Abstract
Background:
Globally, adolescent girls aged 15–19 years give birth to approximately 16 million children annually, accounting for 11% of all births. Low- and middle-income nations carry the burden of these births, with 95% happening in Africa, where maternal mortality rates continue to be high. In Sub-Saharan Africa, early marriages persist, with roughly half of women delivering before age 20.
Objectives:
This scoping review aimed to map evidence on the accessibility and barriers to maternal health services for adolescent girls in Sub-Saharan Africa.
Eligibility criteria:
Included studies were peer-reviewed articles published in English between 2014 and 2025, focusing on adolescent girls (10–19 years) and maternal health services in Sub-Saharan Africa.
Sources of evidence:
Literature searches were conducted in PubMed, Scopus, Web of Science, Directory of Open Access Journals and Google Scholar.
Charting methods:
The review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses 2020 Scoping Review extension guidelines. Data were extracted using a pre-designed template and analysed thematically. Results were synthesized narratively and presented in tables.
Results:
A total of 652 records were identified, with 26 articles included. Key findings indicate that financial constraints, stigma, geographical distance and restrictive policies are significant barriers to access. While most studies focused on accessibility, aspects of quality such as provider attitudes, adherence to guidelines and respectful care were less frequently and deeply explored, representing a significant evidence gap. Community-based programmes and youth-friendly services were identified as key facilitators. Unmarried adolescents and those with lower education levels faced compounded barriers.
Conclusion:
Given their reproductive health vulnerabilities, maternal health services targeting adolescents should be prioritized in Sub-Saharan Africa. Interventions must address both access barriers and critically improve service quality, including provider training in adolescent-sensitive care, though the current evidence base on quality-specific interventions is limited. Further research is needed to develop standardized metrics for quality care in this population.
Plain language summary
This research paper reviews studies on the challenges adolescent girls face in getting maternal healthcare in Sub-Saharan Africa, where teenage pregnancy rates are high. The review found that major barriers like high costs, long distances to clinics and harsh social stigma often prevent young mothers from seeking vital care before and after childbirth. While some services exist, the research shows that the specific quality of care offered to adolescents, such as respectful treatment by staff or care tailored to their needs, is not well understood or measured. The paper concludes that to truly help young mothers, efforts must not only make services easier to access by removing financial and geographical obstacles but must also seriously focus on improving how they are treated by healthcare systems, including training providers to be more supportive and understanding.
Keywords
Introduction
Worldwide, adolescent girls aged 15–19 give birth to approximately 16 million children annually, accounting for 11% of all births. 1 Low- and middle-income nations carry the burden of these births, with 95% happening in these regions, where maternal mortality rates continue to be high. 1 While adolescent fertility rates have declined since 1990, they remain persistently high in Sub-Saharan Africa, where early marriages continue, with approximately half of women delivering before age 20.2,3 Adolescent pregnancy is associated with increased risks of adverse outcomes, including premature birth, low birth weight, perinatal mortality, obstructed labour and maternal death. 1 However, there is ongoing debate about whether these risks are directly due to the biological immaturity of adolescent mothers or are influenced by socioeconomic marginalization and limited access to healthcare. 1
Attaining the Sustainable Development Goals, especially Goal 3, hinges on ensuring vulnerable women have equal access to quality maternal services, which is important for meeting the target of less than 70 maternal mortalities per 100,000 live births globally by 2030. 4 According to World Health Organization, Sub-Saharan Africa alone accounted for 70% of global adolescent maternal deaths in 2020, with an estimated 1000 deaths per 100,000 live births among adolescents. 5
Focusing on the Sub-Saharan Africa region, Uganda, Malawi, Zimbabwe, Zambia and the Democratic Republic of Congo, adolescents face substantial disparities in maternal healthcare access, making them exceptionally vulnerable. 3 Stigma and social judgement from families, communities and healthcare providers are well-established barriers that prevent adolescents from seeking care. 4 In some contexts, adolescents or their families may attempt to conceal a pregnancy due to this stigma, further delaying or preventing access to essential services. Furthermore, harmful cultural practices, such as early and forced marriage, traditional ‘cleansing’ rituals and gender-based power imbalances, significantly increase adolescents’ vulnerability to unintended pregnancy and restrict their autonomy in seeking healthcare. 2 It is also critical to note that a significant number of adolescent pregnancies, particularly among the youngest girls, are not the result of consensual activity. In many jurisdictions across Sub-Saharan Africa, including Zimbabwe and South Africa, sexual activity with a child below the age of consent is legally defined as statutory rape, as individuals in this age group are deemed unable to provide informed consent. This framing situates many early pregnancies squarely within the context of sexual abuse and coercion.
It is worth noting that interventions like mobile health (mHealth), defined as the use of mobile technologies such as smartphones and wearable devices to support and improve healthcare, have the potential to improve accessibility. However, the most vulnerable adolescents may still be unable to access healthcare due to a lack of access to technology. 8 Outreach programmes have also been shown to improve accessibility of maternal health services for adolescent girls in Sub-Saharan Africa. 2
In South Africa, adolescents account for a huge percentage of births, with a rate of 49 per 1000. 4 Unfortunately, maternal complications are the second leading cause of mortality among adolescent girls, showing the elevated risks of pregnancy and childbirth challenges in this age group. 4 Pregnant adolescents face significant obstacles in accessing healthcare, preventing their ability to get HIV testing, treatment and timely identification of possible adverse health complications. 4 Consequently, early antenatal care (ANC) is of urgent importance to prevent maternal sickness and death in these vulnerable communities. 4
In Zimbabwe, 21% of adolescents aged 15–19 get pregnant, with fertility rates around 120 per 1000 girls in rural areas and 70 per 1000 in urban areas. 6 This significant pattern places adolescent mothers at increased risk of negative effects on maternal and neonatal health outcomes. According to the National Adolescent Fertility Study, a substantial 58.4% of adolescent pregnancies in Zimbabwe are correlated to harmful cultural practices. 6 These procedures, including forced and early teenage marriage, traditional ‘cleaning wife’ pledging and HIV ‘cleansing’ rituals, increase adolescents’ vulnerability to unintended pregnancy. Given the high rates of adolescent pregnancy, maternal mortality and the significant barriers to accessing quality maternal health services in Sub-Saharan Africa, this scoping review was aimed at exploring the existing literature to identify gaps and inform future interventions. The specific objectives of the study were as follows.
To describe the socio-demographic characteristics of pregnant adolescent girls in Sub-Saharan Africa.
To determine the maternal health services that are offered to pregnant adolescents in Sub-Saharan Africa.
To identify barriers and facilitators to accessing maternal health services for pregnant adolescent girls in Sub-Saharan Africa.
To explore intervention access to maternal health services by pregnant girls in Sub-Saharan Africa.
Methods
Literature sources
A literature search was performed across five electronic databases: PubMed, Scopus, Web of Science, Directory of Open Access Journals and Google Scholar. These databases were selected to capture relevant results since they include journals that publish articles related to public health in general and adolescent maternal health services in particular. An information specialist was consulted to refine the search strategy. Literature from the reference lists of the retrieved articles was also used and included in the study.
The review searched and focused on studies that reported on adolescent maternal health services in Sub-Saharan Africa. Included were cross-sectional studies, cohort studies, randomized controlled trials and other quantification studies or qualification studies. The search was limited to articles published in English, which is a potential source of language bias acknowledged as a limitation.
Literature search
The review followed the guidelines outlined in the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA 2020) statement. A standard Boolean literature search strategy based on Population/Problem, Intervention, Comparison and Outcome (PICO) was performed across the databases.
The electronic sources were searched between January and February 2025 for articles published from 2014 to 2025. Only English-language publications were eligible. The researcher considered that articles older than 10 years might be outdated due to the dynamic nature of the field. Unpublished and non-peer-reviewed literature were excluded from the primary synthesis but consulted for reference purposes. The search employed a combination of relevant keywords and controlled vocabulary to ensure exhaustive coverage. The following search string was adopted: (‘maternal health services’ OR ‘reproductive health services’) AND (‘adolescent girls’ OR ‘teenage pregnancy’) AND (‘sub-Saharan Africa’) AND (‘accessibility’ OR ‘quality’). The literature search was conducted between January and February 2025. The searches were stored in the Zotero citation software. For the inclusion and exclusion criteria, see Table 1. Screening of titles, abstracts and full texts was conducted independently by two reviewers (first and second authors) using Covidence 2.0. Conflicts were resolved through discussion.
Inclusion and exclusion criteria.
Data extraction and synthesis
The Cochrane Data Extraction Template was used to extract data from each of the 26 included studies in Covidence 2.0. The data extraction tool was pilot-tested first, using five randomly selected articles from those included in the review. A descriptive literature analysis was done to extract data that answers the review objectives. The objective concerning service quality, data were extracted on reported themes such as provider attitudes, adherence to clinical guidelines, measures of respectful maternity care and patient satisfaction, where available. The synthesis of quantitative results involved extracting results and recommendations from similar studies and comparing them according to the context in which they were performed. Data from qualitative studies were classified and coded, and a coding framework was developed for this study. The resulting codes and their units of meaning were analysed by topic to obtain salient themes. Analysis was done using tables and themes that emerged from different literature. All relevant findings were then summarized in tabular form by topics that emerged.
Quality assessment
The reporting of this scoping review was conducted in accordance with the PRISMA extension for Scoping Reviews (PRISMA-ScR) checklist. 7 The primary aim of this tool was to measure the scientific quality and thoroughness of the scoping process. A completed PRISMA-ScR checklist is provided as a Supplemental File.
Results
A total of 652 literature sources from electronic databases were obtained, as shown in Figure 1. After excluding 410 duplicates, 242 records were screened by titles and abstracts, resulting in the exclusion of 213 records. Twenty-nine full-text articles were assessed for eligibility, and three sources were excluded due to the wrong setting (n = 2) and wrong population (n = 1). A total of 26 articles were included in the scoping review. This section categorizes themes that emerged from the literature. The most notable themes include socio-demographic characteristics of pregnant adolescent girls, maternal health services, factors affecting access and interventions. The findings are summarized in Tables 2 to 5.
Document review process.
Socio-demographic characteristics.
Maternal health services in Sub-Saharan Africa.
Factors affecting access to maternal health services.
Interventions to promote maternal health services.
Socio-demographic characteristics
Age range of adolescent pregnant girls
Ten of the 26 studies defined an adolescent as an individual aged 10–19 years. Six out of these ten studies pointed out that most adolescent pregnancies occur between 15 and 19 years. However, four studies6,8,9 highlighted that in some countries within Sub-Saharan Africa, like Zimbabwe, Lesotho and Malawi, there are documented instances where adolescents as young as 11 years fell pregnant and gave birth (Table 2). Given that children of this age are unable to legally or developmentally consent to sexual activity, most of these very early pregnancies must be understood as a result of sexual abuse and statutory rape. This issue is addressed further in the discussion.
Differences in maternal health outcomes within the age range 10–19 years
The scoping review found that while maternal health outcomes in Sub-Saharan Africa share common challenges across adolescence, significant variations exist based on age (Table 2). Contrary to the initial broad statement, six of the included studies2,6,12,13 argued that adolescent mothers between 10 and 14 years of age were at a substantially higher risk of complications during pregnancy and childbirth due to biological immaturity. They noted that common complications included obstructed labour, preeclampsia, postpartum haemorrhage, preterm births, higher maternal mortality rates, increased risk of HIV transmission, as well as social and psychological challenges. Nunu 16 and Singh 19 highlighted that the age range with the highest pregnancy rate was 16–19 years, but this group often faces different, though still serious, risks influenced more by socioeconomic than purely biological factors.
Financial barriers to accessing maternal health services
As presented in Table 2, 11 studies that reported on financial barriers10–20 indicated that a very high proportion (up to 90% in some studies, though this figure should be interpreted in the context of the specific study populations and may not be generalizable across Sub-Saharan Africa) of the adolescent girls who faced problems in accessing maternal health services were from poor families. This proportion was as high as 90% in some study populations (though this figure should be interpreted in context and may not be generalizable across Sub-Saharan Africa). These were largely from low- and middle-income countries as well as those in armed conflicts such as Zimbabwe, DRC and Rwanda. These studies also highlighted that about 76% of pregnant adolescents and their families from rural set-ups generally have low-income levels, which significantly impacts their access to healthcare, education and social services.
Level of education completed by pregnant adolescents
Eleven studies10–13,15,17,20–24 highlighted that level of education plays a crucial role in influencing adolescent pregnancies in Sub-Saharan Africa, impacting both the likelihood of pregnancy during adolescence and the health and social outcomes associated with it (Table 2). Ndayishimiye 15 argues that education, particularly for girls, is closely tied to a range of social, economic and health factors that affect adolescent pregnancy rates and outcomes in the region.
Correlation between education level and maternal health service utilization
Five of the 26 included studies10,11,15,17,25 found the correlation between education level and maternal health service utilization in Sub-Saharan Africa as strong and positive (Table 2), meaning that as a woman’s education level increases, she is more likely to utilize maternal health services.
Proportion of married versus unmarried pregnant adolescents
As shown in Table 2, 8 of the 26 included studies10–12,15,17,19,21,26 pointed out that the proportion of married versus unmarried pregnant adolescents in Sub-Saharan Africa varies across different countries and regions, but generally, married pregnant adolescents make up a larger proportion compared to unmarried pregnant adolescents. For instance, eight included studies reported that between 40% and 50% of girls in Sub-Saharan Africa are married before the age of 18. According to data from the United Nations Population Fund (UNFPA) and other international organizations, approximately 40%–50% of girls in Sub-Saharan Africa are married before the age of 18. 27 The data from UNFPA have been added to the introduction for context. 27
Impact of marital status on access to maternal health services
Four of the 26 included studies10,22,24,28 believed that the marital status of pregnant adolescent girls in Sub-Saharan Africa significantly influences their access to maternal health services (Table 2). They argued that marital status can affect not only the decision to seek care but also the quality of care received and health outcomes for both the mother and the child. These studies found that married adolescent girls had a higher likelihood of seeking maternal health services than their unmarried counterparts, potentially due to reduced stigma and greater financial or social support from a partner’s family.
Living with parents, partners or alone
Living arrangements were not well covered in the included studies. However, as presented in Table 2, two studies17,21 did mention, though not in detail, about living arrangements of adolescent girls (whether living with parents, partners or alone), and highlighted that this can significantly impact their maternal health-seeking behaviour. The studies seemed to suggest that these arrangements affect decision-making, access to resources, social support and the overall empowerment of adolescent girls, all of which influence whether they seek or utilize maternal health services such as ANC and postnatal care (PNC).
Maternal health services in Sub-Saharan Africa
Antenatal care
All the 26 included studies (Table 3) pointed out that maternal health services in Sub-Saharan Africa were diverse and somehow tailored to meet the specific needs of women during pregnancy, childbirth and the postnatal period. However, according to Althabe, 1 the availability and quality of these services can vary significantly between urban and rural areas, as well as across different countries. ANC is one of the essential services available for monitoring the health of pregnant women and detecting any potential complications early.11,12,28 According to Guetterman et al., 8 it involves regular visits to healthcare facilities by pregnant women to monitor maternal and foetal health, blood pressure, blood tests, nutrition counselling, as well as iron and folate supplements, typically starting early in pregnancy and continuing throughout. As presented in Table 3, six studies2,10,11,13,15,17 argued that the provision of skilled care during labour and delivery is crucial for reducing maternal and infant mortality. For example, studies by Banke-Thomas et al. 2 and Nambile Cumber et al. 13 emphasized that the presence of a skilled birth attendant was a key factor in preventing obstetric complications.
Postnatal care
As shown in Table 3, 11 of the 26 studies10–13,15,17,20–22,24,26 pointed out that PNC is critical to ensure the health and well-being of both the mother and the baby in the weeks following childbirth. PNC is essential for checking the mother’s physical recovery, offering breastfeeding support, monitoring the newborn’s health, providing immunizations, offering contraception counselling and addressing mental health issues like postpartum depression.13,17
Family planning services
According to 5 of the 26 included studies,11,15,17,21,22 family planning is an integral part of maternal health, helping women and couples to space pregnancies, plan for healthier families and reduce maternal and child mortality (Table 3). According to Helleringer, 29 services include access to a variety of contraceptive options and information. 29
HIV, STIs and malaria screening services
As presented in Table 3, six of the studies11,12,15,19,21,22 pointed out that Sub-Saharan Africa has a high burden of HIV and malaria. Routine HIV screening during pregnancy to prevent mother-to-child transmission (PMTCT), provision of insecticide-treated nets (ITNs) and intermittent preventive treatment (IPT) for malaria are carried out.
Mental health services
Seven of the studies10,13,17,22,24,29,30 indicated that postpartum depression and anxiety are significant concerns. Mental health services include screening and counselling for at-risk women (Table 3). However, studies such as those by Erasmus et al. 4 and Yakubu and Salisu 21 noted that these services are often scarce and not routinely integrated into maternal health care for adolescents.
Nutrition and diet services
Six of the studies10,12,13,17,21,24 highlighted that proper nutrition during pregnancy is critical (Table 3). Services include iron and folic acid supplementation, other vitamin supplements and dietary counselling.
Immunizations
Eight studies10–13,15,17,19,22 pointed out that maternal immunizations, such as Tetanus Toxoid Vaccination, play a vital role in protecting both the mother and the baby from infectious diseases (Table 3).
Accessibility of maternal health services
According to 8 of the 26 included studies,10–13,15,17,24,25 access to maternal health services in Sub-Saharan Africa is a critical issue (Table 3). Several factors affect accessibility and quality, leading to high maternal and infant mortality rates. Many rural areas in Sub-Saharan Africa lack adequate healthcare facilities.10,13,17 Even when facilities exist, they may be understaffed, underfunded and lack essential medical equipment and supplies, compromising the quality of care. Availability is also an issue, as some facilities only offer ANC and PNC on specific days.
Distance is a major barrier, with women in remote areas often facing long travel times to the nearest healthcare centre. Most countries in Sub-Saharan Africa have maternal health services that are expensive, even in public systems. Costs related to care can be prohibitive for low-income families, and many women pay out of pocket for medical services and the lack of health insurance. 1 Migration of trained healthcare professionals exacerbates staff shortages.10,13 Weak health systems, insufficient funding and ineffective policy implementation are systemic challenges.
As presented in Table 3, five of the included studies11–13,15,17 claimed that adolescent-friendly services were essential. They argued that adolescents face significant barriers, including conservative cultural attitudes towards sexual and reproductive health (SRH), gender inequality, lack of information and economic constraints. Adolescent-friendly services are designed to be accessible, respectful and responsive, ensuring confidentiality and building trust
Four of the included studies11,12,24,25 reiterated that staff training and capacity building are critical in addressing the high rates of maternal morbidity and mortality (Table 3). Healthcare providers must be adequately trained to provide the specialized care and support required for adolescents.
However, the review found that while most studies described services and barriers to access (e.g. distance, cost), detailed assessment of quality aspects such as provider competence, adherence to WHO guidelines, measurement of respectful maternity care or patient satisfaction was less common and often superficial. For instance, while ‘unfriendly providers’ were cited as a barrier (see Table 4), few studies provided specific metrics on provider attitudes or the prevalence of disrespectful care. The evidence on quality is therefore weaker and less specific than the evidence on accessibility.
Factors affecting access to maternal health services
Stigma and discrimination
Ten of the included studies10–13,15,17,19,20,22,24 indicated that stigma and discrimination faced by pregnant adolescents in Sub-Saharan Africa were significant challenges that affect not only their mental and emotional well-being but also their access to maternal healthcare, education and overall quality of life (Table 4). In many parts of Sub-Saharan Africa, early pregnancy, especially before marriage, is highly stigmatized. This is particularly true for adolescents, as early pregnancies are seen as a violation of social norms and traditional expectations. As a result, pregnant adolescents may be shunned by their families, peers and communities. Studies by Nambile Cumber et al. 13 in Uganda and Hokororo et al. 9 in Tanzania provided detailed qualitative evidence of this stigma, reporting that adolescents were often shouted at or judged by healthcare workers.
Social support systems
As presented in Table 4, seven of the included studies10–13,15,17,20 argued that social support systems play a crucial role in influencing access. Six studies highlighted that social support was a determining factor. Family is one of the most influential social support systems for adolescent girls in Sub-Saharan Africa.19,21,22,24,26
Cost of maternal health services
As presented in Table 4, four studies2,21,24,28 pointed out that the cost of services is a significant barrier for adolescents seeking maternal care, particularly those in low- and middle-income countries. Direct costs may include consultation fees, medications and tests, while indirect costs include transportation.10,17
Financial constraints
As shown in Table 4, eight of the included studies10,11,13,15,17,21,26,28 pointed out that financial constraints are a significant barrier impacting the ability to afford frequent medical visits, diagnostic tests and consultations.
Distance to health facilities
Ten of the included studies10–13,15,17,20,21,26,28 concurred that distance to healthcare facilities is a significant barrier for pregnant adolescents in accessing maternal health services, particularly in rural, remote or underserved areas of Sub-Saharan Africa (Table 4). For example, a study by Sychareun et al. 18 in Laos (a comparable LMIC context) and Nunu et al. 16 in Zimbabwe highlighted travel times of over 2 hours as a common barrier.
Transportation challenges
Six of the included studies10,11,13,15,17,21 pointed out that transportation challenges are a major barrier, especially in rural areas of Sub-Saharan Africa. For pregnant adolescents, inadequate access to transportation can delay or prevent timely medical care, which is critical for ensuring both maternal and foetal health.
Long waiting times, lack of information and unfriendly service providers
Four of the included studies10,21,26,28 identified long waiting times, lack of information and unfriendly healthcare providers were significant barriers (Table 4). Unfriendly or judgemental providers can make adolescents feel ashamed, discouraging them from seeking care. 19 As noted in the quality section, studies like Erasmus et al. 4 specifically reported adolescents’ fears of being scolded by nurses in South Africa.
Lack of trained staff
As presented in Table 4, four of the included studies20,22,24,25 reiterated that a shortage of trained staff and resources for adolescent-friendly services is a crucial barrier. This shortage is pronounced in remote communities, which makes it difficult for pregnant teens to access specialized care.
Personal unwillingness to seek services
Seven of the included studies10,11,13,15,17,22,28 postulated that the unwillingness of adolescents to seek maternal health services was a significant barrier, often linked to fear, stigma or lack of awareness.
Interventions to promote maternal health services
Community outreach programmes
Five of the studies,2,6,11,12,15 as presented in Table 5, argued that community outreach programmes play a crucial role in providing support, education and resources free of charge. These programmes aim to address unique challenges through education and awareness campaigns on PNC, SRH and nutrition.19,20,23
Mobile health services
Seven of the studies,10,13,15,17,21,26,28 as presented in Table 5, pointed out that mobile health services are an important tool in addressing adolescent maternal health in most rural areas of Sub-Saharan Africa. 22 These mobile health services use mobile clinics or digital platforms to provide healthcare, education and telemedicine consultations.20,22,24 According to Nambile Cumber, 13 they have a significant impact by reaching remote areas.
Peer education
Six of the studies,2,11,12,15,19,22 as presented in Table 5, agreed that peer education is an effective strategy leveraging peers to educate and support young mothers. It improves communication, builds trust and promotes health-seeking behaviour. Challenges include inconsistent access to resources, limited training opportunities, cultural sensitivity and sustainability and support continue to affect the delivery of peer education in Sub-Saharan Africa.2,19 Examples of successful peer education programmes in Sub-Saharan Africa include the ‘Peer Educator Program’ in Kenya and the ‘Adolescent Peer Education Program’ in South Africa. 23
Financial incentives
Four studies,12,30,31,32 as presented in Table 5, reported that financial incentives can improve access and promote better health outcomes. An example is Kenya’s Cash Transfer for Orphans and Vulnerable Children (CT-OVC).
Youth-friendly clinics
Four studies2,22–24 pointed out that youth-friendly clinics provide safe, accessible and non-judgemental services tailored to adolescents’ needs (Table 5). According to Nambile Cumber et al., 12 the goal is to create a comfortable environment with enhanced confidentiality. Challenges include stigma and social barriers, limited resources and cultural sensitivity.2,24
Discussion
The included studies offered a presentation on the availability and accessibility of adolescent maternal health services in Sub-Saharan Africa, though the exploration of quality was less robust. Socio-demographic characteristics significantly influence health-seeking behaviour.8,9,17,19,20 Factors such as age, marital status, education level, income and location influence the utilization of ANC and PNC.
Younger adolescents (under 15 years) often face greater biological risks and challenges when seeking maternal health services, as alluded to by Chipako 32 and Nunu. 16 Critically, the findings on very early pregnancies (ages 10–14) underscore that these cases are often not merely ‘early’ but are manifestations of sexual abuse, given that these children fall below the age of consent. As noted in the results, the law in countries like South Africa defines this as statutory rape. This framing necessitates a paradigm shift in how healthcare providers and policymakers approach these cases, moving beyond standard maternal care to ensure trauma-informed support, forensic sensitivity, and appropriate safeguarding and legal referrals for survivors. Their immaturity and lack of experience with healthcare systems can contribute to delayed care-seeking or non-utilization of services. They may also be more susceptible to complications such as preterm labour or obstetric fistulas due to their underdeveloped bodies, as highlighted by Chipako. 32 Married adolescents are often more likely to seek services due to social expectations and financial support from their husbands or families. Education level is one of the most significant social determinants, as it increases adolescents’ ability to make informed decisions.11,12,15 Educated girls are more aware of the importance of ANC and PNC. Poverty and low socioeconomic status are major barriers, particularly in rural areas with limited infrastructure.
The review suggests that comprehensive interventions, including education and contraception, can help reduce unintended pregnancies and STIs. Group-based interventions empowering youth to make decisions about taking contraceptives are effective.15,20 Combining educational programmes with service delivery and community outreach to encourage young people, including engaging male partners as advocated by Stern et al.12,15,33
Access is influenced by a range of barriers and facilitators as suggested by Nunu. 16 The barriers of poverty, stigma and geography often compound one another; for example, a poor, unmarried adolescent in a rural area faces a much greater cumulative barrier than one facing only a single issue. Cost, distance and stigma are significant barriers. Cultural norms and gender-based power imbalances can restrict girls’ freedom to seek care. Lack of education or awareness, unfriendly healthcare environments and geographical isolation further discourage access.10,13,17,21,26,28
Facilitators include education, adolescent-friendly services, social support (from family, partners and community leaders) and supportive policies such as free maternal healthcare and legal reforms against child marriage. 16 Educated adolescents are more likely to understand the importance of ANC, delivery by skilled attendants and PNC for both themselves and their babies.
When compared to similar reviews in other LMIC regions (e.g. Asia and Latin America), the barriers in Sub-Saharan Africa are often more severe due to higher levels of poverty, weaker health systems and stronger cultural stigmas, though the themes of cost, distance and stigma are common across regions. 31
A key knowledge gap identified in the reviewed papers is the lack of in-depth analysis of the quality of care received by adolescents. While barriers to access are well documented, less is known about whether services, once accessed, are respectful, evidence-based and tailored to adolescents’ needs. This review found limited evidence on measurable quality indicators such as provider adherence to clinical guidelines for adolescents, patient satisfaction scores or specific outcomes linked to quality of care (e.g. rates of respectful maternity care). Future research should prioritize these aspects.
Overall, literature specifically on pregnant adolescent maternal health service availability and accessibility is limited, and literature on the quality of those services is even scarcer. Literature is saturated with maternal health services in general, but evidently scarce on pregnant adolescent girls, representing a significant gap.
Limitations
This review has several limitations. First, the focus on a scoping review limits our ability to examine intervention impacts in detail statistically. Second, the restriction to English-language publications may have introduced language bias, potentially omitting relevant studies in French or Portuguese. Third, the exclusion of grey literature may have omitted relevant findings from NGO or government reports. Fourth, many included studies relied on self-reported data, which is subject to social desirability bias. Fifth, while two reviewers were involved in screening, the potential for reviewer bias remains. Finally, as this was a scoping review, a formal quality assessment of included studies is not standard; however, we noted a general lack of depth in reporting on quality-of-care metrics, which is both a limitation of the included studies and this review’s ability to synthesize findings on service quality.
Conclusion
Availability and access to maternal health services in Sub-Saharan Africa are shaped by a combination of barriers and facilitators. Key barriers include geographical distance, financial constraints, cultural stigma and healthcare system deficiencies. Furthermore, the review highlights that many pregnancies among the youngest adolescents are a direct consequence of sexual abuse and statutory rape, a critical issue that demands a targeted response from health and legal systems. However, improved education, youth-friendly services, community support and policy reforms can act as facilitators, encouraging women to seek and utilize maternal healthcare services. The evidence on service quality, however, remains underdeveloped and warrants greater attention in both policy and research.
Recommendations
Based on the findings of the review, the following recommendations are made;
Integrate youth-friendly services into national health systems and implement policies for free maternal healthcare for adolescents. Legal reforms to address child marriage and empower adolescents are crucial.
Train healthcare providers on adolescent-sensitive and respectful care to address stigma and improve service quality.
Future research should focus on country-specific interventions, longitudinal studies on the impact of interventions and the development of standardized metrics to evaluate the quality of maternal health care for adolescents, particularly focusing on measurable aspects of quality like respectful care, provider competence and adherence to guidelines.
Supplemental Material
sj-docx-1-reh-10.1177_26334941251403814 – Supplemental material for Accessibility and barriers to maternal health services for adolescents in Sub-Saharan Africa: a scoping review
Supplemental material, sj-docx-1-reh-10.1177_26334941251403814 for Accessibility and barriers to maternal health services for adolescents in Sub-Saharan Africa: a scoping review by Gladmore Muchemwa and Methembe Yotamu Khozah in Therapeutic Advances in Reproductive Health
Footnotes
Acknowledgements
None.
Authors’ Note
GM is a Master’s student at the National University of Science and Technology in Zimbabwe. This manuscript is part of a partial research project, the fulfilment of the Master’s Degree in Environmental Health. MYK is an MSc Environmental Health holder at the National University of Science and Technology (NUST) in Zimbabwe. The author is also a lecturer at the Department of Environmental Health at NUST. This manuscript is part of a partial research project, the fulfilment of the Master’s Degree in Environmental Health.
Declarations
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References
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