A systematic review of risk factors for neonatal mortality in Adolescent Mother’s in Sub Saharan Africa
Identifieur interne : 000806 ( Pmc/Corpus ); précédent : 000805; suivant : 000807A systematic review of risk factors for neonatal mortality in Adolescent Mother’s in Sub Saharan Africa
Auteurs : Astha Ramaiya ; Ligia Kiss ; Paula Baraitser ; Godfrey Mbaruku ; Zoe HildonSource :
- BMC Research Notes [ 1756-0500 ] ; 2014.
Abstract
Worldwide, approximately 14 million mothers aged 15 – 19 years give birth annually. The number of teenage births in Sub Saharan Africa (SSA) is particularly high with an estimated 50% of mothers under the age of 20. Adolescent mothers have a significantly higher risk of neonatal mortality in comparison to adults. The objective of this review was to compare perinatal/neonatal mortality in Sub Saharan Africa and it’s associated risk factors between adolescents and adults.
We systematically searched six databases to determine risk factors for perinatal/neonatal mortality, and pregnancy outcomes, between adolescent and adults in SSA. Article’s quality was assessed and synthesized as a narrative. Being single and having a single parent household is more prevalent amongst adolescents than adults. Nearly
Inter-generational support for single mothers in SSA communities appears essential in preventing both early pregnancies and ensuring healthy outcomes when they occur during adolescence. Future studies should test related hypothesis and seek to unpack the processes that underpin the relationships between being single and other risk indicators for neonatal mortality in young mothers. Current policy initiatives should account for the context of single African women’s lives, low opportunity, status and little access to supportive relationships, or practical help.
The online version of this article (doi:10.1186/1756-0500-7-750) contains supplementary material, which is available to authorized users.
Url:
DOI: 10.1186/1756-0500-7-750
PubMed: 25338679
PubMed Central: 4216370
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PMC:4216370Le document en format XML
<record><TEI><teiHeader><fileDesc><titleStmt><title xml:lang="en">A systematic review of risk factors for neonatal mortality in Adolescent Mother’s in Sub Saharan Africa</title><author><name sortKey="Ramaiya, Astha" sort="Ramaiya, Astha" uniqKey="Ramaiya A" first="Astha" last="Ramaiya">Astha Ramaiya</name><affiliation><nlm:aff id="Aff1">Ifakara Health Institute, Dar-Es-Salaam, Tanzania</nlm:aff></affiliation><affiliation><nlm:aff id="Aff2">Department of Community Health and Prevention, Drexel University, 1121 N Barrett Lane, Newark, DE 19701 USA</nlm:aff></affiliation></author><author><name sortKey="Kiss, Ligia" sort="Kiss, Ligia" uniqKey="Kiss L" first="Ligia" last="Kiss">Ligia Kiss</name><affiliation><nlm:aff id="Aff3">London School of Hygiene and Tropical Medicine, London, UK</nlm:aff></affiliation></author><author><name sortKey="Baraitser, Paula" sort="Baraitser, Paula" uniqKey="Baraitser P" first="Paula" last="Baraitser">Paula Baraitser</name><affiliation><nlm:aff id="Aff4">Kings College Hospital NHS Foundation Trust, London, UK</nlm:aff></affiliation></author><author><name sortKey="Mbaruku, Godfrey" sort="Mbaruku, Godfrey" uniqKey="Mbaruku G" first="Godfrey" last="Mbaruku">Godfrey Mbaruku</name><affiliation><nlm:aff id="Aff1">Ifakara Health Institute, Dar-Es-Salaam, Tanzania</nlm:aff></affiliation></author><author><name sortKey="Hildon, Zoe" sort="Hildon, Zoe" uniqKey="Hildon Z" first="Zoe" last="Hildon">Zoe Hildon</name><affiliation><nlm:aff id="Aff3">London School of Hygiene and Tropical Medicine, London, UK</nlm:aff></affiliation><affiliation><nlm:aff id="Aff5">National University Singapore, Cheng San, Singapore</nlm:aff></affiliation></author></titleStmt><publicationStmt><idno type="wicri:source">PMC</idno><idno type="pmid">25338679</idno><idno type="pmc">4216370</idno><idno type="url">http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4216370</idno><idno type="RBID">PMC:4216370</idno><idno type="doi">10.1186/1756-0500-7-750</idno><date when="2014">2014</date><idno type="wicri:Area/Pmc/Corpus">000806</idno><idno type="wicri:explorRef" wicri:stream="Pmc" wicri:step="Corpus" wicri:corpus="PMC">000806</idno></publicationStmt><sourceDesc><biblStruct><analytic><title xml:lang="en" level="a" type="main">A systematic review of risk factors for neonatal mortality in Adolescent Mother’s in Sub Saharan Africa</title><author><name sortKey="Ramaiya, Astha" sort="Ramaiya, Astha" uniqKey="Ramaiya A" first="Astha" last="Ramaiya">Astha Ramaiya</name><affiliation><nlm:aff id="Aff1">Ifakara Health Institute, Dar-Es-Salaam, Tanzania</nlm:aff></affiliation><affiliation><nlm:aff id="Aff2">Department of Community Health and Prevention, Drexel University, 1121 N Barrett Lane, Newark, DE 19701 USA</nlm:aff></affiliation></author><author><name sortKey="Kiss, Ligia" sort="Kiss, Ligia" uniqKey="Kiss L" first="Ligia" last="Kiss">Ligia Kiss</name><affiliation><nlm:aff id="Aff3">London School of Hygiene and Tropical Medicine, London, UK</nlm:aff></affiliation></author><author><name sortKey="Baraitser, Paula" sort="Baraitser, Paula" uniqKey="Baraitser P" first="Paula" last="Baraitser">Paula Baraitser</name><affiliation><nlm:aff id="Aff4">Kings College Hospital NHS Foundation Trust, London, UK</nlm:aff></affiliation></author><author><name sortKey="Mbaruku, Godfrey" sort="Mbaruku, Godfrey" uniqKey="Mbaruku G" first="Godfrey" last="Mbaruku">Godfrey Mbaruku</name><affiliation><nlm:aff id="Aff1">Ifakara Health Institute, Dar-Es-Salaam, Tanzania</nlm:aff></affiliation></author><author><name sortKey="Hildon, Zoe" sort="Hildon, Zoe" uniqKey="Hildon Z" first="Zoe" last="Hildon">Zoe Hildon</name><affiliation><nlm:aff id="Aff3">London School of Hygiene and Tropical Medicine, London, UK</nlm:aff></affiliation><affiliation><nlm:aff id="Aff5">National University Singapore, Cheng San, Singapore</nlm:aff></affiliation></author></analytic><series><title level="j">BMC Research Notes</title><idno type="eISSN">1756-0500</idno><imprint><date when="2014">2014</date></imprint></series></biblStruct></sourceDesc></fileDesc><profileDesc><textClass></textClass></profileDesc></teiHeader><front><div type="abstract" xml:lang="en"><sec><title>Background</title><p>Worldwide, approximately 14 million mothers aged 15 – 19 years give birth annually. The number of teenage births in Sub Saharan Africa (SSA) is particularly high with an estimated 50% of mothers under the age of 20. Adolescent mothers have a significantly higher risk of neonatal mortality in comparison to adults. The objective of this review was to compare perinatal/neonatal mortality in Sub Saharan Africa and it’s associated risk factors between adolescents and adults.</p></sec><sec><title>Results</title><p>We systematically searched six databases to determine risk factors for perinatal/neonatal mortality, and pregnancy outcomes, between adolescent and adults in SSA. Article’s quality was assessed and synthesized as a narrative. Being single and having a single parent household is more prevalent amongst adolescents than adults. Nearly <italic>all</italic> the adolescent mothers (97%) were raised in single parent households. These single life factors could be interconnected and catalyze other risky behaviors. Accordingly, having co-morbidities such as Sexually Transmitted Infections, or not going to school was more prevalent in younger mothers.</p></sec><sec><title>Conclusions</title><p>Inter-generational support for single mothers in SSA communities appears essential in preventing both early pregnancies and ensuring healthy outcomes when they occur during adolescence. Future studies should test related hypothesis and seek to unpack the processes that underpin the relationships between being single and other risk indicators for neonatal mortality in young mothers. Current policy initiatives should account for the context of single African women’s lives, low opportunity, status and little access to supportive relationships, or practical help.</p></sec><sec><title>Electronic supplementary material</title><p>The online version of this article (doi:10.1186/1756-0500-7-750) contains supplementary material, which is available to authorized users.</p></sec></div></front><back><div1 type="bibliography"><listBibl><biblStruct><analytic><author><name sortKey="Engmann, C" uniqKey="Engmann C">C Engmann</name></author></analytic></biblStruct><biblStruct></biblStruct><biblStruct></biblStruct><biblStruct><analytic><author><name sortKey="Rajaratnam, Jk" uniqKey="Rajaratnam J">JK Rajaratnam</name></author><author><name sortKey="Marcus, Jr" uniqKey="Marcus J">JR Marcus</name></author><author><name sortKey="Flaxman, Ad" uniqKey="Flaxman A">AD Flaxman</name></author><author><name sortKey="Wang, H" uniqKey="Wang H">H Wang</name></author><author><name sortKey="Levin 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<front><journal-meta><journal-id journal-id-type="nlm-ta">BMC Res Notes</journal-id><journal-id journal-id-type="iso-abbrev">BMC Res Notes</journal-id><journal-title-group><journal-title>BMC Research Notes</journal-title></journal-title-group><issn pub-type="epub">1756-0500</issn><publisher><publisher-name>BioMed Central</publisher-name><publisher-loc>London</publisher-loc></publisher></journal-meta><article-meta><article-id pub-id-type="pmid">25338679</article-id><article-id pub-id-type="pmc">4216370</article-id><article-id pub-id-type="publisher-id">3272</article-id><article-id pub-id-type="doi">10.1186/1756-0500-7-750</article-id><article-categories><subj-group subj-group-type="heading"><subject>Research Article</subject></subj-group></article-categories><title-group><article-title>A systematic review of risk factors for neonatal mortality in Adolescent Mother’s in Sub Saharan Africa</article-title></title-group><contrib-group><contrib contrib-type="author" corresp="yes"><name><surname>Ramaiya</surname><given-names>Astha</given-names></name><address><email>aramaiya@ihi.or.tz</email></address><xref ref-type="aff" rid="Aff1"></xref><xref ref-type="aff" rid="Aff2"></xref></contrib><contrib contrib-type="author"><name><surname>Kiss</surname><given-names>Ligia</given-names></name><address><email>Ligia.Kiss@lshtm.ac.uk</email></address><xref ref-type="aff" rid="Aff3"></xref></contrib><contrib contrib-type="author"><name><surname>Baraitser</surname><given-names>Paula</given-names></name><address><email>paula_baraitser@mac.com</email></address><xref ref-type="aff" rid="Aff4"></xref></contrib><contrib contrib-type="author"><name><surname>Mbaruku</surname><given-names>Godfrey</given-names></name><address><email>gmbaruku@ihi.or.tz</email></address><xref ref-type="aff" rid="Aff1"></xref></contrib><contrib contrib-type="author"><name><surname>Hildon</surname><given-names>Zoe</given-names></name><address><email>zoe_hildon@nuhs.edu.sg</email></address><xref ref-type="aff" rid="Aff3"></xref><xref ref-type="aff" rid="Aff5"></xref></contrib><aff id="Aff1"><label></label>Ifakara Health Institute, Dar-Es-Salaam, Tanzania</aff><aff id="Aff2"><label></label>Department of Community Health and Prevention, Drexel University, 1121 N Barrett Lane, Newark, DE 19701 USA</aff><aff id="Aff3"><label></label>London School of Hygiene and Tropical Medicine, London, UK</aff><aff id="Aff4"><label></label>Kings College Hospital NHS Foundation Trust, London, UK</aff><aff id="Aff5"><label></label>National University Singapore, Cheng San, Singapore</aff></contrib-group><pub-date pub-type="epub"><day>23</day><month>10</month><year>2014</year></pub-date><pub-date pub-type="pmc-release"><day>23</day><month>10</month><year>2014</year></pub-date><pub-date pub-type="collection"><year>2014</year></pub-date><volume>7</volume><elocation-id>750</elocation-id><history><date date-type="received"><day>10</day><month>9</month><year>2013</year></date><date date-type="accepted"><day>14</day><month>10</month><year>2014</year></date></history><permissions><copyright-statement>© Ramaiya et al.; licensee BioMed Central Ltd. 2014</copyright-statement><license license-type="open-access"><license-p>This article is published under license to BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (<ext-link ext-link-type="uri" xlink:href="http://creativecommons.org/licenses/by/2.0">http://creativecommons.org/licenses/by/2.0</ext-link>), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly credited. The Creative Commons Public Domain Dedication waiver (<ext-link ext-link-type="uri" xlink:href="http://creativecommons.org/publicdomain/zero/1.0/">http://creativecommons.org/publicdomain/zero/1.0/</ext-link>) applies to the data made available in this article, unless otherwise stated.</license-p></license></permissions><abstract id="Abs1"><sec><title>Background</title><p>Worldwide, approximately 14 million mothers aged 15 – 19 years give birth annually. The number of teenage births in Sub Saharan Africa (SSA) is particularly high with an estimated 50% of mothers under the age of 20. Adolescent mothers have a significantly higher risk of neonatal mortality in comparison to adults. The objective of this review was to compare perinatal/neonatal mortality in Sub Saharan Africa and it’s associated risk factors between adolescents and adults.</p></sec><sec><title>Results</title><p>We systematically searched six databases to determine risk factors for perinatal/neonatal mortality, and pregnancy outcomes, between adolescent and adults in SSA. Article’s quality was assessed and synthesized as a narrative. Being single and having a single parent household is more prevalent amongst adolescents than adults. Nearly <italic>all</italic> the adolescent mothers (97%) were raised in single parent households. These single life factors could be interconnected and catalyze other risky behaviors. Accordingly, having co-morbidities such as Sexually Transmitted Infections, or not going to school was more prevalent in younger mothers.</p></sec><sec><title>Conclusions</title><p>Inter-generational support for single mothers in SSA communities appears essential in preventing both early pregnancies and ensuring healthy outcomes when they occur during adolescence. Future studies should test related hypothesis and seek to unpack the processes that underpin the relationships between being single and other risk indicators for neonatal mortality in young mothers. Current policy initiatives should account for the context of single African women’s lives, low opportunity, status and little access to supportive relationships, or practical help.</p></sec><sec><title>Electronic supplementary material</title><p>The online version of this article (doi:10.1186/1756-0500-7-750) contains supplementary material, which is available to authorized users.</p></sec></abstract><kwd-group xml:lang="en"><title>Keywords</title><kwd>Sub Saharan Africa</kwd><kwd>Neonatal mortality</kwd><kwd>Adolescent pregnancy</kwd><kwd>Adult pregnancy</kwd><kwd>Single</kwd><kwd>Risk factors</kwd></kwd-group><custom-meta-group><custom-meta><meta-name>issue-copyright-statement</meta-name><meta-value>© The Author(s) 2014</meta-value></custom-meta></custom-meta-group></article-meta></front><body><sec id="Sec1"><title>Background</title><p>Forty one percent of all under five childhood deaths occur during the neonatal period (from birth to day 27). Reducing these deaths is one element of millennium development goal 4, which sets a target of reducing child mortality by two thirds [<xref ref-type="bibr" rid="CR1">1</xref>–<xref ref-type="bibr" rid="CR3">3</xref>]. Although, there has been an overall decline; this target is currently met by only 25% countries worldwide [<xref ref-type="bibr" rid="CR4">4</xref>].</p><p>The top five causes of neonatal mortality worldwide are prematurity and low birth weight (LBW) (29%), neonatal infections (25%), birth asphyxia and birth trauma (23%), congenital anomalies (8%), neonatal tetanus (2%) and diarrhoeal disease (2%) [<xref ref-type="bibr" rid="CR2">2</xref>].</p><p>Neonatal mortality is related to maternal age with young women having a higher risk of infant mortality (Additional file <xref rid="MOESM1" ref-type="media">1</xref>: Appendix 1). Worldwide, approximately 14 million adolescents aged 15 – 19 years give birth annually. Sixteen percent of young adults reside in SSA with a fertility rate of 112.84/1000 in comparison to 40.50/1000 in older women [<xref ref-type="bibr" rid="CR5">5</xref>, <xref ref-type="bibr" rid="CR6">6</xref>]. Fifty percent of births in SSA are to mothers <20 years of age [<xref ref-type="bibr" rid="CR5">5</xref>, <xref ref-type="bibr" rid="CR7">7</xref>]. Mothers <15, 16–17 years and 18–19 years have a 55%, 19% and 6% higher risk of neonatal mortality respectively in comparison to mothers ≥20 years [<xref ref-type="bibr" rid="CR8">8</xref>].</p><p>Limited research has been conducted on the risk factors for neonatal mortality among young mothers in comparison with their older peers in SSA. A systematic review was conducted to determine the relationship between neonatal mortality and maternal age in SSA, focusing on indicators of socio-economic deprivation and lack of access to obstetric care.</p></sec><sec id="Sec2" sec-type="methods"><title>Methods</title><p>Focusing on quantitative data measuring neonatal mortality between adolescents <20 years and mothers older than 20 years in SSA, we reviewed literature to determine risk of neonatal mortality stratified by maternal age. There was no existing prior review protocol.Studies were systematically screened from PubMed, Cochrane database, Adolec, Popline, Google Scholar and Global Health Archive on adolescent and adult pregnancy in SSA until February 2013 (Figure <xref rid="Fig1" ref-type="fig">1</xref>).<fig id="Fig1"><label>Figure 1</label><caption><p><bold>Flow chart for literature screening & selection.</bold></p></caption><graphic xlink:href="13104_2013_3272_Fig1_HTML" id="d30e386"></graphic></fig></p><p>The studies were selected based on the main inclusion criteria: Any quantitative study measuring the association between risk factors for perinatal/neonatal mortality (PNM) and pregnancy outcome between adolescent and adults in SSA either comparing directly or as stratified groups. Due to the changing African developing context, we excluded publications prior to 1994. Also excluded were analyses that focused on older mothers, because neonatal mortality risk increases in mothers over 35 years of age, suggesting a potentially different set of risk indicators in this age category (Additional file <xref rid="MOESM1" ref-type="media">1</xref>: Appendix 3) [<xref ref-type="bibr" rid="CR9">9</xref>–<xref ref-type="bibr" rid="CR12">12</xref>].</p><p>Articles were graded using the Quality Assessment Tool for Quantitative Studies [<xref ref-type="bibr" rid="CR13">13</xref>].</p><p>Randomized control trials and cohort studies were viewed as providing more robust findings, although cross-sectional studies were also examined. Risk factors for neonatal mortality were significant if p ≤ 0.05 and 95% Confidence Interval (95% CI) ≠ 0 were met. Articles were graded on the following scale: strong +++, moderate ++ and weak + by AR.</p><p>In order to calculate perinatal/neonatal mortality ratio (PNMR), data was extracted for adolescents and adults from individual studies and calculated using the formula: PNM cases/total number of adolescent or adult population*1000. A proportion of the rates was reported in the results.</p><p>Prevalence rate of risk factors was calculated through the extraction of data from individual studies, using the formula: total cases/total population of adolescent or adult population. If there were multiple studies reporting the same risk factor, the cases and population was totaled stratified by adolescent and adults. A proportion was determined for adolescents and adults in addition to the 95% CI and then a z score was calculated to determine the p-value. Some studies reported odds ratios (OR) and hazard ratios (HR); these were reported to provide additional statistics.</p><p>We report a narrative review comparing perinatal/neonatal mortality in SSA and it’s associated risk factors between mothers 15–19 years and 20–35 years of age.</p></sec><sec id="Sec3" sec-type="results"><title>Results</title><p>A total of seventeen studies were included in the analysis (Additional file <xref rid="MOESM1" ref-type="media">1</xref>: Appendix 2). Forty one percent directly compared outcomes between adolescents and adults and another 59% stratified neonatal mortality or risk factor by age. Geographically, 35% were set in West Africa, 12% in Central Africa, 29% in East Africa, 12% in Southern Africa and 12% in SSA. Twenty nine percent of the studies were strong, 12% moderate and 47% rated weak (Table <xref rid="Tab1" ref-type="table">1</xref>).<table-wrap id="Tab1"><label>Table 1</label><caption><p><bold>Comparison of risk factors for neonatal mortality between adolescents and adults</bold></p></caption><table frame="hsides" rules="groups"><thead><tr><th>Factors contribution to neonatal mortality</th><th>Measure</th><th>Adults (95%CI)</th><th>Adolescents (95%CI)</th><th>P-value</th><th>Reference & Study quality**</th></tr></thead><tbody><tr><td rowspan="3">Perinatal/Neonatal Mortality</td><td>PNMR (/1000 live births)</td><td>23.47 (22.6 – 24.4)^</td><td>39.68 (37.3 – 42.1)^</td><td>≤0.01</td><td>14<sup>+++</sup>, 15<sup>+++</sup>,16<sup>+</sup>, 17<sup>+</sup>,18<sup>+++</sup>,19<sup>+</sup>,20<sup>+++</sup>,21<sup>+</sup>,22<sup>+</sup>,24<sup>+++</sup>,25<sup>+++</sup></td></tr><tr><td>Hazard Ratio</td><td>1</td><td>3.05 (1.3 – 6.81) 1.12 (0.92 – 1.36)</td><td></td><td>17<sup>+</sup> 9<sup>++</sup></td></tr><tr><td>Odds Ratio</td><td>1</td><td>1.3 (0.3 – 6.4)</td><td></td><td>23<sup>++</sup></td></tr><tr><td rowspan="2">Limited schooling (no/primary education)</td><td>Prevalence (%)</td><td>40.29 (35.45 – 45.13)^</td><td>75.93 (71.84 – 80.02)^</td><td>≤0.01</td><td>26<sup>+++</sup>, 28<sup>++</sup></td></tr><tr><td>Odds Ratio</td><td>1</td><td>4.9 (3.14 – 7.68)</td><td></td><td>28<sup>++</sup></td></tr><tr><td rowspan="2">Single</td><td>Prevalence (%)</td><td>18.35 (14.52 – 22.16)^</td><td>47.65 (43.19 – 52.11)^</td><td>≤0.01</td><td>26<sup>+++</sup>,28<sup>++</sup>,27<sup>+++</sup></td></tr><tr><td>Odds Ratio</td><td>1</td><td>2.78 (1.65 – 4.70)</td><td></td><td>28<sup>++</sup></td></tr><tr><td rowspan="2">≤2 - 3 ANC visits</td><td>Prevalence (%)</td><td>21.51 (19.35 – 23.67)^</td><td>22.16 (19.24 – 25.08)^</td><td>0.38</td><td>25<sup>+++</sup>, 26<sup>+++</sup>, 28<sup>++</sup>, 29<sup>++</sup>,</td></tr><tr><td>OR</td><td>1.00</td><td>2.8 <italic>(1.2 - 6.5)</italic></td><td></td><td>29<sup>++</sup></td></tr><tr><td rowspan="2">Partner’s limited schooling (no/primary education)</td><td>Prevalence (%)</td><td>35.96 (30.08 – 41.92)</td><td>52.20 (45.68 – 58.72)</td><td>≤0.01</td><td>28<sup>++</sup></td></tr><tr><td>OR</td><td>1.00</td><td>1.95 (1.23 – 3.08)</td><td></td><td>28<sup>++</sup></td></tr><tr><td>Parent’s not married</td><td>Prevalence (%)</td><td>38.54 (32.95 – 44.13)</td><td>97.34 (95.59 – 91.11)</td><td>≤0.01</td><td>28<sup>++</sup></td></tr><tr><td>First pregnancy/primiparous</td><td>Prevalence</td><td>36.99 (27.7 – 46.28)^</td><td>79.82 (73.64 – 86.00)^</td><td>≤0.01</td><td>26<sup>+++</sup>,27<sup>+++</sup>,</td></tr><tr><td rowspan="2">Preterm delivery (<35-38 weeks)</td><td>Prevalence (%)</td><td>20.87 (19.14 – 22.60)^</td><td>44.04 (38.51 – 49.57)^</td><td>≤0.01</td><td>15<sup>+++</sup>, 17<sup>+</sup>, 29<sup>++</sup></td></tr><tr><td>OR</td><td>1.00</td><td>1.3 (0.6 – 2.6)</td><td></td><td>29<sup>++</sup></td></tr><tr><td rowspan="2">Maternal co-morbidity*</td><td>Prevalence (%)</td><td>1.70 (1.0 – 2.42)^</td><td>7.60 (4.27 – 10.93)^</td><td>≤0.01</td><td>26<sup>+++</sup>, 27<sup>+++</sup>, 29<sup>++</sup></td></tr><tr><td>OR</td><td>1.00</td><td>5.9 (1.7 – 19.9)</td><td></td><td></td></tr><tr><td>Pregnancy/labour complications<sup>#</sup></td><td>Prevalence (%)</td><td>19.02 (13.95 – 24.05)^</td><td>29.82 (22.75 – 36.85)^</td><td>0.02</td><td>26<sup>+++</sup>, 27<sup>+++</sup>,</td></tr><tr><td rowspan="2">Very/ Low Birth Weight</td><td>Prevalence (%)</td><td>13.49 (12.26 – 14.72)^</td><td>23.05 (19.95 – 26.15)^</td><td>≤0.01</td><td>15<sup>+++</sup>, 17<sup>+</sup>, 25<sup>+++</sup>,27<sup>+++</sup>, 29<sup>++</sup></td></tr><tr><td>OR</td><td>1.00</td><td>2.9 <italic>(1.5 - 5.6)</italic></td><td></td><td>29<sup>++</sup></td></tr></tbody></table><table-wrap-foot><p>*Maternal co-morbidities: HIV, Malaria, Syphilis, TB, hyptertension, maternal infection.</p><p>#Pregnancy/labour complications: pre-eclamptic toxemia, eclampsia, premature rupture of membrane, ante-partum hemorrhage/post partum hemorrhage and obstructed labour.</p><p>**References listed following the order in which statistics appear, ratings are: +++strong; ++moderate, +weak;</p><p>^Average of studies.</p></table-wrap-foot></table-wrap></p><p>Thirteen studies reported PNM across age categories [<xref ref-type="bibr" rid="CR9">9</xref>, <xref ref-type="bibr" rid="CR14">14</xref>–<xref ref-type="bibr" rid="CR25">25</xref>]. The PNMR between adolescents and adults was 39.68 deaths/1000 live births and 23.47 deaths/1000 live births respectively (p ≤ 0.01) [<xref ref-type="bibr" rid="CR9">9</xref>, <xref ref-type="bibr" rid="CR14">14</xref>–<xref ref-type="bibr" rid="CR25">25</xref>]. Three studies had OR (1.3 (95% CI: 0.3 – 6.4)) and HR (1.12 (95% CI: 0.92 – 1.36) & 3.05 (1.3 – 6.81)) reported [<xref ref-type="bibr" rid="CR9">9</xref>, <xref ref-type="bibr" rid="CR17">17</xref>, <xref ref-type="bibr" rid="CR23">23</xref>]. Although all studies indicated a higher odds and prevalence of neonatal mortality amongst adolescents, there were two studies which showed non significant findings [<xref ref-type="bibr" rid="CR9">9</xref>, <xref ref-type="bibr" rid="CR23">23</xref>].</p><p>Being single and having a single parent household (not living with partner/not married) was 2.6 and 2.5 times more prevalent amongst younger mothers than adults (p ≤ 0.01) respectively [<xref ref-type="bibr" rid="CR26">26</xref>–<xref ref-type="bibr" rid="CR28">28</xref>]. Strikingly, nearly <italic>all</italic> the adolescent mothers (97%) had grown up in single parent households. These single life factors appear to be key interrelated risk indicators that catalyze other risky behaviors. For instance, not going to school was 1.89 times more prevalent amongst younger mothers (p ≤ 0.01) [<xref ref-type="bibr" rid="CR26">26</xref>, <xref ref-type="bibr" rid="CR28">28</xref>]; maternal comorbidity (HIV, syphilis, malaria, TB etc.) was a sizeable 4.5 times more likely in adolescents’, who may have multiple sexual partners, and risky lifestyles that expose them to transmittable diseases.</p><p>Although single status was quite likely for young mothers (47%), for those who were in relationships, partners education was also limited (52%) compared to older couples (36%, p ≤ 0.01) [<xref ref-type="bibr" rid="CR28">28</xref>]. The socio-economic disadvantages of these circumstances appear to cascade into the birthing experience and physical outcomes of younger mother and their children.</p><p>Moreover, adolescents were 2.2 times more likely to give birth to their first child, compared to their adult counterparts (p ≤ 0.01) [<xref ref-type="bibr" rid="CR26">26</xref>, <xref ref-type="bibr" rid="CR27">27</xref>]. It is therefore unsurprising that they are also 1.6 times more likely to face pregnancy and labour complications (pre-eclamptic toxemia, eclampsia, premature rupture of membrane, ante-partum hemorrhage/post partum hemorrhage and obstruction) (p ≤ 0.01) [<xref ref-type="bibr" rid="CR26">26</xref>, <xref ref-type="bibr" rid="CR27">27</xref>, <xref ref-type="bibr" rid="CR29">29</xref>]. Prevalence of premature delivery between adolescents and adults was 44% and 21% (p ≤ 0.01) respectively [<xref ref-type="bibr" rid="CR15">15</xref>, <xref ref-type="bibr" rid="CR17">17</xref>, <xref ref-type="bibr" rid="CR29">29</xref>], while the young mothers also had a 1.7 times greater chance of having a LBW neonate (p ≤ 0.01) [<xref ref-type="bibr" rid="CR15">15</xref>, <xref ref-type="bibr" rid="CR17">17</xref>, <xref ref-type="bibr" rid="CR25">25</xref>, <xref ref-type="bibr" rid="CR27">27</xref>, <xref ref-type="bibr" rid="CR29">29</xref>].</p></sec><sec id="Sec4" sec-type="discussion"><title>Discussion</title><p>Our review shows that younger mothers in SSA have increased social and biological risk factors associated with neonatal mortality. Although, analyses were limited by the heterogeneity of the study contexts, and some quality issues, this is the first analysis to pool studies and consider risk by maternal age. Moreover, given the diversity of included studies, we have found a remarkable consistency in data highlighting significant vulnerabilities of adolescent mothers.</p><p>Within SSA, the proportion of young women getting married has decreased, but the age of their first sexual encounter has stayed the same [<xref ref-type="bibr" rid="CR30">30</xref>]. Reasons for this early sexual initiation include: lower socioeconomic status, lack of sexual education, friends sexual behavior, parental marital status and media/pornography access [<xref ref-type="bibr" rid="CR31">31</xref>]. Within a developed country setting, father’s absence has shown to increase early sexual activity and consequently adolescent pregnancy [<xref ref-type="bibr" rid="CR32">32</xref>], our study suggests that the same may be true in the developing context.</p><p>It has been demonstrated that in SSA (Ethiopia, Kenya, Malawi, Tanzania and Zimbabwe), it is not uncommon to become a single mother (total likelihood ranging from 30% - 68.8%) [<xref ref-type="bibr" rid="CR33">33</xref>]. Moreover, the term ‘single mother family’ is viewed interchangeably with those households being particularly vulnerable [<xref ref-type="bibr" rid="CR33">33</xref>]. For instance, the lack of family structure leads to worse child outcomes, intergenerational transmission of lower economic mobility, racial inequality and gender inequality [<xref ref-type="bibr" rid="CR33">33</xref>, <xref ref-type="bibr" rid="CR34">34</xref>]. Our data appears to confirm that being a lone female parent will predispose daughters to follow the same circumstances, entrenching gendered vulnerabilities.</p><p>Nevertheless, our data did not cover all bases, and we would argue that overriding parental absence is the role of positive parental engagement, and appropriate handling of teenage pregnancies. Cultural understanding of this issue in SSA may lead to angry parenting, partners and community reactions. We know from qualitative studies, such as this one in Uganda [<xref ref-type="bibr" rid="CR35">35</xref>], that teenage mothers may experiences a backlash to their circumstances, precisely because they are unmarried and dependent. As one teenage girl put it – “One may have a very harsh parent, myself I have a very harsh father. I fear that if I tell him he can beat me up. … in the community there are some aged women who recognize the pregnancy and talk about it” [<xref ref-type="bibr" rid="CR35">35</xref>]. This study also mentioned that adolescents face difficulties in accessing and utilizing health services due to socioeconomic burden, stigmatization, lack of privacy and negative attitude from health staff.</p><p>Family support and return to school after childbearing is a protective factor towards good maternal and neonatal outcomes in teenagers [<xref ref-type="bibr" rid="CR36">36</xref>, <xref ref-type="bibr" rid="CR37">37</xref>]. For example a study in South Africa has shown that if parent’s of the adolescent mother committed to taking care of the infant, adolescents would return to school and have a delay in the birth of the next child [<xref ref-type="bibr" rid="CR37">37</xref>]. Yet, young mothers in SSA, as demonstrated in this report, are likely to have little partner support, or extended family to depend on, since they come from a single parent home.</p><p>We recommend that future studies should test related hypothesis and seek to unpack the processes that underpin the relationships between single status and other risk indicators for neonatal mortality in young SSA mothers. Current policy initiatives should consider the context of single African women’s lives, low opportunity, status and little access to supportive relationships, or practical help. For example, reinstating adolescent girls into school after the pregnancy increases health services utilization and reduces maternal co-morbidities, pregnancy complications and adverse neonatal outcomes.</p></sec><sec id="Sec5" sec-type="conclusions"><title>Conclusions</title><p>Overall, we have demonstrated that young mothers in these communities need to be recognized as having their own public health and intervention needs. Policy makers and health care providers need to account for family circumstances and make services more youth friendly and accessible. Crucially inter-generational education for single mothers in the community may stop the cycle of vulnerability of young women into early and/or risky pregnancies.</p><sec id="Sec6"><title>Availability of supporting data</title><p>The data set supporting the results of this article is included within the article (and its additional file).</p></sec></sec><sec sec-type="supplementary-material"><title>Electronic supplementary material</title><sec id="Sec7"><supplementary-material content-type="local-data" id="MOESM1"><media xlink:href="13104_2013_3272_MOESM1_ESM.docx"><caption><p>Additional file 1:
<bold>Appendix 1: Factors influencing neonatal mortality within literature.</bold><bold>Appendix 2.</bold> Review of adolescent and adult risk factors and strength of evidence. <bold>Appendix 3.</bold> Search Strategy. (DOCX 96 KB)</p></caption></media></supplementary-material></sec></sec></body><back><glossary><title>Abbreviations</title><def-list><def-list><def-item><term>95% CI</term><def><p>95% Confidence interval</p></def></def-item><def-item><term>ANC</term><def><p>Antenatal care</p></def></def-item><def-item><term>HR</term><def><p>Hazard ratio</p></def></def-item><def-item><term>LBW</term><def><p>Low birth weight</p></def></def-item><def-item><term>OR</term><def><p>Odds ratio</p></def></def-item><def-item><term>PNM</term><def><p>Perinatal neonatal mortality</p></def></def-item><def-item><term>PNMR</term><def><p>Perinatal neonatal mortality rate</p></def></def-item><def-item><term>SSA</term><def><p>Sub Saharan Africa.</p></def></def-item></def-list></def-list></glossary><fn-group><fn><p><bold>Competing interests</bold></p><p>None of the authors have any financial or non-financial competing interests to disclose. The manuscript has not been submitted elsewhere for patents and has not been accepted or published elsewhere.</p></fn><fn><p><bold>Authors’ contributions</bold></p><p>AR developed the outline and wrote the first draft of the manuscript as part of her thesis requirement. LK, GM, ZH aided in conceptualizing the manuscript. ZH aided in the synthesis and monitoring of data collection and data analysis. LK, GM and PB aided in the background information and review of the drafts. All the authors have reviewed the manuscript and approve the manuscript for submission.</p></fn></fn-group><ack><title>Acknowledgements</title><p>This systematic review was supported by Ifakara Health Institute to understand the risks of adolescent pregnancy. 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