [ 10 ] Retrospective cohort African Region (AFR) Kenya Urban and Rural 2019–2020 Adolescent pregnancy 10–14, 15–19, 10–19 years 253,218 Adolescent pregnancy rate Decrease in adolescent pregnancy Proportion of adolescent pregnancy reduced from 0.4 to 0.3 in 10–14 years olds (p < 0.0001) and from 8.4 to 7.0 in 15–19 year olds (p < 0.0001) Kassie et al [ 11 ] Retrospective cohort African Region (AFR) Ethiopia Urban and Rural March–June 2019, March–June 2020 Proportion of teenage pregnancy, proportion of teenage abortion Not defined beyond "teenage" 644 Pregnancies in those < 19 years Increase in adolescent pregnancy The proportion of teenage pregnancy increased from 7.5–13.1% Forum for African Women Educationalists (FAWE) Uganda Chapter [ 12 ] Retrospective cohort African Region (AFR) Uganda Urban and Rural March to October 2020 Adolescent pregnancy 10 to 14 subgroup 237892 1st ANC attendance Increase in adolescent pregnancy In 10-14-year olds, the number of young girls who attended first ANC increased by 366.5% from 290 in March 2020when the country entered into a lock down to 1,353 in September 2020. Barron et al [ 13 ] Retrospective cohort African Region (AFR) South Africa Urban and Rural 2017–2021 Numbers of deliveries in the public sector to adolescent girls aged 10–14 years and 15 - 19 years 10–14, 15–19, 10–19 years 686487* Adolescent pregnancy rate Increase in adolescent pregnancy Pregnancy rate 10–19 years, per 1 000: 2017: 25.8, 2018: 27.9, 2019: 28.7, 2020: 28.4, 2021: 30.0 Zulaika et al [ 14 ] Prospective cohort African Region (AFR) Kenya Rural 2018–2021 Incident pregnancy in girls who became pregnant during Forms 3–4 (est. age 17–18) Enrollment via school year. Mean age 17.2 in pre-COVID cohort, and 17.5 in COVID-19 cohort 910 Adolescent pregnancy rate Increase in adolescent pregnancy Incident pregnancy between the start of Form 3 and completion of examinations was 10.9% among COVID-19 cohort girls versus 5.2% in the pre-COVID-19 cohort. Martin et al [ 15 ] Retrospective cohort Region of the Americas (AMR) United States of America Urban and Rural 2021 Birth rate by age All age groups, sub-group 15–19 Not reported, total of 3,664,292 births in whole population in 2021, 3,613,647 in 2020 Adolescent birth rate. Age-specific birth rates: Births per 1,000 females in the specified age group. Decrease in adolescent pregnancy The birth rate for teenagers aged 15–19 declined 7% from 2020 to 2021 (15.0 to 13.9 per1,000 births); this rate declined by 10% from 2019 to 2020 Alunyo et al [ 16 ] Retrospective cohort African Region (AFR) Uganda Unsure March 2019 to March 2021 First access of antenatal care (ANC) services for adolescent girls aged 10–19 10 to 19 4,122 first access of antenatal care (ANC) services for adolescent girls aged 10–19 Increase in adolescent pregnancy Increased by 1.53 pregnancies per month [95% CI: -3.4 to 6.0] after lockdown commenced Overall, 8% increase in teenage pregnancies in the district during COVID-19 lockdowns Paudel et al [ 17 ] Retrospective cohort Region of the Americas (AMR) United States of America Urban and Rural January - June 2019, January - June 2021 Adolescent pregnancy Not defined beyond "adolescent" 244 Adolescent pregnancy rate No change in adolescent pregnancy 5.8% of 4151 pregnancies in Pre-COVID era (4.9–6.9 9%CI) in pre COVID 19 era, 5.9% of pregnancies (5.0–7.1 95% CI ) Musinguzi et al [ 18 ] Cross-sectional African Region (AFR) Uganda Unsure December 2021 to January 2022. Pregnancy among teenage girls aged 13–19 years 13–19 years 314 Ever pregnant during the COVID-19 pandemic Increase in adolescent pregnancy 30.6% of teenage girls had gotten pregnant during the COVID-19 pandemic. 2019 adolescent pregnancy rate 29% in this region. Monteiro et al [ 19 ] Retrospective cohort Region of the Americas (AMR) Brazil Urban and Rural 2001–2022 Adolescent pregnancy 10 to 19 381653 Adolescent pregnancy rate Decrease in adolescent pregnancy Adolescent pregnancy in Brazil in 2020 represented 14% of total LB, which is equivalent to a reduction of 8.4% in relation to 2019. Table 2 Risk of Bias scores of included papers Study author Country Bias score Monteiro et al Brazil high risk of bias Kassie et al Ethiopia high risk of bias Zulaika et al Kenya high risk of bias Shikuku et al Kenya high risk of bias Barron et al South Africa high risk of bias Alunyo et al Uganda high risk of bias Forum for African Women Educationalists (FAWE) Uganda Chapter Uganda high risk of bias Musinguzi et al Uganda high risk of bias Martin et al USA high risk of bias Paudel et al USA high risk of bias Table 3 GRADE assessment for certainty of evidence GRADE Assessment for the effect of lockdown measures on rate of adolescent pregnancies (studies n = 10) GRADE criteria Rating Comment Certainty of evidence Study Designs Observational Downgraded 2 for lack of controlled setting ⮾○○○ Very low Risk of Bias Very serious Downgraded 2. All studies were assessed as having a high risk of bias due as data came from different study groups and no adjustment for confounding was performed Inconsistency Very serious Downgraded 2.Half of included studies indicated an increase in adolescent pregnancy and half indicated a decrease. There was a large variation in the magnitude of effect. Imprecision Some concern Confidence intervals for baseline or outcome data not provided. Most studies had sufficient size of information extracted from national registries. A synthesis of data was not possible due to heterogeneity of study settings, study design, and type of outcome measurements. Indirectness Very serious Downgraded 2. The ouctome of interest was by definition measured in different study groups, before and during the pandemic respectively but always in the same setting. Four studies used proportion of adolescent pregnancies and not pregnancy rate as outcome measure. Publication bias None detected Other considerations (upgrading factors) None detected Result of individual studies A total of 10 studies were included in the final analysis (Table 1 ). All studies came from two regions: Africa (7/10) and the Americas (3/10). Most studies (8/10) were performed in low- or middle-income settings. A mix of study designs were reported. We noted many authors self-defined their studies as cross-sectional when retrospective analysis of regional or national datasets had been performed. These studies were classified as retrospective cohorts by reviewers as it was felt to be a more accurate definition of study design. The predominant study type involved retrospective analysis of regional or national datasets or retrospective cohorts (8/10), with cross-sectional studies (1/10) and prospective cohort studies (1/10) being the minority. Increase in adolescent pregnancy was noted in just over half of the studies (6/10, 54.5%), all of which were undertaken in Africa. Other studies took place in Brazil (1/10) and the United States of America (2/10). The results of individual studies by region are discussed below. A brief description of school closures in each country is also provided (see Fig. 2 ). Figure 2 , School Closure status by country, source: UNESCO map on school closures and UIS, March 2022 [ 1 ]. Africa Uganda In Uganda, all schools closed in March 2020 with a partial reopening in October 2020. Schools were closed again in June 2021 and reopened fully in January 2022. Uganda had the longest school closure globally, with a total of 66 weeks of full closure and 23 weeks of partial closure [ 1 ]. Three studies were performed in Uganda across different regions of the country. Musinguzi et al [ 18 ] performed a cross-sectional study between December 2021 to January 2022 in Hoima district, Western Uganda. Of the 319 girls aged 13–19 enrolled via multi-stage sampling across the district, there was a rate of adolescent pregnancy of 30.6% during the study period. The authors noted a preceding adolescent pregnancy rate of 29% in the region, though no statistical analysis was performed to examine the significance of this variation. An interrupted time series analysis examining first access of antenatal care (ANC) for girls aged 10–19 was undertaken between March 2019 to March 2021 in Pakwach district, Northern Uganda, by Alunyo et al [ 16 ]. The records of 4,122 adolescents were included in the study. After the implementation of COVID-19 lockdowns the adolescent pregnancies increased by 1.53 pregnancies per month [95% CI: -3.4 to 6.0], with an overall 8% increase in teenage pregnancies in the district. The increase was not statistically significant. Analysis of risk and protective factors was not undertaken. A report by the Forum for African Women Educationalists (FAWE) in Uganda reviewed results of the National Health Management Information System (HMIS) [ 12 ]. Between March and October 2020, a total of 234,839 pregnancies in 10–14-year-olds and 434,939 pregnancies in 15–19-year-olds were recorded. Amongst the youngest girls, aged 10–14, the number attending first ANC rose from 290 in March 2020 to 1,353 in September 2020, a rise of 366.5%. Kikuube district, Western Uganda, reported the highest number of cases (n = 1,106). Some districts reported no cases (Buhweju, Ibanda, Karenga, Kisoro, Rubanda, and Nabilatuk), though pregnancies in more rural areas with limited antenatal services had not been captured. In girls aged 15–19, the highest increase in ANC attendance were recorded between March and June 2020 with an increase of 25.5% between these months. By October 2020, cases had fallen back to pre-lockdown numbers. Kenya In Kenya, all schools closed on the 16th March 2020. Guidelines were developed by June 2020 to facilitate school reopening and a phased opening of certain grades commenced in October 2020. In January 2021, there was full resumption of in-person instruction [ 1 ]. Two studies were performed in Kenya. Shikuku et al [ 10 ] performed a retrospective cohort study examining the Kenyan Health Information System (KHIS) utilisation data for 2019 and 2020. Data for adolescents aged 10–14 and 15–19 were reviewed. Hospital data for the first four months of the pandemic (March to June 2020) were compared with the same period in 2019. For 10–14-year-olds, there were 4,971 pregnancies in the 2020 time period (proportion of all pregnancies, 0.3%) compared to 6,872 in the same period in 2019 (proportion of all pregnancies 0.4%). A similar trend was seen in girls aged 15–19 (107,667 pregnancies in 2020 compared to 133,708 pregnancies in 2019; proportion of all pregnancies, 8.4%). Significance testing in both age groups suggests a true reduction in adolescent pregnancies in March-June 2020 compared to the same months in 2019 ( p < 0.001). Adolescent maternal deaths (10–19 years) rose as a proportion of all maternal deaths from 6.2% in 2019 (23/373) to 10.9% (45/412) in 2020 ( p = 0.009). In contrast to this, a prospective cohort study of schoolgirls performed by Zulaika et al [ 14 ] in Siaya County, Western Kenya, performed between May 2018 and March 2021 reported that school disruptions caused by lockdowns doubled the risk of adolescent pregnancy amongst girls in the COVID-19 cohort (Relative Risk = 2.11,; CI: 1.13 to 3.95). The rate of pregnancy in the COVID-19 cohort was 10.9% compared to 5.2% in the pre-COVID group. Pregnancy incidence increased from 5.2 per 100 person-years at risk between January 2019 to March 2020 (CI: 3.64 to 7.37) to 8.8 per 100 person-years at risk during the 7 months in which schools were closed (March to October 2020) (CI: 5.91 to 13.16, p = 0.046). Ethiopia Schools in Ethiopia closed in March 2020, with a phase re-opening commencing in October 2020 [ 1 ]. A retrospective cohort study was performed in South-West Ethiopia by Kassie et al [ 11 ], comparing the pregnancies of girls under the age of 19 in 2019 and 2020 (March – June in both time periods). Data were extracted from the medical records at selected governmental medical facilities. The proportion of adolescent pregnancy increased from 7.5% in 2019 (n = 285) to 13.1% in 2020 (n = 359) . South Africa Schools in South Africa closed in March 2020 for a total of 10 weeks, with a subsequent phased reopening. Schools were closed again in July 2020 amidst a rising wave of infections. There were, then, phases of easing restrictions following trends in infection. Schools re-opened in February 2021 [ 1 ]. In South Africa, Barron et al [ 13 ] performed a time-series analysis on public health data for the years 2017–2021. Data were presented in girls aged 10–14 and in those aged 15–19. Overall, the pregnancy rate for 10–19 year-olds rose annually from 27.9 per 1000 girls in 2018 to 30 per 1000 girls in 2021. The upward trend in adolescent pregnancy occurred year on year, but occurred at higher rates in more rural provinces. No further analysis of data from the COVID-19 era to the pre-COVID-19 era was performed. The Americas Brazil Brazilian state and municipal governments first adopted non-pharmaceutical interventions to mitigate COVID-19 in March 2020. A total of 26 states and the Federal District closed schools. Remote learning programmes were developed, but had limited accessibility. Schools re-opened for in-person learning in the second half of 2020 and in 2021 [ 1 ]. In Brazil, Monteiro et al [ 19 ] examined the Live Births Data System (SINASC) of the Brazilian Health Ministry. Data were obtained on the number of live births per region and by age groups (10–14 and 15–19 years) in 2019 and 2020. Age specific fertility rate per 1,000 adolescents in the same age group was calculated. In 2020, the adolescent mothers accounted for 14% of all live births, a reduction of 8.4% compared to 2019. Age specific fertility rates decreased in both age groups by 8% and 8.4%, respectively. No statistical testing was performed. USA The first COVID-19 school closure occurred in late February 2020 in Washington state. By the end of March all but one US public school district was closed,with learning shifting to online platforms. State policies varied on return to in-person learning [ 1 ]. Two studies were performed in the USA. Paudel et al examined adolescent pregnancy in urban and rural Appalachian populations by reviewing electronic medical records between January-June 2019 and January-June 2021 [ 17 ]. There was no significant difference in the rate of adolescent pregnancies between the two time points (5.8–5.9%). Martin et al examined the National Centre for Health Statistics to review birth records from 2020 and 2021 to assess pregnancy rates in girls aged 15–19 [ 15 ]. The birth rate for this group fell by 10% between 2019 to 2020 and fell again by 7% between 2020 and 2021 (15.0 to 13.9 per 1,000 births). Discussion The COVID-19 pandemic and its associated public health measures have raised concerns about the potential adverse impacts on adolescent sexual and reproductive health globally [36 ]. According to our results adolescent pregnancy rates may have increased, decreased or been unchanged during the COVID-19 pandemic depending on country setting. The quality of the data limits our ability to draw firm conclusions. Adolescents are likely to have been affected indirectly by the pandemic, with lockdown restrictions causing disruption to education and access to SRH services (SRH). Plausible factors exacerbating the risk of pregnancy during the pandemic include early or coerced marriage, sexual violence [ 20 ], income loss [ 14 ], and limited access to reproductive health services and contraception [ 3 , 21 , 22 ]. However, the extent to which such mediators impact adolescent pregnancies amid lockdowns remains unquantified. Available evidence shows that staying in school can protect girls against pregnancy as well as early marriage [ 23 , 24 ]. During the Ebola outbreak in West Africa in 2014, adolescent pregnancy in certain communities in Sierra Leone increased significantly [ 4 ]. Girls were also noted to be at increased risk of sexual violence [ 25 ]. Our data suggests that this trend may have been mirrored in other low-resource countries within Africa. Across our studies we found increased, decreased or unchanged rates of pregnancy with no clear pattern by study setting. This fact does not necessarily invalidate results, as lockdown measures may well have had different impacts on different populations. Most study results however suffered from a high degree of uncertainty which hindered any overall conclusion. Results from four studies [ 10 , 11 , 17 , 18 ] were unreliable because they presented adolescent pregnancy rates as proportions of all pregnancies/births. Although a change in this proportion may indicate a true increase or decrease in adolescent pregnancy, it could also mean that pregnancy rates in the adult population decreased or increased [ 26 , 27 ]. Only one study presented incident pregnancy rates [ 14 ], i.e. the occurrence of pregnancy among teenagers as opposed to booking for ANC and adolescent births. Although the latter outcome is consistent with the definition of adolescent fertility rate it fails to register the pregnancies that end in legal or illegal abortion. Globally, the proportion of teenage pregnancies that end in abortion is 55% [ 28 ]. Access to abortion services was also severely affected during the COVID-19 pandemic which could have increased adolescent births rates even if conception rates had remained stable or decreased [ 29 – 31 ]. Importantly, only two studies [ 13 , 15 ] provided data for two or more consecutive time periods preceding the COVID-19 in order to put any change in adolescent pregnancy rate in relation to an ongoing trend. These studies respectively saw an increase [ 13 ] and decrease [ 15 ] in adolescent pregnancy rates during the pandemic but in both cases this was consistent with a trend that started in the years prior to the pandemic. No study adjusted for factors, other than the pandemic and lockdown, that may have affected adolescent pregnancy rates. Limitations This review has limitations, including scarcity and low-quality of evidence, geographic gaps, and heterogeneity of both data and study design. The dearth of data restricts insights into the pandemic impacts and policy responses for this vulnerable population. No studies from Asia were found, despite South Asia being home to more adolescents than any other region [ 32 ]. This knowledge gap should be a priority for national and international policy makers, researchers, and healthcare workers to fill. The data were, by definition, extracted from different time periods of the pandemic and from different data sources. There was heterogeneity between study designs and indicators utilised to assess adolescent pregnancy. All studies were rated as being of high risk of bias. Controlling for confounders in the retrospective analysis of datasets is a challenge, and so inference from results should be performed with caution. Indeed, the number of studies showing high risk of bias highlights the need for more robust methodological design in order to best explore a complex phenomenon. Recommendations It is imperative to prioritize monitoring and mitigating interruptions to health and social services during public health emergencies to safeguard adolescent well-being. Preparedness planning can strengthen crisis resilience. The relationship between lockdown measures and adolescent pregnancy is complex, context-specific, and dependent on the interplay of social, cultural, and economic factors unique to each setting. Caution when generalizing findings within and between regions is needed. Adolescent girls are a vulnerable population and at risk of adverse health outcomes during health emergencies such as epidemics, pandemics, conflict and climate-related health disruptions. More research is required to guide protective interventions, especially when the adolescent pregnancy risk is high. Studies must elucidate the multidimensional factors affecting adolescent reproductive outcomes during crises. Qualitative community-based studies that capture adolescent perspectives and experiences could provide vital nuanced insights alongside broader quantitative data. Global coordination can accelerate evidence generation and enhance adolescents’ health resilience. Ultimately, data-driven action is key to mitigating the shadow pandemic's toll and promoting an equitable future for adolescent girls worldwide. Conclusions on the association between of periods of lockdown and adolescent pregnancy cannot be made until more data from national databases recording adolescent births among the whole female adolescent population become available and are presented over several consecutive years, optimally adjusting for other potential confounders. Together with the recording of the occurrence and outcome of adolescent pregnancy before and after the pandemic, to account for pregnancies that end in abortion, as well as qualitative research to explain and nuance these findings, this data will provide a more complete explanation. Conclusion In summary, while the findings presented in this review offer some insights, the data is of insufficient quality to make any conclusions about the impact of lockdown measures on adolescent pregnancy rates. This likely dynamic relationship warrants ongoing multifaceted research and adaptive policies to safeguard adolescent sexual and reproductive health during and beyond the pandemic. Declarations Acknowledgements This research was undertaken by the Maternal, Neonatal and Child Health Working Group (MNCH WG) of the Coalition for Equitable Research in Low-Resource Settings (CERCLE https://cerclecoalition.org/ , formerly - COVID-19 Clinical Research Coalition); a global research response to COVID-19 driven by the needs of low-resource settings [12, 13]. The coalition includes institutions and individuals working, leading and participating in research in low-resource settings [13]. We would like to acknowledge all members of the Coalition and in particular those of the MNCH working group who assisted in this project. We would also like to acknowledge the support provided by the Biblioteca Médica Nacional, Universidad Nacional Autónoma de Honduras (UNAH), for their support in the country specific data bases search for the Americas. Other info Registration and protocol – link to The protocol can be seen at Prospero, Record ID CRD42022308354 Available at: https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42022308354 Support – financial The CERCLE coalition is funded by the German Federal Ministry of Education and Research (BMBF) through KfW. Individual authors received no financial support for this research. Competing interests The authors have no competing interests to declare Availability of data, code and other materials Data available upon request to corresponding author. Ethics considerations: As this study involved a systematic review of existing literature, individual participant consent was not applicable. All the data extracted from the included studies were aggregated and reported at the group level. No personally identifiable information was disclosed in any publication or report from this systematic review. For transparency in reporting, we provided a clear and comprehensive description of our methods, including the inclusion and exclusion criteria, to ensure that readers can assess the reliability and validity of our findings. References Statistics UIf. COVID-19 Education Response 2023 [cited 2023 30.11.23 ]; Available from: https://covid19.uis.unesco.org/global-monitoring-school-closures-covid19/country-dashboard/ . Bank TW. The State of the Global Education Crisis: A Path to Recovery . 2021. Okeke SR, Idriss-Wheeler D, Yaya S. Adolescent pregnancy in the time of COVID-19: what are the implications for sexual and reproductive health and rights globally? 2022, BioMed Central. p. 1–5. Page MJ, et al. 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Impact of the COVID-19 pandemic on adolescents’ sexual and reproductive health in low-and middle-income countries. Int J Environ Res Public Health. 2021;18(24):13221. Murewanhema G. Adolescent girls, a forgotten population in resource-limited settings in the COVID-19 pandemic: implications for sexual and reproductive health outcomes. Pan Afr Med J. 2020;37(Supplement 1):41. Burt JF, et al. Indirect effects of COVID-19 on maternal, neonatal, child, sexual and reproductive health services in Kampala, Uganda. BMJ Global Health. 2021;6(8):e006102. Biddlecom A, et al. Associations between premarital sex and leaving school in four sub-Saharan African countries. Stud Fam Plann. 2008;39(4):337–50. Jukes M, Simmons S, Bundy D. Education and vulnerability: the role of schools in protecting young women and girls from HIV in southern Africa. Aids. 2008;22:S41–56. Onyango MA et al. Gender-based violence among adolescent girls and young women: a neglected consequence of the West African Ebola outbreak. Pregnant in the time of Ebola: women and their children in the 2013–2015 West African epidemic, 2019: p. 121–132. Pomar L, et al. Impact of the first wave of the COVID-19 pandemic on birth rates in Europe: a time series analysis in 24 countries. Hum Reprod. 2022;37(12):2921–31. Stout MJ, et al. Use of electronic medical records to estimate changes in pregnancy and birth rates during the COVID-19 pandemic. JAMA Netw Open. 2021;4(6):e2111621–2111621. WHO. Adolescet Pregnancy 2023 [cited 2024 24 January ]; Available from: https://www.who.int/news-room/fact-sheets/detail/adolescent-pregnancy . Tschann M, et al. Changes to medication abortion clinical practices in response to the COVID-19 pandemic. Contraception. 2021;104(1):77–81. Polis CB, et al. Impacts of COVID-19 on contraceptive and abortion services in low- and middle-income countries: a scoping review. Sex Reproductive Health Matters. 2022;30(1):2098557. Tiew A, et al. The impact of COVID-19 on safe abortion access in Africa: An analysis through a framework of reproductive justice and lens of structural violence. Front Global Women's Health. 2022;3:958710. UNICEF. Adolesents in South Asia 2021 [cited 2023 4 December ]; Available from: https://www.unicef.org/rosa/what-we-do/adolescents . Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-3956706","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":277883870,"identity":"ece7888e-f395-4c9d-8eed-7d26a97936b0","order_by":0,"name":"Lauren 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Witswatersrand","correspondingAuthor":false,"prefix":"","firstName":"Tanusha","middleName":"","lastName":"Ramdin","suffix":""}],"badges":[],"createdAt":"2024-02-14 17:48:06","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-3956706/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-3956706/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":52451829,"identity":"9e48c55a-5a9c-4ae0-8b81-f6191116df16","added_by":"auto","created_at":"2024-03-11 19:15:09","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":27372,"visible":true,"origin":"","legend":"\u003cp\u003ePRISMA flowchart\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePRISMA flow diagram depicting the number of papers identified, screened and excluded.\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"Figure118.png","url":"https://assets-eu.researchsquare.com/files/rs-3956706/v1/9cd6b2c0d4b497c44bf5bc4d.png"},{"id":52451830,"identity":"c3c11849-f21e-445a-bc30-8c25274de9e6","added_by":"auto","created_at":"2024-03-11 19:15:09","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":283403,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eSchool closures in included countries\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSchool Closure status by country, source: UNESCO map on school closures and UIS, March 2022 [1].\u003c/p\u003e","description":"","filename":"Figure2.png","url":"https://assets-eu.researchsquare.com/files/rs-3956706/v1/582c6a9429ffaa4b34123600.png"},{"id":76621548,"identity":"99864c26-083f-401d-ad59-4bc37d561a95","added_by":"auto","created_at":"2025-02-19 04:46:50","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1174893,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-3956706/v1/7913b2c4-f536-4b0f-819d-1d41d8907e6d.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Impact of COVID-19 Lockdowns on Rates of Adolescent Pregnancies: A Systematic Review","fulltext":[{"header":"Background","content":"\u003cp\u003eIn response to the evolving COVID-19 pandemic, from March 2020 onwards, governments worldwide imposed restrictions on movement and travel both within and between countries. These non-pharmaceutical interventions or “lock-down” restrictions included stay at home orders, school closures, and curfews. School closures were a common restrictive measure to limit the spread of the virus, with over 1\u0026nbsp;billion children affected at any one time during the pandemic [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eLockdown restrictions caused disruption to education and access to sexual and reproductive health (SRH) services across the globe on an unprecedented scale. Loss of household heads during the pandemic further resulted in adolescent girls coerced into early marriage, and exchanging sexual services for financial support, putting them at greater risk of unintended pregnancies [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe epidemiological association between exposure to the pandemic-related lock-down restrictions and adolescent pregnancy is unclear. Early reports of a significant pandemic-related spike in adolescent pregnancies may be unreliable and research to clarify this issue is needed. This study aims to bridge this gap, inform policy makers, and act as a springboard for future research to protect vulnerable girls globally in future outbreaks and pandemics.\u003c/p\u003e \u003cp\u003eObjectives\u003c/p\u003e \u003cp\u003eWe aimed to examine the relationship between non-pharmaceutical interventions (informally known as “lock-down restrictions”) imposed secondary to the COVID-19 pandemic and worldwide rates of adolescent pregnancies (10–19 years).\u003c/p\u003e "},{"header":"Methods","content":"\u003cp\u003eThe reporting of this systematic review complies with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eEligibility Criteria\u003c/p\u003e\u003cp\u003eThe population of interest was girls aged 10–19 years old. Studies which provided data outside of this age group, from pre-pandemic (defined as March 2020), or which did not provide data on adolescent pregnancy or fertility rates were excluded. Case reports, review articles and commentary pieces were also excluded.\u003c/p\u003e\u003cp\u003eInformation sources\u003c/p\u003e\u003cp\u003eElectronic databases were systematically searched, including the grey literature. This included PUBMED/MEDLINE (National Library of Medicine), COCHRANE, EMBASE (Elsevier), Web of Science (Clarivate Analytics), CINAHL (EBSCO), SCOPUS (Elsevier), WHO database – COVID-19 Global literature on coronavirus disease, WHO Index Medicus, Literatura Latinoamericana y Caribe en Ciencias de la Salud (LILACS), and Google Scholar. The reference list of each included study was searched as well, with identified studies screened for relevance.\u003c/p\u003e\u003cp\u003eSearch strategy\u003c/p\u003e\u003cp\u003eA list of search terms can be found in the Appendix, Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. Preliminary searches were run by reviewers using search strings that were developed for each database. Articles in English, Spanish, and French were included in the review without formal translation being required. Articles in other languages could be included if translation could be undertaken.\u003c/p\u003e\u003cp\u003eSelection Process\u003c/p\u003e\u003cp\u003eReferences were imported into Rayyan [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e] with all abstracts reviewed against inclusion and exclusion criteria to ensure that the target research topic, methodology, and population, were included in the study. Full-text articles were reviewed if it was unclear whether a study met inclusion criteria via abstract alone. Full-text copies of articles identified as potentially meeting inclusion criteria were obtained for full-text review. All references were managed in Endnote v20 [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Discrepancies amongst reviewers (LH, RE, AN, CR, KL, ZM, AL, SS) on inclusion or exclusion of a study were resolved by independent third reviewers (TR, KLD). Reasons for exclusion were recorded at each stage of the review. Each article was reviewed by at least two reviewers.\u003c/p\u003e\u003cp\u003eData collection process\u003c/p\u003e\u003cp\u003eThe data extraction form was piloted and tested by data extractors on a small subset of studies (n = 5). Authors completed data extraction independently using an Excel template [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Data was then compared for consensus (GM, CR, SS, LH).\u003c/p\u003e\u003cp\u003eData items\u003c/p\u003e\u003cp\u003eData extraction included study design and identifiers; participant, participant’s age, exposure (i.e., timing, duration, type of lock-down restrictions), outcome information; and information about analytical methods. Missing information was noted. Information on author’s names, study title, publication date, publication type, journal (including volume, issue, and page numbers); study design, period of study (i.e., the time frame), and geographical area or zone of interest (i.e. country and region) was also extracted. If data presented in a study were unclear, missing or presented in a form that were non-extractable or unusable, authors of these studies were contacted via e-mail for clarification.\u003c/p\u003e\u003cp\u003eReporting bias assessment and certainty of evidence\u003c/p\u003e\u003cp\u003eRisk of bias tools were used depending on the type of study or data extracted. The ROBINS-E tool provides a structured approach to assessing the risk of bias in observational epidemiological studies [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eEffect measures\u003c/p\u003e\u003cp\u003eThe effect measure was defined as the rate/frequency of adolescent pregnancy and early childbearing before and after the onset of the COVID-19 pandemic (post March 2020). This could be captured via the adolescent fertility rate, defined as births per 1,000 women aged 15–19. Data on conceptions to women aged under 18, defined as conceptions per 1,000 women aged under 18 were also eligible. Alternative outcomes which captured data on adolescent pregnancy were also included and outcome parametres documented in the data extraction form.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eStudy selection\u003c/p\u003e \u003cp\u003eSearches were performed on 4th May, 2022 with a repeat search performed on 21st August, 2023. A total of 3,049 articles were reviewed after duplicates were removed, with 2,970 being excluded on initial screening. Seventy-nine texts were eligible for full review, and 10 studies were included in the final review. Common reasons for exclusion were lack of original data inclusive of the COVID-19 pandemic era and wrong article type (i.e, commentary). The PRISMA flowchart can be seen in Fig.\u0026nbsp;1.\u003c/p\u003e \u003cp\u003eFigure 1: PRISMA flowchart\u003c/p\u003e \u003cp\u003e \u003cb\u003eFigure legen: PRISMA flow diagram depicting the number of papers identified, screened and excluded.\u003c/b\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eThe characteristics of the included studies can be seen in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. The risk of bias scores for each included study can be seen in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e. All studies were graded as having high risk of bias. The certainty of evidence (GRADE [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]) can be seen in Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eCharacteristics of included studies\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"12\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c10\" colnum=\"10\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c11\" colnum=\"11\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c12\" colnum=\"12\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAuthors\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eStudy type\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eStudy Region\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eCountry\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eStudy sites\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eTime period of study\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eStudy outcomes\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003eAge of participants\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c9\"\u003e \u003cp\u003eNumber of adolescents included\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c10\"\u003e \u003cp\u003eData collected\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c11\"\u003e \u003cp\u003eOverall result\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c12\"\u003e \u003cp\u003eStudy results\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eShikuku et al [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRetrospective cohort\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAfrican Region (AFR)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eKenya\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eUrban and Rural\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e2019\u0026ndash;2020\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eAdolescent pregnancy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e10\u0026ndash;14, 15\u0026ndash;19, 10\u0026ndash;19 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e253,218\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eAdolescent pregnancy rate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003eDecrease in adolescent pregnancy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003eProportion of adolescent pregnancy reduced from 0.4 to 0.3 in 10\u0026ndash;14 years olds (p\u0026thinsp;\u0026lt;\u0026thinsp;0.0001) and from 8.4 to 7.0 in 15\u0026ndash;19 year olds (p\u0026thinsp;\u0026lt;\u0026thinsp;0.0001)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eKassie et al [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRetrospective cohort\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAfrican Region (AFR)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eEthiopia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eUrban and Rural\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eMarch\u0026ndash;June 2019, March\u0026ndash;June 2020\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eProportion of teenage pregnancy, proportion of teenage abortion\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eNot defined beyond \"teenage\"\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e644\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003ePregnancies in those\u0026thinsp;\u0026lt;\u0026thinsp;19 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003eIncrease in adolescent pregnancy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003eThe proportion of teenage pregnancy increased from 7.5\u0026ndash;13.1%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eForum for African Women Educationalists (FAWE) Uganda Chapter [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRetrospective cohort\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAfrican Region (AFR)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eUganda\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eUrban and Rural\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eMarch to October 2020\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eAdolescent pregnancy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e10 to 14 subgroup\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e237892\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e1st ANC attendance\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003eIncrease in adolescent pregnancy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003eIn 10-14-year olds, the number of young girls who attended first ANC increased by 366.5% from 290 in March 2020when the country entered into a lock down to 1,353 in September 2020.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBarron et al [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRetrospective cohort\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAfrican Region (AFR)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eSouth Africa\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eUrban and Rural\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e2017\u0026ndash;2021\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eNumbers of deliveries in the public sector to adolescent girls aged 10\u0026ndash;14 years and 15 -\u003c/p\u003e \u003cp\u003e19 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e10\u0026ndash;14, 15\u0026ndash;19, 10\u0026ndash;19 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e686487*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eAdolescent pregnancy rate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003eIncrease in adolescent pregnancy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003ePregnancy rate 10\u0026ndash;19 years, per 1 000: 2017: 25.8, 2018: 27.9, 2019: 28.7, 2020: 28.4, 2021: 30.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eZulaika et al [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eProspective cohort\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAfrican Region (AFR)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eKenya\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eRural\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e2018\u0026ndash;2021\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eIncident pregnancy in girls who became pregnant during Forms 3\u0026ndash;4 (est. age 17\u0026ndash;18)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eEnrollment via school year. Mean age 17.2 in pre-COVID cohort, and 17.5 in COVID-19 cohort\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e910\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eAdolescent pregnancy rate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003eIncrease in adolescent pregnancy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003eIncident pregnancy between the start of Form 3 and completion of examinations was 10.9% among COVID-19 cohort girls versus 5.2% in the pre-COVID-19 cohort.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMartin et al [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRetrospective cohort\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eRegion of the Americas (AMR)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eUnited States of America\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eUrban and Rural\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e2021\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eBirth rate by age\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eAll age groups, sub-group 15\u0026ndash;19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eNot reported, total of 3,664,292 births in whole population in 2021, 3,613,647 in 2020\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eAdolescent birth rate. Age-specific birth rates: Births per 1,000 females in the specified age group.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003eDecrease in adolescent pregnancy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003eThe birth rate for teenagers aged 15\u0026ndash;19 declined 7% from 2020 to 2021 (15.0 to 13.9 per1,000 births); this rate declined by 10% from 2019 to 2020\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAlunyo et al [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRetrospective cohort\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAfrican Region (AFR)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eUganda\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eUnsure\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eMarch 2019 to March 2021\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eFirst access of antenatal care (ANC) services for adolescent girls aged 10\u0026ndash;19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e10 to 19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e4,122\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003efirst access of antenatal care (ANC) services for adolescent girls aged 10\u0026ndash;19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003eIncrease in adolescent pregnancy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003eIncreased by 1.53 pregnancies per month [95% CI: -3.4 to 6.0] after lockdown commenced\u003c/p\u003e \u003cp\u003eOverall, 8% increase in teenage pregnancies in the district during COVID-19 lockdowns\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePaudel et al [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRetrospective cohort\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eRegion of the Americas (AMR)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eUnited States of America\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eUrban and Rural\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eJanuary - June 2019, January - June 2021\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eAdolescent pregnancy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eNot defined beyond \"adolescent\"\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e244\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eAdolescent pregnancy rate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003eNo change in adolescent pregnancy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e5.8% of 4151 pregnancies in Pre-COVID era (4.9\u0026ndash;6.9 9%CI) in pre COVID 19 era, 5.9% of pregnancies (5.0\u0026ndash;7.1 95% CI )\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMusinguzi et al [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCross-sectional\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAfrican Region (AFR)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eUganda\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eUnsure\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eDecember 2021 to January 2022.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003ePregnancy among teenage girls aged 13\u0026ndash;19 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e13\u0026ndash;19 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e314\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eEver pregnant during the COVID-19 pandemic\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003eIncrease in adolescent pregnancy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e30.6% of teenage girls had gotten pregnant during the COVID-19 pandemic. 2019 adolescent pregnancy rate 29% in this region.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMonteiro et al [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRetrospective cohort\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eRegion of the Americas (AMR)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eBrazil\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eUrban and Rural\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e2001\u0026ndash;2022\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eAdolescent pregnancy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e10 to 19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e381653\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eAdolescent pregnancy rate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003eDecrease in adolescent pregnancy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003eAdolescent pregnancy in Brazil in 2020 represented 14% of total LB, which is equivalent to a reduction of 8.4% in relation to 2019.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eRisk of Bias scores of included papers\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStudy author\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCountry\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eBias score\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMonteiro et al\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBrazil\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ehigh risk of bias\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eKassie et al\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eEthiopia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ehigh risk of bias\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eZulaika et al\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eKenya\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ehigh risk of bias\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eShikuku et al\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eKenya\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ehigh risk of bias\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBarron et al\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSouth Africa\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ehigh risk of bias\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAlunyo et al\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUganda\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ehigh risk of bias\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eForum for African Women Educationalists (FAWE) Uganda Chapter\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUganda\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ehigh risk of bias\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMusinguzi et al\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUganda\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ehigh risk of bias\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMartin et al\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUSA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ehigh risk of bias\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePaudel et al\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUSA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ehigh risk of bias\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eGRADE assessment for certainty of evidence\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"4\" nameend=\"c4\" namest=\"c1\"\u003e \u003cp\u003eGRADE Assessment for the effect of lockdown measures on rate of adolescent pregnancies (studies n\u0026thinsp;=\u0026thinsp;10)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGRADE criteria\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRating\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eComment\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eCertainty of evidence\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStudy Designs\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eObservational\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eDowngraded 2 for lack of controlled setting\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\" morerows=\"6\" rowspan=\"7\"\u003e \u003cp\u003e⮾○○○ Very low\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRisk of Bias\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eVery serious\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eDowngraded 2. All studies were assessed as having a high risk of bias due as data came from different study groups and no adjustment for confounding was performed\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eInconsistency\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eVery serious\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eDowngraded 2.Half of included studies indicated an increase in adolescent pregnancy and half indicated a decrease. There was a large variation in the magnitude of effect.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eImprecision\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSome concern\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eConfidence intervals for baseline or outcome data not provided. Most studies had sufficient size of information extracted from national registries. A synthesis of data was not possible due to heterogeneity of study settings, study design, and type of outcome measurements.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIndirectness\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eVery serious\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eDowngraded 2. The ouctome of interest was by definition measured in different study groups, before and during the pandemic respectively but always in the same setting. Four studies used proportion of adolescent pregnancies and not pregnancy rate as outcome measure.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePublication bias\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNone detected\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOther considerations (upgrading factors)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNone detected\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eResult of individual studies\u003c/p\u003e \u003cp\u003eA total of 10 studies were included in the final analysis (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). All studies came from two regions: Africa (7/10) and the Americas (3/10). Most studies (8/10) were performed in low- or middle-income settings.\u003c/p\u003e \u003cp\u003eA mix of study designs were reported. We noted many authors self-defined their studies as cross-sectional when retrospective analysis of regional or national datasets had been performed. These studies were classified as retrospective cohorts by reviewers as it was felt to be a more accurate definition of study design. The predominant study type involved retrospective analysis of regional or national datasets or retrospective cohorts (8/10), with cross-sectional studies (1/10) and prospective cohort studies (1/10) being the minority. Increase in adolescent pregnancy was noted in just over half of the studies (6/10, 54.5%), all of which were undertaken in Africa. Other studies took place in Brazil (1/10) and the United States of America (2/10). The results of individual studies by region are discussed below. A brief description of school closures in each country is also provided (see Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eFigure \u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e2\u003c/span\u003e, \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eSchool Closure status by country, source: UNESCO map on school closures and UIS, March 2022\u003c/span\u003e [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e].\u003c/p\u003e\n\u003ch3\u003eAfrica\u003c/h3\u003e\n\u003cp\u003eUganda\u003c/p\u003e \u003cp\u003eIn Uganda, all schools closed in March 2020 with a partial reopening in October 2020. Schools were closed again in June 2021 and reopened fully in January 2022. Uganda had the longest school closure globally, with a total of 66 weeks of full closure and 23 weeks of partial closure [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThree studies were performed in Uganda across different regions of the country. Musinguzi et al [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e] performed a cross-sectional study between December 2021 to January 2022 in Hoima district, Western Uganda. Of the 319 girls aged 13\u0026ndash;19 enrolled via multi-stage sampling across the district, there was a rate of adolescent pregnancy of 30.6% during the study period. The authors noted a preceding adolescent pregnancy rate of 29% in the region, though no statistical analysis was performed to examine the significance of this variation.\u003c/p\u003e \u003cp\u003eAn interrupted time series analysis examining first access of antenatal care (ANC) for girls aged 10\u0026ndash;19 was undertaken between March 2019 to March 2021 in Pakwach district, Northern Uganda, by Alunyo et al [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. The records of 4,122 adolescents were included in the study. After the implementation of COVID-19 lockdowns the adolescent pregnancies increased by 1.53 pregnancies per month [95% CI: -3.4 to 6.0], with an overall 8% increase in teenage pregnancies in the district. The increase was not statistically significant. Analysis of risk and protective factors was not undertaken.\u003c/p\u003e \u003cp\u003eA report by the Forum for African Women Educationalists (FAWE) in Uganda reviewed results of the National Health Management Information System (HMIS) [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Between March and October 2020, a total of 234,839 pregnancies in 10\u0026ndash;14-year-olds and 434,939 pregnancies in 15\u0026ndash;19-year-olds were recorded. Amongst the youngest girls, aged 10\u0026ndash;14, the number attending first ANC rose from 290 in March 2020 to 1,353 in September 2020, a rise of 366.5%. Kikuube district, Western Uganda, reported the highest number of cases (n\u0026thinsp;=\u0026thinsp;1,106). Some districts reported no cases (Buhweju, Ibanda, Karenga, Kisoro, Rubanda, and Nabilatuk), though pregnancies in more rural areas with limited antenatal services had not been captured. In girls aged 15\u0026ndash;19, the highest increase in ANC attendance were recorded between March and June 2020 with an increase of 25.5% between these months. By October 2020, cases had fallen back to pre-lockdown numbers.\u003c/p\u003e \u003cp\u003eKenya\u003c/p\u003e \u003cp\u003eIn Kenya, all schools closed on the 16th March 2020. Guidelines were developed by June 2020 to facilitate school reopening and a phased opening of certain grades commenced in October 2020. In January 2021, there was full resumption of in-person instruction [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eTwo studies were performed in Kenya. Shikuku et al [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e] performed a retrospective cohort study examining the Kenyan Health Information System (KHIS) utilisation data for 2019 and 2020. Data for adolescents aged 10\u0026ndash;14 and 15\u0026ndash;19 were reviewed. Hospital data for the first four months of the pandemic (March to June 2020) were compared with the same period in 2019. For 10\u0026ndash;14-year-olds, there were 4,971 pregnancies in the 2020 time period (proportion of all pregnancies, 0.3%) compared to 6,872 in the same period in 2019 (proportion of all pregnancies 0.4%). A similar trend was seen in girls aged 15\u0026ndash;19 (107,667 pregnancies in 2020 compared to 133,708 pregnancies in 2019; proportion of all pregnancies, 8.4%). Significance testing in both age groups suggests a true reduction in adolescent pregnancies in March-June 2020 compared to the same months in 2019\u003c/p\u003e \u003cp\u003e(\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Adolescent maternal deaths (10\u0026ndash;19 years) rose as a proportion of all maternal deaths from 6.2% in 2019 (23/373) to 10.9% (45/412) in 2020 (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.009).\u003c/p\u003e \u003cp\u003eIn contrast to this, a prospective cohort study of schoolgirls performed by Zulaika et al [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e] in Siaya County, Western Kenya, performed between May 2018 and March 2021 reported that school disruptions caused by lockdowns doubled the risk of adolescent pregnancy amongst girls in the COVID-19 cohort (Relative Risk\u0026thinsp;=\u0026thinsp;2.11,; CI: 1.13 to 3.95). The rate of pregnancy in the COVID-19 cohort was 10.9% compared to 5.2% in the pre-COVID group. Pregnancy incidence increased from 5.2 per 100 person-years at risk between January 2019 to March 2020 (CI: 3.64 to 7.37) to 8.8 per 100 person-years at risk during the 7 months in which schools were closed (March to October 2020) (CI: 5.91 to 13.16, p\u0026thinsp;=\u0026thinsp;0.046).\u003c/p\u003e \u003cp\u003eEthiopia\u003c/p\u003e \u003cp\u003eSchools in Ethiopia closed in March 2020, with a phase re-opening commencing in October 2020 [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eA retrospective cohort study was performed in South-West Ethiopia by Kassie et al [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e], comparing the pregnancies of girls under the age of 19 in 2019 and 2020 (March \u0026ndash; June in both time periods). Data were extracted from the medical records at selected governmental medical facilities. The proportion of adolescent pregnancy increased from 7.5% in 2019 (n\u0026thinsp;=\u0026thinsp;285) to 13.1% in 2020 (n\u0026thinsp;=\u0026thinsp;359) .\u003c/p\u003e \u003cp\u003eSouth Africa\u003c/p\u003e \u003cp\u003eSchools in South Africa closed in March 2020 for a total of 10 weeks, with a subsequent phased reopening. Schools were closed again in July 2020 amidst a rising wave of infections. There were, then, phases of easing restrictions following trends in infection. Schools re-opened in February 2021 [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn South Africa, Barron et al [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e] performed a time-series analysis on public health data for the years 2017\u0026ndash;2021. Data were presented in girls aged 10\u0026ndash;14 and in those aged 15\u0026ndash;19. Overall, the pregnancy rate for 10\u0026ndash;19 year-olds rose annually from 27.9 per 1000 girls in 2018 to 30 per 1000 girls in 2021. The upward trend in adolescent pregnancy occurred year on year, but occurred at higher rates in more rural provinces. No further analysis of data from the COVID-19 era to the pre-COVID-19 era was performed.\u003c/p\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eThe Americas\u003c/h2\u003e \u003cp\u003eBrazil\u003c/p\u003e \u003cp\u003eBrazilian state and municipal governments first adopted non-pharmaceutical interventions to mitigate COVID-19 in March 2020. A total of 26 states and the Federal District closed schools. Remote learning programmes were developed, but had limited accessibility. Schools re-opened for in-person learning in the second half of 2020 and in 2021 [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn Brazil, Monteiro et al [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e] examined the Live Births Data System (SINASC) of the Brazilian Health Ministry. Data were obtained on the number of live births per region and by age groups (10\u0026ndash;14 and 15\u0026ndash;19 years) in 2019 and 2020. Age specific fertility rate per 1,000 adolescents in the same age group was calculated. In 2020, the adolescent mothers accounted for 14% of all live births, a reduction of 8.4% compared to 2019. Age specific fertility rates decreased in both age groups by 8% and 8.4%, respectively. No statistical testing was performed.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eUSA\u003c/h2\u003e \u003cp\u003eThe first COVID-19 school closure occurred in late February 2020 in Washington state. By the end of March all but one US public school district was closed,with learning shifting to online platforms. State policies varied on return to in-person learning [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eTwo studies were performed in the USA. Paudel et al examined adolescent pregnancy in urban and rural Appalachian populations by reviewing electronic medical records between January-June 2019 and January-June 2021 [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. There was no significant difference in the rate of adolescent pregnancies between the two time points (5.8\u0026ndash;5.9%).\u003c/p\u003e \u003cp\u003eMartin et al examined the National Centre for Health Statistics to review birth records from 2020 and 2021 to assess pregnancy rates in girls aged 15\u0026ndash;19 [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. The birth rate for this group fell by 10% between 2019 to 2020 and fell again by 7% between 2020 and 2021 (15.0 to 13.9 per 1,000 births).\u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe COVID-19 pandemic and its associated public health measures have raised concerns about the potential adverse impacts on adolescent sexual and reproductive health globally [36 ]. According to our results adolescent pregnancy rates may have increased, decreased or been unchanged during the COVID-19 pandemic depending on country setting. The quality of the data limits our ability to draw firm conclusions.\u003c/p\u003e \u003cp\u003eAdolescents are likely to have been affected indirectly by the pandemic, with lockdown restrictions causing disruption to education and access to SRH services (SRH). Plausible factors exacerbating the risk of pregnancy during the pandemic include early or coerced marriage, sexual violence [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e], income loss [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e], and limited access to reproductive health services and contraception [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. However, the extent to which such mediators impact adolescent pregnancies amid lockdowns remains unquantified. Available evidence shows that staying in school can protect girls against pregnancy as well as early marriage [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. During the Ebola outbreak in West Africa in 2014, adolescent pregnancy in certain communities in Sierra Leone increased significantly [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Girls were also noted to be at increased risk of sexual violence [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. Our data suggests that this trend may have been mirrored in other low-resource countries within Africa.\u003c/p\u003e \u003cp\u003eAcross our studies we found increased, decreased or unchanged rates of pregnancy with no clear pattern by study setting. This fact does not necessarily invalidate results, as lockdown measures may well have had different impacts on different populations. Most study results however suffered from a high degree of uncertainty which hindered any overall conclusion. Results from four studies [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e] were unreliable because they presented adolescent pregnancy rates as proportions of all pregnancies/births. Although a change in this proportion may indicate a true increase or decrease in adolescent pregnancy, it could also mean that pregnancy rates in the adult population decreased or increased [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. Only one study presented incident pregnancy rates [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e], i.e. the occurrence of pregnancy among teenagers as opposed to booking for ANC and adolescent births. Although the latter outcome is consistent with the definition of adolescent fertility rate it fails to register the pregnancies that end in legal or illegal abortion. Globally, the proportion of teenage pregnancies that end in abortion is 55% [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. Access to abortion services was also severely affected during the COVID-19 pandemic which could have increased adolescent births rates even if conception rates had remained stable or decreased [\u003cspan additionalcitationids=\"CR30\" citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eImportantly, only two studies [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e] provided data for two or more consecutive time periods preceding the COVID-19 in order to put any change in adolescent pregnancy rate in relation to an ongoing trend. These studies respectively saw an increase [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e] and decrease [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e] in adolescent pregnancy rates during the pandemic but in both cases this was consistent with a trend that started in the years prior to the pandemic. No study adjusted for factors, other than the pandemic and lockdown, that may have affected adolescent pregnancy rates.\u003c/p\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eLimitations\u003c/h2\u003e \u003cp\u003eThis review has limitations, including scarcity and low-quality of evidence, geographic gaps, and heterogeneity of both data and study design. The dearth of data restricts insights into the pandemic impacts and policy responses for this vulnerable population. No studies from Asia were found, despite South Asia being home to more adolescents than any other region [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e]. This knowledge gap should be a priority for national and international policy makers, researchers, and healthcare workers to fill. The data were, by definition, extracted from different time periods of the pandemic and from different data sources. There was heterogeneity between study designs and indicators utilised to assess adolescent pregnancy. All studies were rated as being of high risk of bias. Controlling for confounders in the retrospective analysis of datasets is a challenge, and so inference from results should be performed with caution. Indeed, the number of studies showing high risk of bias highlights the need for more robust methodological design in order to best explore a complex phenomenon.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eRecommendations\u003c/h3\u003e\n\u003cp\u003eIt is imperative to prioritize monitoring and mitigating interruptions to health and social services during public health emergencies to safeguard adolescent well-being. Preparedness planning can strengthen crisis resilience. The relationship between lockdown measures and adolescent pregnancy is complex, context-specific, and dependent on the interplay of social, cultural, and economic factors unique to each setting. Caution when generalizing findings within and between regions is needed.\u003c/p\u003e \u003cp\u003eAdolescent girls are a vulnerable population and at risk of adverse health outcomes during health emergencies such as epidemics, pandemics, conflict and climate-related health disruptions. More research is required to guide protective interventions, especially when the adolescent pregnancy risk is high. Studies must elucidate the multidimensional factors affecting adolescent reproductive outcomes during crises. Qualitative community-based studies that capture adolescent perspectives and experiences could provide vital nuanced insights alongside broader quantitative data. Global coordination can accelerate evidence generation and enhance adolescents\u0026rsquo; health resilience. Ultimately, data-driven action is key to mitigating the shadow pandemic's toll and promoting an equitable future for adolescent girls worldwide.\u003c/p\u003e \u003cp\u003eConclusions on the association between of periods of lockdown and adolescent pregnancy cannot be made until more data from national databases recording adolescent births among the whole female adolescent population become available and are presented over several consecutive years, optimally adjusting for other potential confounders. Together with the recording of the occurrence and outcome of adolescent pregnancy before and after the pandemic, to account for pregnancies that end in abortion, as well as qualitative research to explain and nuance these findings, this data will provide a more complete explanation.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eIn summary, while the findings presented in this review offer some insights, the data is of insufficient quality to make any conclusions about the impact of lockdown measures on adolescent pregnancy rates. This likely dynamic relationship warrants ongoing multifaceted research and adaptive policies to safeguard adolescent sexual and reproductive health during and beyond the pandemic.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003eAcknowledgements\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThis research was undertaken by the Maternal, Neonatal and Child Health Working Group (MNCH WG) of the Coalition for Equitable Research in Low-Resource Settings (CERCLE https://cerclecoalition.org/ , formerly - COVID-19 Clinical Research Coalition); a global research response to COVID-19 driven by the needs of low-resource settings [12, 13]. The coalition includes institutions and individuals working, leading and participating in research in low-resource settings [13]. We would like to acknowledge all members of the Coalition and in particular those of the MNCH working group who assisted in this project. We would also like to acknowledge the support provided by the Biblioteca M\u0026eacute;dica Nacional, Universidad Nacional Aut\u0026oacute;noma de Honduras (UNAH), for their support in the country specific data bases search for the Americas.\u003c/p\u003e\n\u003cp\u003eOther info\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eRegistration and protocol \u0026ndash; link to\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe protocol can be seen at Prospero, Record ID CRD42022308354\u003c/p\u003e\n\u003cp\u003eAvailable at: https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42022308354\u003c/p\u003e\n\u003cp\u003eSupport \u0026ndash; financial\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe CERCLE coalition is funded by the German Federal Ministry of Education and Research (BMBF) through KfW. Individual authors received no financial support for this research.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eCompeting interests\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe authors have no competing interests to declare\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAvailability of data, code and other materials\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eData available upon request to corresponding author.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics considerations:\u003c/strong\u003e As this study involved a systematic review of existing literature, individual participant consent was not applicable.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAll the data extracted from the included studies were aggregated and reported at the group level. No personally identifiable information was disclosed in any publication or report from this systematic review.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eFor transparency in reporting, we provided a clear and comprehensive description of our methods, including the inclusion and exclusion criteria, to ensure that readers can assess the reliability and validity of our findings.\u0026nbsp;\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eStatistics UIf. \u003cem\u003eCOVID-19 Education Response\u003c/em\u003e 2023 [cited 2023 30.11.23 ]; Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://covid19.uis.unesco.org/global-monitoring-school-closures-covid19/country-dashboard/\u003c/span\u003e\u003cspan address=\"https://covid19.uis.unesco.org/global-monitoring-school-closures-covid19/country-dashboard/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBank TW. \u003cem\u003eThe State of the Global Education Crisis: A Path to Recovery\u003c/em\u003e. 2021.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eOkeke SR, Idriss-Wheeler D, Yaya S. \u003cem\u003eAdolescent pregnancy in the time of COVID-19: what are the implications for sexual and reproductive health and rights globally?\u003c/em\u003e 2022, BioMed Central. p. 1\u0026ndash;5.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePage MJ, et al. 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Use of electronic medical records to estimate changes in pregnancy and birth rates during the COVID-19 pandemic. JAMA Netw Open. 2021;4(6):e2111621\u0026ndash;2111621.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWHO. \u003cem\u003eAdolescet Pregnancy\u003c/em\u003e 2023 [cited 2024 24 January ]; Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.who.int/news-room/fact-sheets/detail/adolescent-pregnancy\u003c/span\u003e\u003cspan address=\"https://www.who.int/news-room/fact-sheets/detail/adolescent-pregnancy\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTschann M, et al. Changes to medication abortion clinical practices in response to the COVID-19 pandemic. Contraception. 2021;104(1):77\u0026ndash;81.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePolis CB, et al. Impacts of COVID-19 on contraceptive and abortion services in low- and middle-income countries: a scoping review. Sex Reproductive Health Matters. 2022;30(1):2098557.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTiew A, et al. The impact of COVID-19 on safe abortion access in Africa: An analysis through a framework of reproductive justice and lens of structural violence. Front Global Women's Health. 2022;3:958710.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eUNICEF. \u003cem\u003eAdolesents in South Asia\u003c/em\u003e 2021 [cited 2023 4 December ]; Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.unicef.org/rosa/what-we-do/adolescents\u003c/span\u003e\u003cspan address=\"https://www.unicef.org/rosa/what-we-do/adolescents\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"","lastPublishedDoi":"10.21203/rs.3.rs-3956706/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-3956706/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eBackground: Education is known to protect adolescent girls from unplanned pregnancy. School closures were component of COVID-19 “lockdown measures”. The impact of these measures on adolescent pregnancy worldwideis unknown.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eMethods: We performed a systematic review to find evidence of the impact of “lockdowns” and school closures on adolescent pregnancy events during the COVID-19 pandemic. Databases including Pubmed, EMBASE, CINAHL, WHO Index Medicus, and Literatura Latinoamericana y Caribe en Ciencias de la Salud (LILACS) were searched. Studies that provided data on pregnancy rates in girls aged 10-19 before, during, and after the onset of the COVID-19 pandemic (defined as March 2020) were eligible for inclusion. Extracted data included study design, study location, age of participants, exposure period, and percentage or pregnancy rate data.\u003c/p\u003e\n\u003cp\u003eFindings: On August 21\u003csup\u003est\u003c/sup\u003e, 2023, 3049 studies were screened, with 79 eligible for full-text review. Ten studies were included in the final review: Seven performed in Africa (Uganda, Kenya, South Africa, and Ethiopia), and three in the Americas (USA and Brazil). Adolescent pregnancy increased in six out of the seven African studies while a decrease or no change was noted in USA and Brazil.All studies were at a high risk of bias.\u003c/p\u003e\n\u003cp\u003eInterpretation:\u0026nbsp;\u0026nbsp; Adolescent pregnancy rates during the COVID-19 pandemic may have substantially increased in sub-Saharan Africa. Data scarcity and low-quality evidence are significant limitations. The dynamic relationship between lockdown measures and adolescent pregnancies warrants ongoing multifaceted research and adaptive policies to safeguard adolescent sexual and reproductive health during health crisis.\u003c/p\u003e\n\u003cp\u003eSystematic Review Registration: PROSPERO registration number CRD42022308354.\u003c/p\u003e","manuscriptTitle":"Impact of COVID-19 Lockdowns on Rates of Adolescent Pregnancies: A Systematic Review","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-03-11 19:15:04","doi":"10.21203/rs.3.rs-3956706/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"cb9c16eb-074c-4cbe-aa12-27d84e6f03a6","owner":[],"postedDate":"March 11th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-02-19T04:38:38+00:00","versionOfRecord":[],"versionCreatedAt":"2024-03-11 19:15:04","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-3956706","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-3956706","identity":"rs-3956706","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}