This study aimed to analyze the prevalence, trend and determinants of adolescent childbearing in Burundi using data from the three DHS conducted in Burundi in 1987 [25], 2010 [24], and 2016–17 [14] respectively. Our findings showed that the prevalence of adolescent childbearing increased from 5.9% in 1987 to 8.3% in 2016/17. Indeed, analysis of the trend in adolescent childbearing over a 30-year period (1987 to 2017) shows that there was an increase in adolescent childbearing between 1987 and 2010, which would likely be the result of the various consequences of the 1993–2005 civil war. These consequences include sexual violence [34], the increase in the poverty rate [13, 35, 36] and the gradual deterioration of social norms that prohibited pregnancy outside of marriage, especially in urban areas [37]. Afterwards, there was a slight decrease in adolescent childbearing between 2010 and 2017, which would be attributable to the general increase in education in Burundi since 1987 but especially since 2010 after the implementation of the free Primary School Policy (FPSP) by the Burundian government in 2005 [38]. However, the effect of this general increase in school enrollment (at the individual and especially at the community level) would have been mitigated by the increase in the poverty rate among households especially after the 2015 post-election crisis [39] as some girls opt for early marriage to escape the poor household conditions in the parental home [35], while others move alone to the cities, especially in Bujumbura Mairie, in search of work and are often vulnerable to sexual exploitation which puts them at high risk of becoming pregnant [34], the gradual deterioration of social norms that severely prohibited pregnancy outside of marriage especially in urban areas [37], and finally the difficulties of access/low utilization of family planning services by adolescents girls in Burundi [23, 40, 41]. Although this upward trend in adolescent childbearing was not statistically significant, Burundi should make greater efforts to reverse this trend given the negative impact of adolescent childbearing in Burundi on the young mothers and their babies’ well-being [21, 34, 42] and on the current demographic pressure [11, 13]. Moreover, several studies showed that the high level of maternal and infant morbidity and mortality can be reduced by reducing the adolescent childbearing rates in developing countries [3, 43, 44]. In addition, Burundi should take as a good example most of its neighboring countries that are currently showing a downward trend in adolescent childbearing after having made enormous efforts [4, 7].
Our study identified some key determinants of adolescent childbearing in the Burundian settings. Indeed, our findings indicated that adolescents aged 18–19 years were more likely to start childbearing than those aged 15–17 years. This positive correlation between adolescent age and risk of childbearing could be explained by increased exposure to sexual intercourse and marriage as the age of adolescent increases [4, 10]. Our results are consistent with those of many previous studies [4, 7, 10] that showed that the odd of adolescent pregnancy increases with adolescent age.. However, it should be noted that the consequences of childbearing can be much more serious for 15–17 year old girls than for 18–19 year old girls, both in terms of their health (given their physical immaturity) and that of their babies, in terms of acceptance in the community given that the legal age of marriage in Burundi is 18, and in terms of an increase in their reproductive age which would contribute to a high fertility rate further exacerbating the demographic pressure in Burundi [11]. Therefore, intervention programs to reduce/prevent adolescent childbearing in Burundi should preferably target all age groups of adolescent girls.
Similarly, our results showed that adolescents who had no education were more likely to start childbearing than those who had a secondary or high education. Such an association could be explained by the fact that out-of-school adolescent girls do not have access to comprehensive sexuality education (CSE) [45] and skills necessary to negotiate sexuality and reproductive options [3]. The protective effect of education against adolescent childbearing has also been reported in several previous studies. Indeed, adolescents who had no education had about 2 times higher odds of childbearing compared to those who were in school [3]. Teenage girls who had no education had about 3 times higher odds of childbearing than those who had a secondary or high education [45] . Other similar results were reported in studies conducted in Malawi [10], and in five East African countries that do not include Burundi [7]. In Burundi, a significant increase in the school attendance rate, especially at the primary level, was observed following the implementation of the FPSP initiated by the Burundian government since 2005 [38]. However, there is still a gender gap in school attendance, especially at the secondary and higher levels [14, 38]. Moreover, CSE was certainly integrated into the education program in Burundi even in extracurricular school clubs [22]. However, this is not enough as the emphasis was placed on abstinence as the only accepted method for avoiding adolescent pregnancy [37, 38]. The information available on the benefits of using contraceptive methods would be also very limited to have a positive effect on girls’ possibilities to protect themselves [22]. Furthermore, many adolescent girls are eventually forced to drop out of school because of the very poor living conditions in the parental home [35, 36] and face an increased risk of pregnancy while trying to provide for their basic needs themselves [34, 35, 38]. Given the importance of education, particularly at the secondary and tertiary levels, in preventing teenage childbearing, policymakers should do everything possible to promote young girls education at all levels of the Burundian education system while significantly improving the household socio-economic conditions and the quality of the CSE provided.
Our findings also revealed that household poverty or living in poor communities is associated with higher odds of adolescent childbearing. In the Burundian context, this association could be explained by the fact that Burundian society was highly affected economically by the civil war of 1993–2005 [34, 37]. Consequently, 64.9% of Burundians live below the national poverty line of US$1.27 and 38.7% live in extreme poverty [35, 36]. Thus, some rural adolescents arrive alone in cities in search of work and are often vulnerable to sexual exploitation, which exposes them to a high risk of unwanted pregnancies [34, 38]. On the other hand, some adolescent girls, especially those from rural areas, are eventually forced to drop out of school, either because they have no money to buy sanitary pads during menstruation or because they are unable to learn much without some food before school or at lunchtime [38]. Some malicious men (shopkeepers, drivers, teachers, etc.) take advantage of this precariousness to offer them money in exchange for sex, which often results in unwanted pregnancies [13, 22].. Our results corroborate those of the study by Vikat et al. [17] and those of the study by Kearney and his colleague [18]. Although the relationship between poverty and adolescent childbearing may be a vicious cycle [3], our findings and available evidence [7, 9, 13] underscore the importance of improving the households’ socioeconomic status in general, but especially of disadvantaged communities, to reduce the prevalence of adolescent childbearing, thereby improving their sexual and reproductive health.
Unexpectedly, Bujumbura Mairie, which is generally considered less poor than other regions and where more youth have access to education [38], was found to be associated with a higher risk of adolescent pregnancy than other regions. This finding could be explained by two main reasons. The first is that in order to escape poor living conditions in parental households, some rural adolescents arrive alone in Bujumbura Mairie in search of work and are often vulnerable to sexual exploitation, which puts them at increased risk of becoming pregnant [34]. The second reason is that rural families are even more attached to social norms against out-of-wedlock pregnancies than urban families [34, 37]. Therefore, to escape the stigma of their families, some rural adolescents who experience an unwanted pregnancy prefer to move to Bujumbura Mairie as soon as possible before the family realizes that their daughter is pregnant.
This study also found that the adolescent early marriage is associated with a higher odd of childbearing. This link between early marriage and higher risk of adolescent childbearing could be justified by the fact that early marriage implies early sexual debut and therefore a major risk of early pregnancy and childbearing [7, 9, 46]. In addition, several previous studies [3, 4, 9, 46] reported similar results. In Burundi, early marriage is associated with not only young mothers’ and their babies’ poor health outcomes [14], but also with high fertility rate [11]. While the official age of marriage for girls in Burundi is 18, early marriage remains a common practice, especially in rural areas, as a way to escape poor living conditions in the parental home [35]. Therefore, the Burundian government should ensure the strict enforcement of any law aimed at combating early marriage while improving the socio-economic conditions of households. Indeed, apart from the findings of our study, several other researchers [3, 4, 46, 47] suggest that investing in the prevention of child marriage is important not only to reduce teenage pregnancies and related complications, but also to improve a country’s economic development.
Similarly, our findings showed that both the lack of knowledge of any contraceptive methods and the non-use of modern contraceptive methods were associated with higher odds of adolescent childbearing. The positive influence of good knowledge and use of family planning services in preventing or reducing the rate of unintended pregnancies among adolescent girls has been widely reported in the scientific literature [9, 10, 42, 46]. However, most Burundian adolescent girls do not use contraception, and some do not even plan to use it in the future [14]. Indeed, the prevalence of contraceptive use among adolescent girls remains very low (2.5%) and the percentage of adolescents girls who do not intend to use contraception increased from 17.8% in 2010 to 24.8% in 2016–17. Moreover, the percentage of adolescents who had knowledge of any contraceptive methods decreased from 91.8% in 2010 to 89.9% in 2016–17 [14, 24]. The results of this study as well as the available evidence [46, 47] highlight the importance of interventions such as CSE [42] at all levels of the Burundian education system and provision of contraceptive services [48] to adolescents and creating supportive environments such as knowledge and support from parents, teachers, church, mass media campaign, governance, and a peer education program [42, 46] to reduce the prevalence of adolescent childbearing in Burundi. The strength of our study is that it would be among the first to focus on trend analyses and community-level factors in the analysis of determinants of adolescent childbearing in Burundi. In addition, this study is the first to use an advanced logistic regression model (multilevel model) to investigate the determinants of adolescent childbearing in Burundi. However, our study also suffers from some limitations. The 1987 DHS database did not contain some of the variables of interest to our study. Therefore, we limited ourselves to the analysis of the available variables. Moreover, the results of this study may suffer from misreporting bias regarding the respondents current ages. Indeed, respondents’ ages may not always have been reported correctly, either intentionally by trying to report a higher age than the real age given the stigma surrounding adolescent pregnancy [21] and the legal consequences of early marriage, or by not knowing the real age given that Burundi has suffered from repeated outbreaks of mass violence and political crisis [34, 37] during which registration of birth dates in government records was often impossible [49]. In addition, our study looked only at current pregnancies or previous births of adolescents to assess the prevalence of adolescent childbearing and did not consider adolescent pregnancies that ended in miscarriage, abortion, or stillbirth. This consideration is very important in the interpretation of the results of this study by readers, as there may be an underestimation bias in the prevalence. Indeed, given the Burundian culture, which still considers pregnancy outside of marriage to be a disgrace to the family [21], many cases of induced and clandestine abortion are quite possible in Burundi, as was found in two recent studies conducted in two of Burundi’s neighboring countries, in Uganda [50] and in Ethiopia [51], which showed that nearly one in six adolescent pregnancies ends in an induced and clandestine abortion. Further studies that include adolescent pregnancies that ended in miscarriage, abortion, or stillbirth in prevalence estimate are needed to better understand the extent of the problem in Burundi.
