WHO guidelines on preventing early pregnancy and poor reproductive health outcomes among adolescents in developing countries. 1.Pregnancy in adolescence -prevention and control. 2.Pregnancy, High-risk. 3.Pregnancy outcomes. 4.Adolescent health services. 5.Reproductive health services. 6.Evidence-based medicine. 7.Developing countries 8.Guidelines. I.World Health Organization.# FOREwORD
Joey O'Loughlin determinants and consequences of early pregnancy
The role and approach of WhO intRODuCtiOn care services that enable women to go safely through pregnancy and childbirth, and the right for couples to have the best chance of having healthy children.
WHO's Global reproductive health strategy emphasizes the importance of legislative and regulatory frameworks that support and facilitate universal and equitable access to sexual and reproductive health services. It notes that it may often be necessary to remove existing legal and policy barriers that impede the use of life-saving interventions and other necessary services. Political, legal and regulatory environments are key determinants of accessibility to, and availability and quality of health services. Further,

# i. DEtAilED mEtHODOlOgY
The WHO Child and Adolescent Health (CAH) department developed and presented a proposal to the WHO Guidelines Review Committee, which gave its approval in April 2009. In compliance with the recommended process for development of WHO recommendations/ guidelines, a core group (WHO Guidelines Group) of professional staff from different WHO departments (CAH, Reproductive Health and Research (RHR), Making Pregnancy Safer (MPS) working in the area of sexual and reproductive health, and led by CAH, was formed to work on the development of guidelines.
The CAH team drafted a list of main outcomes that impact adolescent sexual and reproductive health in developing countries with a focus on preventing early pregnancies among adolescents. The WHO CAH department developed a series of key questions for each of the selected outcomes. RHR and MPS staff provided inputs and participated in meetings where all outcomes and questions were revised.
A peer review process was used to review key questions, summaries of evidence and draft recommendations emerging from the expert panel meeting. The WHO Guidelines Group sent the proposed questions to a multidisciplinary group of experts in the field (30 researchers, programme experts, advocates, policy-makers, UN partners and/or donors) for comments and peer review.
The experts were asked to rate the outcomes according to its importance in reducing adolescent pregnancy and adolescent maternal morbidity and mortality. Experts were asked to rate each outcome on a scale of 1-9. Outcomes were defined as critical if they scored between 7 and 9 on average; important but not critical if they scored between 4 and 6 on average; and not important if they scored less than 4 on average. In addition, experts were asked to provide their perspectives about the relevance of each question to the outcome and to the overarching goal of the review. Experts were requested to provide inputs for each of the questions related to each outcome. They were asked to add other outcomes and questions that they considered necessary. All expert responses were reviewed by the WHO Guidelines Group, which formulated the final list of outcomes and key questions (see Annex 3).
In December 2009, CAH convened a meeting with the institutions commissioned for the review. The institutions were selected based on their technical expertise in research and in each of the topics relevant for the guidelines. See the table below listing the commissioned institutions by outcome.

# i. DEtAilED mEtHODOlOgY
Based on agreed key outcomes and questions, the WHO Guidelines Group developed search strategies for each outcome. The search strategies are appended by outcome (see Annexes 4 and 5).
The following are the parameters of the search strategies: - There were no language restrictions. Reviewers were able to read English, French, Portuguese and Spanish. Reports in other languages were translated into English for those who required an English translation. Those who were able to read documents in their original language did so.
- Published and unpublished studies were included.
- Studies published until January 2010 were included. The search terms used included adolescents and primary terms from the outcomes and key questions decided by the expert panel and finalized by the WHO/CAH core team.
- Specific definitions and principles underlying some search terms were as follows:
-Children: Human rights agreements (e.g. Convention on the Rights of the Child) define children as up to 18 years of age.
-Early marriage: Before 18 years of age. Marriage before this age truncates important processes of reproductive organs development.
-Early pregnancy: Pregnancy at less than 20 years of age, based on the assumption of pregnancy occurring at least one year after marriage.
-Marginalized adolescents: Girls who are marginalized due to poverty, societal traditions and/or geographic location. These marginalizing factors hinder adolescents' access to education, health information and services, and safe places for personal growth and development.
- The settings were included in the search terms, based on the list of countries that fall under the World Bank groupings of low-income, lower-middle-income and uppermiddle-income countries.
- Search strategies were customized for each electronic database according to their individual subject headings or searching structure.
- The databases that were searched are indicated for each outcome.
The search strategies were implemented between January 2009 and February 2010. Commissioned organizations were given an electronic file with a compilation of relevant abstracts and asked to screen the titles and abstracts for relevant systematic reviews and individual studies. For systematic reviews and studies that responded to key questions and fitted the inclusion criteria, the full text was reviewed. All consultants were asked to identify relevant studies and reports from the grey literature.
To formulate recommendations for the guidelines the WHO followed a standard development process that is outlined in the WHO handbook for guideline development (2010) (10). The research group responsible for each outcome area conducted systematic developing search strategies

# Implementing search strategies
GRAdE evidence profiles and evidence for expert review i. DEtAilED mEtHODOlOgY reviews of the literature. Once this evidence was collected it had to be summarized according to WHO methodology.
According to the revised WHO handbook (10), the formation of guidelines require the following:
- synthesis of all available evidence;
- formal assessment of quality of evidence;
- evidence summaries for group meetings using a standard template.
WHO uses the GRADE system for assessing evidence. The systematic reviews and individual studies that met the inclusion criteria were assessed for quality of evidence using the GRADE criteria (10,11).
A detailed description of the GRADE system is outlined below.
- Study design -randomized controlled trials or observational studies.
- Limitations of the study design -sources of bias including lack of allocation concealment, lack of blinding, incomplete accounting of patients and outcomes for randomized trials and failure to adequately control confounding; flawed measurement of exposure and outcome for observational studies.
- Consistency of results -variability of results across or within studies; heterogeneity.
- Direct applicability of evidence -are the studies assessing the outcome of interest? Is the study population the same as the population of interest?
- Imprecision -few patients and few events; wide confidence intervals.
- Publication bias -potential systematic over-or under-estimate of effect due to selective publication of studies.
The GRADE approach allows for "downgrading" of evidence based on the above criteria. For example, in considering limitations of study design an adjudicator has the option of selecting 'none', 'serious' or 'very serious'. If 'serious' or 'very serious' are selected then the reason for this must be provided in footnotes to the GRADE table. The same options ('none', 'serious', 'very serious') apply to all criteria. The quality of evidence can also be "upgraded", such as when there is a large effect or a dose-response relationship.
A quality level is assigned to the evidence based on the following criteria:
- High -further research is very unlikely to change our confidence in the estimate of effect;
- Moderate -further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate;
- Low -further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate;
- Very low -any estimate of effect is very uncertain.

# i. DEtAilED mEtHODOlOgY
The GRADE software (4) consists of a template for entering information about the evidence, potentially downgrading the quality of evidence due to the reasons mentioned above, or upgrading it.
For dichotomous outcomes the number experiencing the outcome (e.g. unintended pregnancy) is entered for both the intervention and control groups. The effect -whether a mean difference, relative risk, odds ratio, hazard ratio or another outcome, as well as 95% confidence intervals -is entered. GRADE then produces an estimate of relative effect and absolute effect.
Once this information of study quality as well as results are entered, a GRADE table can be produced -this table identifies the type of evidence used, any quality issues with the evidence (these are explained in footnotes to the GRADE table), the summary of findings, a ranking of the quality of evidence and the 'importance' of the outcome considered.

# Limitations of GRADE for assessing evidence relevant to priority topics
Given that the research area -preventing early pregnancy and poor reproductive outcomes in adolescents in developing countries -does not lend itself to randomized controlled trials, or comparative observational studies, it is clear that much of the evidence available for the priority topics will not "fit" into GRADE. This is largely because many of the available studies are either non-comparative, or if comparisons are made they are not provided in a manner that fits into GRADE. For example, the findings from a study may report that 75% of adolescents receiving the intervention increased their use of contraceptives while 60% of those in the control group also increased contraceptive use -but neither a comparison of these proportions is provided, nor any indication of statistical significance.

# Alternate evidence summaries
To summarize this type of evidence a summary table is compiled to document the following information: - Study design;
- Objective of the study;
- Patient population and n (number of subjects);
- Intervention(s) used;
- Brief summary of key results;
- Statement on relevance -whether the study is relevant to the identified priority topic and questions specified to address the topic.

# Evidence and recommendations
With the evidence entered into the GRADE system and/or summarized, the next step is to formulate recommendations. The recommendations take both the evidence and other factors (such as values and preferences) into account. The following are key points to consider when formulating recommendations:
- Recommendations are judgements, based on the quality of evidence, the trade-off between health benefits and harms, values, preferences and costs.

# i. DEtAilED mEtHODOlOgY
- The strength of a recommendation is the degree of confidence that the desirable effects of adherence to a recommendation outweigh the undesirable effects. Desirable effects are health benefits, low burden of disease and resource savings, while undesirable effects are harms, increased burden of disease and resource costs.
- WHO uses two categories for strengths of recommendation, strong and weak: i) A strong recommendation is one for which the panel is confident that the desirable effects of adherence to a recommendation outweigh the undesirable effects. ii) A weak recommendation is one for which the panel concludes that the desirable effects of adherence to a recommendation probably outweigh the undesirable effects, but the panel is not confident about the trade-offs. The reasons for not being confident can include the absence of high quality evidence, the presence of imprecise estimates of health benefits or harms, uncertainty or variation in how different individuals value outcomes, small health benefits, or because benefits may not be worth the costs (including the costs of implementing the recommendation).
When making a judgement about the strength of a recommendation, the following should be considered:
- There is no precise threshold for going from a strong to a weak recommendation;
- The presence of important concerns about one or more of the factors regarding recommendation strength (quality of evidence, precision of estimates, uncertainty in value of outcomes; size of benefits; cost worthiness) make a weak recommendation more likely;
- Panels should consider all of these factors and make the reasons for their judgement explicit;
- Recommendations should specify the perspective that is taken (i.e. individual patient, health system) and which outcomes were considered (including which, if any, costs).
The implications of a strong recommendation are:
- Patients: most people in a particular situation would want the recommended course of action and only a small proportion would not.
- Clinicians: most patients should receive the recommended course of action.
- Policy-makers: the recommendation can be adapted as a policy in most situations.
The implications of a weak recommendation are:
- Patients: the majority of people in a particular situation would want the recommended course of action, but many would not.
- Clinicians: be prepared to help patients to make a decision that is consistent with their own values.
- Policy-makers: there is need for substantial debate and involvement of stakeholders.
An external methodologist, with expertise in GRADE methodology, reviewed systematic reviews and individual studies, assessed the quality of evidence based on GRADE criteria, and generated GRADE evidence profiles. For those studies that did not meet the GRADE criteria, separate tables were prepared to summarize the evidence in each study,

# i. DEtAilED mEtHODOlOgY
including details related to the study design and objectives, population, intervention, results, and the quality of study. These tables were shared with the expert panel to inform the formulation of recommendations in the absence of eligible 1 evidence or when eligible evidence was limited.
The protocol applied to generate the summary of evidence for each outcome is included in this document (see Annex 6).
Once the systematic reviews and evidence tables were completed, the WHO core group drafted the recommendations. In November 2010, the WHO convened a multidisciplinary panel of experts that included experts in adolescent sexual and reproductive health, and maternal and neonatal health to discuss, review and achieve consensus on a set of recommendations based on their analyses of available evidence. The panel also included experts on systematic review methodology who were commissioned to conduct systematic reviews and grading of evidence.
For the panel meeting, background documents that included key questions, methodology, individual scientific articles, systematic reviews, summary tables and GRADE tables were made available to participants.
A summary of the evidence for each of the six outcomes was presented. This included a brief narrative presentation of results of systematic reviews, including GRADE table profiles and summaries of ungraded evidence. All relevant documents related to systematic reviews and individual articles were provided for the panel members' reference during the meeting. The discussion focused on recommendations with changes based on group comments recorded electronically during the meeting. In formulating recommendations and rating their strengths, the panel was instructed to weigh four main factors: 1. quality of evidence; 2. balance of benefits and harms or burdens; 2 3. differences in values; 3 4. resource implications. 4 A group agreement was used for reformulating proposed recommendations. The definition of group agreement or consensus that was applied was that the majority agreed, those that disagreed did not have strong objections, and that all would have a chance to express their opinion. If consensus could not be reached, a vote would be taken.
After the expert meeting, WHO/CAH compiled the recommendations drafted during the meeting and sent them back to the experts for review and comment. CAH, in consultation with the RHR and MPS departments, and commissioned institutions, reviewed the input and made decisions about where and how to incorporate comments. WHO finalized the recommendations based on inputs and shared them with selected 1 Eligibility refers to the suitability of the study for entry into a GRADE profile. 2 The larger the difference between the desirable and undesirable consequences, the more likely a strong recommendation is warranted. The smaller the net benefit and the lower the certainty for that benefit, the more likely a conditional/weak recommendation is warranted. 3 The greater the variability or uncertainty in values and preferences, the more likely a conditional or weak recommendation is warranted. 4 The higher the costs of an intervention -that is, the more the resources consumed -the more likely a conditional/weak recommendation is warranted.

# Expert meeting
Summary of the decisionmaking process management of group process and methods for resolving disagreements peer review process i. DEtAilED mEtHODOlOgY external experts for further final comment (including originally commissioned institutions and UNFPA).
WHO/CAH has outlined a plan to disseminate the recommendations developed through systematic review and expert panel process. The immediate plan is to disseminate the guidelines once approved, to identify the gaps in the evidence and areas for further research; and to develop guidance tools for developing priorities for action and research. The long-term objectives are to mobilize support to produce evidence at the country level and promote policy changes with respect to information, services and training and at the global level. Channels for reaching the target audiences include guidelines publication; policy briefs and a CD-ROM toolkit; face-to-face meetings; and high-level launch events such as one global launch, and three regional launches in Africa, Asia and Latin America. Country level launches will take place in selected countries. Additional channels include webinars, social media, blogs, technical and scientific journals, presentations at conferences/workshops and grassroots advocacy efforts.

# Key advocacy partners included:
- United Nations Secretary-General and the Global Strategy for Women's and Children's Health;
- UN agencies;
- UN Adolescent Girls Task Force;
- Campaign to End Obstetric Fistula;
- Countdown to 2015 and the Partnership for Maternal, Newborn and Child Health;
- IPPF, Family Care International, Women Deliver, FHI;
- Latin American Task Force on Maternal Mortality;
- African Public Health Alliance;
- USAID Connect;
- Reproductive Health Supplies Coalition.
After dissemination, CAH/WHO will seek to secure additional funding in order to evaluate the usefulness and impact of the guidelines, as this was not included in the original implementation budget.

# Recommendation for research
Undertake research to identify effective interventions that result in the formulation, enforcement and monitoring of laws and policies, including unintended harmful consequences.

# Remarks and summary of panel discussion
The systematic review process did not identify any studies that addressed this question.
The panel observed that efforts to formulate laws and policies, to enforce and monitor their enforcement are unlikely to be addressed by intervention studies. The panel noted the following factors that influence child marriage rates: the state of the country's civil registration system (which provides proof of age for children); the existence of an adequate legislative framework and an accompanying enforcement mechanism to address cases of child marriage; and the existence of customary or religious laws that condone the practice. Interventions are needed to protect and ensure the rights of those before 18 years of age (who are children as defined by the Convention on the Rights of the Child).
The panel agreed that interventions to prohibit marriage before 18 years of age through the formulation and enforcement of laws and policies are important from both rights-based and public health perspectives. Panel members noted that physical, social and psychological development of adolescent girls can be promoted by preventing tooearly marriage and too-early pregnancy during adolescence. The panel also discussed the potential harms of these interventions. First, the enforcement of such laws could penalize those who contravene them such as to endanger the livelihoods and wellbeing of adolescent girls and their families. Second, the introduction of these laws and policies may create conflict by disrupting existing social norms.
Despite limited evidence, the panel concluded that ongoing efforts are needed to promote laws prohibiting marriage before 18 years of age as an important measure to fulfil girls' rights and to prevent too-early pregnancy. The higher the quality of evidence, the more likely a strong recommendation is warranted.

# o yES o nO
The systematic review process did not identify any eligible studies for inclusion.
uncertainty about the balance of benefits versus harms and burdens (is there uncertainty?)
The larger the difference between the desirable and undesirable consequences, the more likely a strong recommendation is warranted. The smaller the net benefit and the lower the certainty for that benefit, the more likely a conditional/weak recommendation is warranted.

# o yES o nO
Not applicable uncertainty or differences in values (is there uncertainty?)
The greater the variability or uncertainty in values and preferences, the more likely a conditional/weak recommendation is warranted.
- yES o nO

# Not applicable

# Resource implications
The higher the costs of an intervention -that is, the more the resources consumed -the more likely a conditional/ weak recommendation is warranted. The higher the quality of evidence, the more likely a strong recommendation is warranted.

# o yES o nO
The systematic review process did not identify any eligible studies for inclusion.
uncertainty about the balance of benefits versus harms and burdens (is there uncertainty?)
The larger the difference between the desirable and undesirable consequences, the more likely a strong recommendation is warranted. The smaller the net benefit and the lower the certainty for that benefit, the more likely a conditional/weak recommendation is warranted.

# o yES o nO
Not applicable uncertainty or differences in values (is there uncertainty?)
The greater the variability or uncertainty in values and preferences, the more likely a conditional/weak recommendation is warranted.
- yES o nO

# Not applicable

# Resource implications
The higher the costs of an intervention -that is, the more the resources consumed -the more likely a conditional/ weak recommendation is warranted.

# Remarks and summary of panel discussion
The systematic review process did not find any studies that were eligible for grading.
The panel considered ungraded evidence (1-10) that demonstrated improvements in community members' knowledge and attitudes regarding the potential dangers of early marriage as a result of community-level and family-level interventions. The panel noted weaknesses in the methodology of these studies, such as lack of control groups, nonrandomized sample selection, lack of significance testing, and the lack of intervention specificity.
The panel noted that these interventions would have several benefits. First, social norm change is an essential component for ending the practice of early marriage. Second, adolescent girls usually require approval from families and communities to participate in health and education programmes. Therefore, interventions to influence family and community norms can improve participation of girls in health and education programmes. Finally, communities can facilitate the implementation of interventions that are aimed at preventing early marriage. The panel recognized that these interventions may cause conflict in some communities by disrupting existing social norms. It also noted that the cost implications of these interventions were not formally assessed.
Despite the limited evidence, the panel recommended interventions directed at families and community members to change social norms regarding the age of marriage as a way to fulfil the rights of adolescent girls. The higher the quality of evidence, the more likely a strong recommendation is warranted.

# o yES o nO
The systematic review process did not identify any eligible studies for inclusion.
uncertainty about the balance of benefits versus harms and burdens (is there uncertainty?)
The larger the difference between the desirable and undesirable consequences, the more likely a strong recommendation is warranted. The smaller the net benefit and the lower the certainty for that benefit, the more likely a conditional/weak recommendation is warranted.

# o yES o nO
Not applicable uncertainty or differences in values (is there uncertainty?)
The greater the variability or uncertainty in values and preferences, the more likely a conditional/weak recommendation is warranted.
- yES o nO

# Not applicable

# Resource implications
The higher the costs of an intervention -that is, the more the resources consumed -the more likely a conditional/ weak recommendation is warranted.

# o yES o nO

# Not applicable

# Overall strength of recommendation
Strong ii. RECOmmEnDAtiOns Question 1.4 Is there evidence that economic incentives for families are effective in delaying the marriage of girls under age 18?

# Recommendation for action
No specific intervention is recommended. Please refer to the recommendation for research related to this question.

# Recommendation for research
Undertake research to determine the feasibility, effectiveness and long-term impact of economic incentives on adolescent girls and their families as a means of delaying the age of marriage until girls are 18 years of age.

# Remarks and summary of panel discussion
The systematic review process did not find any evidence that was eligible for grading. The panel noted several ungraded studies (1,2,10-13) that collectively indicated an improvement in school retention as well as a reduction in early marriage due to interventions that involved economic incentives. Panel members noted methodological flaws in the evaluation design that limited the attribution of the outcomes observed to the interventions implemented.
The panel also discussed the following issues. First, there is considerable uncertainty about the balance between benefits and harms. For example, it is unclear whether girls who receive economic incentives directly could face increased risk to their safety and security as a result. In addition, these interventions could lead to discrimination against boys. Second, there is no information on the long-term sustainability of these interventions.
Given the weak evidence and the panel members' concerns, the panel concluded that further research on the effect of economic incentives to influence attitudes and behaviours related to early marriage is required. The higher the quality of evidence, the more likely a strong recommendation is warranted.

# o yES o nO
The systematic review process did not identify any eligible studies for inclusion.
uncertainty about the balance of benefits versus harms and burdens (is there uncertainty?)
The larger the difference between the desirable and undesirable consequences, the more likely a strong recommendation is warranted. The smaller the net benefit and the lower the certainty for that benefit, the more likely a conditional/weak recommendation is warranted.

# o yES o nO
Not applicable uncertainty or differences in values (is there uncertainty?)
The greater the variability or uncertainty in values and preferences, the more likely a conditional/weak recommendation is warranted.
- yES o nO

# Not applicable

# Resource implications
The higher the costs of an intervention -that is, the more the resources consumed -the more likely a conditional/ weak recommendation is warranted.

# Recommendation for research
Undertake research on the feasibility and scaling-up of these interventions.

# Remarks and summary of panel discussion
The systematic review process did not identify any studies that were eligible for grading. The panel considered ungraded evidence (3)(4)(5)7,8,10,12,(14)(15)(16)(17)(18)(19) that demonstrated that interventions to inform and empower girls, in combination with interventions to influence family and community norms, can positively affect attitudes and behaviours related to delaying the age of marriage. Panel members noted several methodological flaws that limited the ability to attribute outcomes to the interventions including: selection bias of intervention participants, lack of randomization, lack of control groups, unclear sampling strategies, and the combined implementation of different types of interventions.
The panel agreed that informing and empowering adolescent girls is important from both rights-based and public health perspectives. It noted that the potential benefits of these interventions exceed the technical concerns about their implementation as well as any potential harms. However, panel members agreed that these interventions must be combined with interventions that target families and communities in order to create a supportive environment for adolescent girls to act on information that they receive and to express their empowerment. These interventions may encounter resistance in some communities because they challenge existing norms. The cost implications of these interventions were not assessed.
Despite the limited evidence, the panel recommended the implementation of these interventions to fulfil the rights of adolescent girls. The panel also agreed on the importance of research on the feasibility and scaling-up of these interventions. The higher the quality of evidence, the more likely a strong recommendation is warranted.

# o yES o nO
The systematic review process did not identify any eligible studies for inclusion.
uncertainty about the balance of benefits versus harms and burdens (is there uncertainty?)
The larger the difference between the desirable and undesirable consequences, the more likely a strong recommendation is warranted. The smaller the net benefit and the lower the certainty for that benefit, the more likely a conditional/weak recommendation is warranted.

# o yES o nO
Not applicable uncertainty or differences in values (is there uncertainty?)
The greater the variability or uncertainty in values and preferences, the more likely a conditional/weak recommendation is warranted.
- yES o nO

# Not applicable

# Resource implications
The higher the costs of an intervention -that is, the more the resources consumed -the more likely a conditional/ weak recommendation is warranted.

# o yES o nO

# Not applicable

# Overall strength of recommendation
Strong (for the action recommendation)
ii. RECOmmEnDAtiOns Question 1.6 Is there evidence that efforts to expand the availability of education for girls are effective in delaying marriage among girls under age 18?
Recommendation for action -Strong recommendation 1. Increase educational opportunities for girls through formal and non-formal channels to delay marriage until 18 years of age.

# Recommendation for research
Undertake research to assess the impact of improved educational availability and school enrolment on the age of marriage.

# Remarks and summary of panel discussion
The systematic review process did not identify any studies eligible for grading. The panel noted population-level data as well as ungraded evidence (2,4,7,10,(12)(13)(14)19,20) that demonstrated a positive, protective relationship between the level of schooling and age of marriage. Panel members noted that methodological flaws, such as lack of randomization, lack of control groups, or lack of baseline data limited the ability to attribute outcomes to the interventions.
The panel observed that increasing educational opportunities for girls through formal and non-formal channels is important from both rights-based and public health perspectives. Also, it noted that improving access to education for adolescent girls had important economic and social benefits in addition to delaying the age of marriage. The panel recognized the potential for an increased risk of violence or harassment directed at adolescent girls while in school or on their way to and from school, especially in unstable or insecure environments. These interventions could also generate resistance in some communities as they challenge existing norms.
Despite the low quality of evidence, the panel concluded that increasing access to education for girls in order to delay marriage before the age of 18 years is important for social, economic and public health reasons. The higher the quality of evidence, the more likely a strong recommendation is warranted.

# o yES o nO
The systematic review process did not identify any eligible studies for inclusion.
uncertainty about the balance of benefits versus harms and burdens (is there uncertainty?)
The larger the difference between the desirable and undesirable consequences, the more likely a strong recommendation is warranted. The smaller the net benefit and the lower the certainty for that benefit, the more likely a conditional/weak recommendation is warranted.

# o yES o nO
Not applicable uncertainty or differences in values (is there uncertainty?)
The greater the variability or uncertainty in values and preferences, the more likely a conditional/weak recommendation is warranted.
- yES o nO

# Not applicable

# Resource implications
The higher the costs of an intervention -that is, the more the resources consumed -the more likely a conditional/ weak recommendation is warranted.

# o yES o nO

# Not applicable

# Overall strength of recommendation
Strong (for the action recommendation)
ii. RECOmmEnDAtiOns Question 1.7 Is there evidence that expanding the availability of livelihood opportunities for girls is effective in delaying marriage among girls under age 18?

# Recommendation for action
No specific intervention is recommended. Please refer to the recommendation for research related to this question.

# Recommendation for research
Undertake research on the feasibility of interventions to improve the livelihoods of adolescent girls as well as their impact on delaying their age of marriage.

# Remarks and summary of panel discussion
The systematic review process did not identify any studies eligible for grading. The panel noted ungraded evidence (3,4,7,8,10,17,18,20,21) regarding interventions to improve the livelihoods of adolescent girls in relation to delaying marriage. While the interventions were effective at delaying marriage among girls under 18 years of age, panel members discussed the weaknesses in study design as well as challenges in implementing these interventions. The panel also noted that none of the studies tested the effect of livelihood approaches alone.
The panel observed that these interventions had important potential social, economic and health-related benefits, including changes in gender norms. However, it also discussed several potential harms of these interventions. First, participation in these interventions could pose safety and security challenges for adolescent girls in some communities. Second, these interventions could result in unfulfilled expectations about the ability of participants and their families to earn money. Third, income-generating activities could act as disincentives to send adolescent girls to school. The panel noted that interventions to increase participation of girls in the economy could encounter resistance in some communities as they challenge existing norms.
The panel recognized the importance of protecting very young adolescent girls from labour. However, it noted that improving the capacity of adolescents to earn could have social and economic benefits at the individual and community levels that override potential harms. Due to the limited evidence, the panel could not recommend a specific intervention. It therefore recommended additional research to determine effective interventions to delay the age of marriage by improving the livelihoods of adolescent girls. The higher the quality of evidence, the more likely a strong recommendation is warranted.

# o yES o nO
The systematic review process did not identify any eligible studies for inclusion.
uncertainty about the balance of benefits versus harms and burdens (is there uncertainty?)
The larger the difference between the desirable and undesirable consequences, the more likely a strong recommendation is warranted. The smaller the net benefit and the lower the certainty for that benefit, the more likely a conditional/weak recommendation is warranted.

# Resource implications
The higher the costs of an intervention -that is, the more the resources consumed -the more likely a conditional/ weak recommendation is warranted.

# Remarks and summary of panel discussion
The panel considered low to moderate quality evidence from a graded systematic review (GRADE Table 1 (1)) that demonstrated reductions in unintended pregnancies relative to control groups among those exposed to the interventions. The panel noted that while the studies reviewed achieved the outcome of reducing pregnancy before the age of 20 years, this effect could not be attributed to interventions targeted at a specific group, such as parents or community leaders. It observed that while some of the studies were conducted in developing countries (Mexico and Nigeria), most included in the review were done among high-risk groups such as low socioeconomic segments in developed countries. All intervention studies in this review targeted girls or specifically adolescent girls. Some targeted additional audiences such as males, parents and community members. None of the studies reviewed explicitly targeted policy makers. Given the limitations of the available evidence, the panel acknowledged the need for research to identify intervention strategies that are effective for different target groups in order to reduce the chances of pregnancy before the age of 20 years. The panel noted that these interventions have clear social and health-related benefits and bear no identifiable harms. Panel members agreed that, although there are no identified conflicts in values, these interventions may generate resistance in some communities because they challenge accepted norms. Finally, the cost implications of these interventions were not formally assessed.
Despite the low quality of evidence, the panel recognized the importance of these interventions as well as the need for further research. The higher the quality of evidence, the more likely a strong recommendation is warranted.

# T nO
Low to moderate quality evidence from a graded systematic review (GRADE Table 1 (1)) demonstrated reductions in unintended pregnancies for intervention groups compared to controls. The panel noted that while the studies reviewed achieved the outcome of reducing pregnancy before age 20, there was no way to attribute this effect to interventions targeted at a specific group, such as parents or community leaders. It observed that while some of the studies were conducted in developing countries, most of the studies included in the review were done among poorer socioeconomic segments in developed countries. All of the intervention studies in this review targeted girls or specifically adolescent girls. Some targeted additional audiences such as males, parents and community members. None of the studies reviewed explicitly targeted policy makers.
uncertainty about the balance of benefits versus harms and burdens (is there uncertainty?)
The larger the difference between the desirable and undesirable consequences, the more likely a strong recommendation is warranted. The smaller the net benefit and the lower the certainty for that benefit, the more likely a conditional/weak recommendation is warranted.

# T nO
There are clear health-related and social benefits to reducing pregnancies before the age of 20 years and no identifiable harms.
uncertainty or differences in values (is there uncertainty?)
The greater the variability or uncertainty in values and preferences, the more likely a conditional/weak recommendation is warranted.

# T nO
There are no identified conflicts in values. However, these interventions could face resistance in some communities as they challenge current norms.

# Resource implications
The higher the costs of an intervention -that is, the more the resources consumed -the more likely a conditional/ weak recommendation is warranted.

# T yES o nO
These interventions will require resources for implementation and monitoring. The cost implications of these interventions were not assessed.

# Overall strength of recommendation
Strong (for the action recommendation)
Is there evidence that efforts to improve the economic situation of girls are effective in reducing pregnancy among girls under age 20?

# Recommendation for action
No specific intervention is recommended. Please refer to the recommendation for research related to this question.

# Recommendation for research
Undertake research to explore the effect of socioeconomic improvements brought about by employment and school retention on adolescent pregnancy and its mediating determinants.

# Remarks and summary of panel discussion
The systematic review process did not find any eligible studies for inclusion. The panel considered one ungraded study (2) that demonstrated a reduction in pregnancy before the age of 20 years by using a cash transfer intervention. As the strength of the evidence was insufficient to recommend this intervention, the panel noted the need for further research to demonstrate the evidence-based link between adolescent pregnancy and economic betterment (including employment). The higher the quality of evidence, the more likely a strong recommendation is warranted.

# o yES o nO
The systematic review process did not find any eligible studies for inclusion.
uncertainty about the balance of benefits versus harms and burdens (is there uncertainty?)
The larger the difference between the desirable and undesirable consequences, the more likely a strong recommendation is warranted. The smaller the net benefit and the lower the certainty for that benefit, the more likely a conditional/weak recommendation is warranted.

# Resource implications
The higher the costs of an intervention -that is, the more the resources consumed -the more likely a conditional/weak recommendation is warranted.

# Question 2.3b
Is there evidence that efforts directed at adolescents and other stakeholders to increase school retention among girls are effective in reducing the chances of second pregnancies during adolescence?
Recommendation for action (for questions 2.3a and 2.3b) -Strong recommendation 1. Maintain and improve efforts to retain girls in schools, both at the primary and secondary levels.

# Recommendations for research
Undertake research on the effect of availability of formal and non-formal education on adolescent pregnancy prevention. This research should consider potential mediating factors such as socioeconomic status and marital status. Undertake research on the effect of targeted interventions for education retention (e.g. conditional or unconditional cash-transfer interventions) and policies (including support for adolescent mothers) on delaying pregnancy and reducing second pregnancy.

# Remarks and summary of panel discussion
The systematic review process did not find any eligible studies for inclusion. The panel considered one ungraded review (3) that demonstrated reduced pregnancy rates as a result of a multi-component intervention that included early childhood education and youth development programs. The panel noted that these interventions were implemented only in developed-country settings. The panel recognized the significant protective association between secondary school retention and adolescent pregnancy and acknowledged that school retention for adolescent girls is important from both rightsbased and public health perspectives. Despite limited evidence, the panel recommended action to increase school retention of adolescent girls in order to reduce pregnancies during adolescence.
In addition to recommending action, the panel recognized the need to conduct further research in several areas related to this issue. First, it suggested that research must explore the association between school retention and adolescent pregnancy. Second, panel members recognized the importance of disaggregating data by social status due to the differing barriers faced by married and unmarried adolescents in different sociocultural contexts. Third, the panel suggested that research should test conceptual models related to school retention and delaying pregnancy. Fourth, the panel recommended that research into school retention should include measures of both quality and coverage of education programmes. Finally, the panel discussed possible methodologies for researching these outcomes. The higher the quality of evidence, the more likely a strong recommendation is warranted.

# o yES o nO
The systematic review process did not find any eligible studies for inclusion.
uncertainty about the balance of benefits versus harms and burdens (is there uncertainty?)
The larger the difference between the desirable and undesirable consequences, the more likely a strong recommendation is warranted. The smaller the net benefit and the lower the certainty for that benefit, the more likely a conditional/weak recommendation is warranted.

# o yES o nO
Not applicable uncertainty or differences in values (is there uncertainty?)
The greater the variability or uncertainty in values and preferences, the more likely a conditional or weak recommendation is warranted.
- yES o nO

# Not applicable

# Resource implications
The higher the costs of an intervention -that is, the more the resources consumed -the more likely a conditional/weak recommendation is warranted.  1 with contraceptive promotion to adolescents in order to reduce pregnancy rates.

# Remarks and summary of panel discussion
The panel considered low to moderate quality evidence from a graded systematic review that demonstrated a reduction in rates of unintended pregnancy as a result of sexuality education for adolescents (GRADE Table 1 (1)). Although this review included studies from both developing and developed countries, the majority of the interventions were implemented in developed countries and the panel noted this limitation. The panel members discussed several aspects of the delivery of this intervention. First, curriculum-based sexuality education may be delivered both in and out of school settings. Second, it is important to provide contraceptives in addition to education interventions. Third, policy-related and other barriers to implementation must be overcome if these interventions are to succeed. Fourth, since most pregnancy prevention studies focus on in-school populations there is a need for research on interventions for out-of-school adolescents. Fifth, building life skills (such as negotiation) is a critical component of sexuality education programmes. Finally, panel members suggested that research should also explore the role of parents (especially mothers) in influencing the behaviour of adolescent girls.  dEcISIOn EXplAnATIOn lower quality evidence (is there lower quality evidence?)
The higher the quality of evidence, the more likely a strong recommendation is warranted.

# T nO
Low to moderate quality evidence (GRADE Table 1 (1)) suggests that interventions that include curriculumbased sexuality education (CBSE) can reduce rates of unintended pregnancy.
uncertainty about the balance of benefits versus harms and burdens (is there uncertainty?)
The larger the difference between the desirable and undesirable consequences, the more likely a strong recommendation is warranted. The smaller the net benefit and the lower the certainty for that benefit, the more likely a conditional/weak recommendation is warranted.

# T nO
There are no identified harms. Despite common misconceptions, there is no evidence that sexuality education leads to early or increased sexual activity.
uncertainty or differences in values (is there uncertainty?)
The greater the variability or uncertainty in values and preferences, the more likely a conditional/weak recommendation is warranted.

# T nO
In some communities these interventions may face resistance because they challenge existing norms.

# Resource implications
The higher the costs of an intervention -that is, the more the resources consumed -the more likely a weak recommendation is warranted.

# T yES o nO
The costs of this intervention have not been assessed.

# Overall strength of recommendation
Strong ii. RECOmmEnDAtiOns Question 2.5 Is there evidence that efforts to provide postpartum and post-abortion contraception are effective in reducing second pregnancies among adolescents?
Recommendation for action -Strong recommendation 1. Offer and promote postpartum and post-abortion contraception to adolescents through multiple home visits and/or clinic visits to reduce the chances of second pregnancies among adolescents.

# Remarks and summary of panel discussion
The panel considered very low quality evidence from a graded systematic review to inform its recommendation (GRADE Table 2 (4)). The evidence demonstrated that interventions involving multiple postpartum contacts in home or health facility settings can improve contraceptive use and thereby reduce repeat pregnancies during adolescence. None of the interventions in the review examined the effect of providing post-abortion contraception to adolescents. The panel noted that the majority of the studies in this review were conducted in developed countries and a few were conducted in developing countries. It observed methodological flaws in the studies such as unclear methods, small sample sizes and short follow-up periods.
The benefits of interventions that provide postpartum and post-abortion contraception to adolescents are substantial with no identifiable harms. There are no conflicts in values associated with such interventions. The cost implications of these interventions have not been assessed. The panel noted that, where such services already exist, the cost of expanding access to these services for adolescents is minimal.
Despite the limited evidence, the panel recommended that these interventions should be offered to adolescent girls. InTERVEnTIOn: Multiple contacts through structured home visits and/or clinic visits.
dEcISIOn EXplAnATIOn lower quality evidence (is there lower quality evidence?)
The higher the quality of evidence, the more likely a strong recommendation is warranted.

# T yES o nO
Very low quality evidence from a graded systematic review (GRADE Table 2 (4 uncertainty about the balance of benefits versus harms and burdens (is there uncertainty?)
The larger the difference between the desirable and undesirable consequences, the more likely a strong recommendation is warranted. The smaller the net benefit and the lower the certainty for that benefit, the more likely a conditional/weak recommendation is warranted.

# T nO
The benefits of these interventions are substantial. There are no identified harms.
uncertainty or differences in values (is there uncertainty?)
The greater the variability or uncertainty in values and preferences, the more likely a conditional/weak recommendation is warranted.

# T nO
There are no identified conflicts in values.

# Resource implications
The higher the costs of an intervention -that is, the more the resources consumed -the more likely a conditional/weak recommendation is warranted.

# T nO
Where such programmes exist, the cost implications for expanding coverage to include adolescents are minimal.

# Overall strength of recommendation
Strong ii. RECOmmEnDAtiOns

# Question 2.6
Is there evidence that social support programmes are effective in reducing second pregnancies during adolescence?

# Recommendation for action
No specific intervention is recommended. Please refer to the recommendation for research related to this question.

# Recommendation for research
Undertake research about the design, feasibility, and effectiveness of social support interventions to reduce the chances of repeat pregnancies among adolescents.

# Remarks and summary of panel discussion
The systematic review process did not find any eligible studies for inclusion. The panel considered one ungraded review (5) that demonstrated a short-term reduction in repeat pregnancies as a result of an intervention that included home visits for social support.
The panel discussed several issues with respect to this question. First, it discussed the importance of establishing and testing definitions of social support within different sociocultural contexts. Second, the panel members acknowledged that efforts to prevent second pregnancy are consistent with efforts to increase birth spacing. Finally, since the evidence reviewed came only from developed countries, the panel highlighted the need for research in developing countries related to social support interventions to reduce the chances of repeat pregnancies among adolescents. The higher the quality of evidence, the more likely a strong recommendation is warranted.

# o yES o nO
The systematic review process did not find any eligible studies for inclusion.
uncertainty about the balance of benefits versus harms and burdens (is there uncertainty?)
The larger the difference between the desirable and undesirable consequences, the more likely a strong recommendation is warranted. The smaller the net benefit and the lower the certainty for that benefit, the more likely a conditional/weak recommendation is warranted.

# o yES o nO
Not applicable uncertainty or differences in values (is there uncertainty?)
The greater the variability or uncertainty in values and preferences, the more likely a conditional/weak recommendation is warranted.
- yES o nO

# Not applicable

# Resource implications
The higher the costs of an interventionthat is, the more the resources consumed -the more likely a conditional/weak recommendation is warranted. ii. RECOmmEnDAtiOns Question 3.1 Is there evidence that efforts directed at political leaders/planners, including those at the community level, have resulted in the formulation of laws and policies that increase access to contraceptive information and services for adolescents?
Is there evidence that efforts directed at political leaders/planners, including those at the community level, have resulted in the formulation of laws and policies that increase access to emergency contraception for adolescents?
Recommendation for action (for Question 3.1 and 3.2) -Strong recommendation 1. Undertake efforts with political leaders and planners to formulate laws and policies to increase adolescent access to contraceptive information and services, including emergency contraceptives.

# Recommendation for research
Undertake research to identify feasible and effective interventions that result in the formulation of such laws and policies.

# Remarks and summary of panel discussion
The systematic review process did not find evidence that was eligible for grading. The panel remarked that efforts to influence laws and policies are rarely subject to evaluations of the type included in this review.
The panel observed that limitations to access that are stipulated in laws and policies most often relate to marital status and age. Therefore, it noted that the existence of laws and policies that mandate adolescent access to contraceptive information and services irrespective of their age or marital status can improve contraceptive use by adolescents. The panel agreed that contraceptive information and services can prevent unwanted pregnancies among all women including adolescents. There are no significant harms foreseen.
The panel agreed that the formulation of laws and policies to improve adolescents' access to contraceptive information and services is important from both rights-based and public health perspectives. It noted that the provision of contraceptive information and services to adolescents can be controversial as it challenges existing norms. It also recognized that this sensitivity is an important consideration for the design of interventions to influence laws and policies. The costs associated with efforts to influence the formulation of laws and policies were not assessed.
The panel concluded that the existence of laws and policies that improve adolescents' access to contraceptive information and services, irrespective of marital status and age, can contribute to preventing unwanted pregnancies among this group. The higher the quality of evidence, the more likely a strong recommendation is warranted.

# o yES o nO
The systematic review process did not find any eligible studies for inclusion.
uncertainty about the balance of benefits versus harms and burdens (is there uncertainty?)
The larger the difference between the desirable and undesirable consequences, the more likely a strong recommendation is warranted.
The smaller the net benefit and the lower the certainty for that benefit, the more likely that a conditional/weak recommendation is warranted.

# Resource implications
The higher the costs of an intervention -that is, the more the resources consumed -the more likely a conditional/weak recommendation is warranted. The higher the quality of evidence, the more likely a strong recommendation is warranted.

# o yES o nO
The systematic review process did not find any eligible studies for inclusion.
uncertainty about the balance of benefits versus harms and burdens (is there uncertainty?)
The larger the difference between the desirable and undesirable consequences, the more likely a strong recommendation is warranted.
The smaller the net benefit and the lower the certainty for that benefit, the more likely a conditional/weak recommendation is warranted.

# Resource implications
The higher the costs of an intervention -that is, the more the resources consumed -the more likely that a conditional/weak recommendation is warranted.
- yES o nO

# Not applicable

# Overall strength of recommendation
Strong (for the action recommendation)
ii. RECOmmEnDAtiOns Question 3.3 Is there evidence that efforts directed at community members and leaders are effective in increasing access to contraceptives for adolescents?
Recommendation for action -Strong recommendation 1. Undertake interventions to influence community members to support access to contraceptives for adolescents.

# Recommendation for research
Undertake research to identify and evaluate interventions that influence community members' support for access to contraceptives for adolescents.

# Remarks and summary of panel discussion
The systematic review process did not find studies that were eligible for grading. The panel noted ungraded evidence from several developing countries that demonstrated increased use of contraceptives resulting from interventions that included efforts directed at community members and leaders (1)(2)(3)(4)(5)(6)(7)(8)(9)(10)(11). These interventions ranged from community-wide mass media education to sensitization of individual parents in communities. The panel recognized the difficulties in attributing observed outcomes to those intervention components that specifically targeted community members and leaders. It also observed that the majority of these studies reported pregnancy as a secondary outcome.
The panel acknowledged that communicating the rationale for adolescent contraceptive provision to the community could facilitate access to and use of contraceptives by adolescents. Panel members noted that a potential harm of this intervention is that a negative response by the community can adversely affect adolescent health programmes including contraceptive provision.
The panel recognized that these interventions would encounter resistance in some communities because they challenge existing norms. Panel members agreed that acceptance of contraceptive provision by the community is important. They also agreed that interventions to understand and respond to a community's concerns about the health and development of adolescents should be implemented. No significant harms were foreseen. The costs of these interventions were not assessed.
Despite limited evidence, the panel recommended interventions to influence community members to support access to contraceptives by adolescents. The higher the quality of evidence, the more likely a strong recommendation is warranted.

# o yES o nO
The systematic review process did not find any eligible studies for inclusion.
uncertainty about the balance of benefits versus harms and burdens (is there uncertainty?)
The larger the difference between the desirable and undesirable consequences, the more likely a strong recommendation is warranted. The smaller the net benefit and the lower the certainty for that benefit, the more likely a conditional/weak recommendation is warranted.

# Resource implications
The higher the costs of an interventionthat is, the more the resources consumed -the more likely a conditional/weak recommendation is warranted.

# o yES o nO

# Overall strength of recommendation
Strong (for the action recommendation)
ii. RECOmmEnDAtiOns Question 3.4 Is there evidence that efforts to improve health services are effective in increasing access to contraceptive information and services (including emergency contraception) for adolescents?
Recommendation for action -Strong recommendation 1. Implement interventions to improve health service delivery to adolescents as a means of facilitating their access to and use of contraceptive information and services.

# Remarks and summary of panel discussion
The panel considered a number of graded studies to inform its recommendation. Very low quality evidence from a graded systematic review (GRADE Table 3) ( 12) reported an increase in subsequent contraceptive use as a result of multiple postnatal visits with health workers. The panel noted that although this review included studies from both developed and developing countries the majority were implemented in developed countries. Moderate quality evidence from another graded study (GRADE Table 4) ( 13) reported increased use of contraceptives as a result of a package of interventions that included improvements in health service delivery to adolescents. Very low quality evidence from a third graded study (GRADE Table 5) ( 14) reported an increase in the use of condoms at last sexual contact as a result of a voucher system to facilitate access to contraceptive information and services. The panel noted that these interventions collectively resulted in increased knowledge about contraceptives and improved use of contraceptive services by adolescents.
The panel also noted ungraded evidence from several low-and middle-income countries that demonstrated increase in knowledge about contraceptives and increased demand for and use of contraceptives among adolescents resulting from improvements to health services (3,7,9,(15)(16)(17)(18).
Panel members noted the importance of access to health services as an important component of adolescent health. The panel recognized that there are endeavours in many countries to improve adolescents' access to health services, including training health workers to influence their attitudes about the provision of contraceptives to adolescents. The panel concluded that, with adequate training, health workers would overcome their reticence and acknowledge the potential health benefits of providing contraceptive information and services to adolescents. The panel also agreed that health services for adolescents should be reoriented to improve access by overcoming the adolescent-specific barriers to their access and use. There are no ascertainable harms or burdens foreseen. The cost implications of these interventions were not assessed.
After examining the existing evidence, the panel made a strong recommendation to implement interventions to improve health service delivery to adolescents.

# OuTcOmE 3: increase use of contraception by adolescents at risk of unintended pregnancy
ii. RECOmmEnDAtiOns factors considered for Question 3.4 pOpulATIOn: Adolescents, health workers and managers, and policy leaders/planners InTERVEnTIOnS: Multiple postnatal visits with health workers (12); multiple interventions that include changes to health facilities, engaging and informing community members and training providers to be youth friendly services (13); voucher system to facilitate access to sexual and reproductive health services (14) fAcTOR dEcISIOn EXplAnATIOn lower quality evidence (is there lower quality evidence?)
The higher the quality of evidence, the more likely a strong recommendation is warranted.

# T nO
A graded (very low quality) systematic review (GRADE Table 3) ( 12) reported an increase in subsequent contraceptive use as a result of multiple postnatal visits with health workers. This review included studies from both developed and developing countries, though the majority were implemented in developed countries. A graded (moderate quality) study (GRADE Table 4) ( 13) reported increase in the use of condoms as a result of a package of interventions that included improvements in health service delivery to adolescents.
A graded (very low quality) study (GRADE Table 5) ( 14) reported an increase in the use of condoms at last sexual contact as a result of a voucher system to facilitate access to contraceptive information and services.
uncertainty about the balance of benefits versus harms and burdens (is there uncertainty?)
The larger the difference between the desirable and undesirable consequences, the more likely a strong recommendation is warranted. The smaller the net benefit and the lower the certainty for that benefit, the more likely a conditional/weak recommendation is warranted.

# T nO
There are no ascertainable harms or burdens based on this type of intervention. Access to health services by adolescents, including the provision of contraceptive information and services, is important for a variety of health reasons including current and future fertility regulation.
uncertainty or differences in values (is there uncertainty?)
The greater the variability or uncertainty in values and preferences, the more likely a conditional/weak recommendation is warranted.

# T nO
There are no identified conflicts in values.

# Resource implications
The higher the costs of an interventionthat is, the more the resources consumed -the more likely a conditional/weak recommendation is warranted.

# T yES o nO
The costs of these interventions were not assessed.

# Overall strength of recommendation
Strong ii. RECOmmEnDAtiOns Question 3.5 Is there evidence that efforts to make hormonal contraceptive methods, including emergency contraception, available over-the-counter are effective in increasing the access to contraceptives by adolescents?

# Recommendation for action
No specific intervention is recommended. Please refer to the recommendation for research related to this question.

# Recommendation for research
Undertake research to identify feasible and effective interventions to improve the availability of over-the-counter hormonal contraceptives to adolescents.

# Remarks and summary of panel discussion
The panel considered low quality evidence from a graded systematic review (GRADE Table 6) ( 19) that included studies assessing unlimited emergency contraceptive provision or pharmacy provision of contraceptives. The panel noted that, although this review included studies from both developed and developing countries, the majority were implemented in developed countries. The panel observed the many instances in which over-the-counter provision of condoms had improved access compared to static health service provision. However, the panel expressed concerns regarding the accuracy and thoroughness of information provided to adolescents about hormonal contraceptives (including emergency contraceptives) when delivered over-the-counter. The panel also recognized that misuse of contraceptives by adolescents due to inaccurate or incomplete information or lack of follow-up was a potential harm for this intervention. The panel agreed that there could be bias or ambiguity among pharmacists or vendors regarding the acceptability of providing contraceptives in light of policies or community norms related to adolescent sexual activity. However, the reluctance of providers may be overcome by training or by appealing to their commercial interests.
Based on the limited research, the panel decided not to recommend a specific intervention but concluded that further research is required to identify interventions that improve contraceptive accessibility. lower quality evidence (is there lower quality evidence?)
The higher the quality of evidence, the more likely a strong recommendation is warranted.

# T yES o nO
Low quality evidence (GRADE Table 6) ( 19) showed an increased rate of hormonal contraceptive use in the intervention group compared to the control group for interventions that aimed to improve overthe-counter access to contraceptives for adolescents. The panel noted that most of the interventions in this systematic review were implemented in developed countries.
uncertainty about the balance of benefits versus harms and burdens (is there uncertainty?)
The larger the difference between the desirable and undesirable consequences, the more likely a strong recommendation is warranted. The smaller the net benefit and the lower the certainty for that benefit, the more likely a conditional/ weak is recommendation.

# o yES o nO
Not applicable uncertainty or differences in values (is there uncertainty?)
The greater the variability or uncertainty in values and preferences, the more likely a conditional/weak recommendation is warranted.
- yES o nO

# Not applicable

# Resource implications
The higher the costs of an interventionthat is, the more the resources consumed -the more likely a conditional/weak recommendation is warranted.

# o yES o nO

# Overall strength of recommendation

# Not applicable
ii. RECOmmEnDAtiOns Question 3.6 Is there evidence that efforts to provide accurate information and education about contraceptives to adolescents are effective in increasing contraceptive use among adolescents?
Recommendation for action -Strong recommendation 1. Implement interventions at scale that provide accurate information and education about contraceptives, in particular CBSE, to increase contraceptive use among adolescents.

# Recommendation for research:
Undertake research to determine the effectiveness of interventions that provide accurate information and education about contraceptives in various settings and populations (both in-school and out-of-school).

# Remarks and summary of panel discussion
The panel considered a number of graded studies to inform its recommendations on this issue. First, it considered low quality evidence from a graded systematic review (GRADE Table 7) ( 19) that demonstrated increased condom use at last sex in intervention groups that were exposed to CBSE. Although this review included studies from both developed and developing countries, the majority were implemented in developed countries; a limitation noted by the panel. Very low quality evidence from a graded study in Brazil (GRADE Table 8) ( 20) demonstrated increased condom use with casual partners as a result of a CBSE intervention. Moderate quality evidence from a graded study of a school-based CBSE intervention in the Bahamas (GRADE Table 9) ( 21) demonstrated an increase in condom use at six and 12 months post-intervention among those exposed to CBSE. Moderate quality evidence from a graded study from rural Tanzania demonstrated increased condom use during the follow-up of a set of interventions that included CBSE (GRADE Table 4) (13). Finally, low quality evidence from a graded study of a culturally sensitive CBSE intervention implemented in Thailand demonstrated an increase in the intent to use condoms among adolescents in the intervention group (GRADE Table 10) (22). The panel also noted the several ungraded studies in low-and middle-income countries that demonstrated increase in contraceptive use due to educational interventions for adolescents (1,(3)(4)(5)(6)(7)(8)10,11,13,15,17,(23)(24)(25)(26)(27)(28)(29)(30)(31)(32). These interventions varied widely in their level of structure (from peer education to CBSE) and setting (both in-school and out-ofschool). The panel noted methodological issues such as small sample sizes, short followups, and lack of comparison groups that limited the ability to attribute outcomes to the interventions. Panel members also noted as a limitation that some of the studies were primarily focused on condom use for HIV prevention rather than for contraception.
The panel recognized that these interventions are important from both rights-based and public health perspectives. It also did not identify any potential harm resulting from these interventions. Despite a common misconception in some communities, the panel noted evidence that CBSE has no effect on the age of sexual initiation (20). It opined that these interventions could encounter resistance in some communities as they challenge existing norms. The panel also noted that, although the costs of these interventions were not assessed, the cost of ensuring the quality and coverage of these interventions would be considerable.
Given the available evidence, the panel recommended interventions to provide accurate information and education about contraceptives to adolescents. lower quality evidence (is there lower quality evidence?)
The higher the quality of evidence, the more likely a strong recommendation is warranted.

# T nO
The panel considered a number of graded studies to inform its recommendations on this issue. First, it considered low quality evidence from a graded systematic review (GRADE Table 7) ( 19) that demonstrated increased condom use at last sex in intervention groups that were exposed to CBSE. Although this review included studies from both developed and developing countries, the majority were implemented in developed countries. The panel noted this limitation. Very low quality evidence from a graded study in Brazil (GRADE Table 8) ( 20) demonstrated increased condom use with casual partners as a result of a CBSE intervention. Moderate quality evidence from a graded study of a school-based CBSE intervention in the Bahamas (GRADE Table 9) ( 21) demonstrated an increase in condom use at 6 and 12 months post-intervention among those exposed to CBSE. Moderate quality evidence from a graded study from rural Tanzania demonstrated increased condom use during the follow-up of a set of interventions that included CBSE (GRADE Table 4) (13). Finally, low quality evidence from a graded study of a culturally sensitive CBSE intervention implemented in Thailand demonstrated an increase in the intent to use condoms among adolescents in the intervention group (GRADE Table 10) (22).
uncertainty about the balance of benefits versus harms and burdens (is there uncertainty?)
The larger the difference between the desirable and undesirable consequences, the more likely a strong recommendation is warranted.
The smaller the net benefit and the lower the certainty for that benefit, the more likely a conditional/weak recommendation is warranted.

# T nO
These interventions are beneficial from rights-based and public health perspectives. No ascertainable harms were identified. The panel noted that CBSE has no effect on the age of sexual initiation (20).
uncertainty or differences in values (is there uncertainty?)
The greater the variability or uncertainty in values and preferences, the more likely a conditional/weak recommendation is warranted.

# T nO
There were no identified conflicts in values.

# Resource implications
The higher the costs of an intervention -that is, the more the resources consumed -the more likely a conditional/weak recommendation is warranted.

# T yES o nO
There are likely to be considerable costs in sustaining and ensuring wide coverage of good quality CBSE programmes.

# Overall strength of recommendation
Strong (for the action recommendation)
ii. RECOmmEnDAtiOns Question 3.7
Is there evidence that efforts to involve males in contraceptive decisions 'by the couple' are effective in increasing contraceptive use among adolescents?

# Recommendation for action
No specific intervention is recommended. Please refer to the recommendation for research related to this question.

# Recommendation for research
Undertake research to identify feasible and effective interventions that aim to involve adolescent and adult males in decisions about contraceptive use by partners as well as by themselves. This research should include interventions that aim to transform gender norms.

# Remarks and summary of panel discussion
The systematic review process did not find evidence that was eligible for grading. The panel noted ungraded evidence related to interventions such as group educational sessions that targeted adolescent boys to transform inequitable gender attitudes (33). This study demonstrated that among males who had reduced agreement with inequitable gender norms as a result of the intervention, reduced STI symptoms and a greater likelihood of condom use at last sex with a primary partner were reported. The panel examined ungraded evidence from a study in India that demonstrated increased demand for and use of contraceptives as a result of an intervention that included efforts directed at males (3). Ungraded evidence from a study in China demonstrated an increase in joint decisions by couples on contraceptive use as a result of an intervention that involved males (7). The panel observed methodological flaws in these studies that limited the ability to attribute the outcomes to those components of the interventions that were specifically directed at males. The panel noted that involvement of males in decisions around contraceptive use can have important health-related and social benefits. The panel recognized the potential harm of causing conflict between partners over reproductive decision-making and noted the barriers that males can present to a woman's autonomous use of contraceptives. The panel recognized the need to work with males (including adolescent males) to reduce these barriers. It did not identify any conflicts in values.
Given the importance of both male and female contraceptive use for reducing early pregnancy, the panel recommended that further research be done to identify effective interventions that involve males in contraceptive decisions. lower quality evidence (is there lower quality evidence?)
The higher the quality of evidence, the more likely a strong recommendation is warranted.

# o yES o nO
The systematic review process did not find any eligible studies for inclusion.
uncertainty about the balance of benefits versus harms and burdens (is there uncertainty?)
The larger the difference between the desirable and undesirable consequences, the more likely a strong recommendation is warranted. The smaller the net benefit and the lower the certainty for that benefit, the more likely a conditional/weak recommendation is warranted.

# o yES o nO
Not applicable uncertainty or differences in values (is there uncertainty?)
The greater the variability or uncertainty in values and preferences, the more likely a conditional/weak recommendation is warranted.
- yES o nO

# Not applicable

# Resource implications
The higher the costs of an intervention -that is, the more the resources consumed -the more likely a conditional/weak recommendation is warranted.
- yES o nO

# Not applicable
Overall strength of recommendation

# Not applicable
ii. RECOmmEnDAtiOns Question 3.8 Is there evidence that efforts to reduce the financial cost of contraceptives for adolescents are effective in increasing contraceptive use among adolescents?
Recommendation for action -conditional recommendation 1. Implement interventions to reduce the financial cost of contraceptives to adolescents.

# Recommendation for research
Undertake research on the feasibility, sustainability and impact of reducing the financial cost of contraceptives specifically to adolescents.

# Remarks and summary of panel discussion
The panel considered low quality evidence from a graded systematic review (GRADE Table 6) ( 19) that included studies that demonstrated higher rates of hormonal contraceptive use as a result of free and advance provision of emergency contraceptives to adolescents. Although this review included studies from both developed and developing countries, the majority were implemented in developed countries; and the panel noted this limitation. The panel also considered very low quality evidence from a graded study (GRADE Table 5) ( 14) in which vouchers were distributed to adolescents for free access to health services. This study demonstrated higher use of modern contraceptives and higher use of condoms at last sex for those who received vouchers compared to those who did not.
The panel made note of ungraded evidence from studies conducted in low-and middle-income countries that demonstrated increased use of contraceptives as a result of interventions that reduced their financial cost (9,10,25,27-29, 31). One study in China (28) involved an intervention that reduced the financial barriers to accessing both health services as well as contraceptives. Panel members noted a lack of evidence for examining efforts to reduce the financial cost of non-condom contraceptives.
The panel noted that there are significant public health benefits to improving access to contraceptives for adolescents by reducing their financial cost. They recognized that these benefits outweigh both the potential costs associated with administering such programmes as well as the costs associated with subsidizing contraceptives for adolescents. The panel did not identify any potential harm associated with these interventions.
The panel noted that these interventions may encounter resistance in some communities because they challenge existing norms. It also noted that the subsidized provision of contraceptives exclusively to adolescents may be considered to discriminate against those adults without adequate financial resources to purchase contraceptives. The panel observed that the costs and sustainability of these interventions were not assessed.
The panel noted that cost is frequently a barrier for adolescents because of their limited financial resources. However, given the limited evidence about the effectiveness of interventions to reduce the cost of contraceptives, the panel recommended additional research on this question. lower quality evidence (is there lower quality evidence?)
The higher the quality of evidence, the more likely a strong recommendation is warranted.

# T nO
Low quality evidence from a graded systematic review (GRADE Table 6) ( 19) demonstrated higher rates of hormonal contraceptive use as a result of free and advance provision of emergency contraceptives to adolescents. Although this review included studies from both developed and developing countries, the majority were implemented in developed countries. The panel noted this limitation. The panel also considered one (very low quality) graded study (GRADE Table 5) ( 14) in which vouchers were distributed to adolescents for free access to services. This study demonstrated higher use of modern contraceptives and higher use of condoms at last sex for those who received vouchers compared to those who did not.
uncertainty about the balance of benefits versus harms and burdens (is there uncertainty?)
The larger the difference between the desirable and undesirable consequences, the more likely a strong recommendation is warranted.
The smaller the net benefit and the lower the certainty for that benefit, the more likely a conditional/weak recommendation is warranted.

# T nO
There is no uncertainty about the balance of benefits versus harms and burdens. The health benefits of contraception to prevent unsafe and/or unwanted pregnancy in adolescents outweigh the associated administrative costs and the real costs of subsidizing contraceptives.
uncertainty or differences in values (is there uncertainty?)
The greater the variability or uncertainty in values and preferences, the more likely a conditional/weak recommendation is warranted.

# T yES o nO
The panel noted that these interventions may encounter resistance in some communities because they challenge existing norms. It also noted that the subsidized provision of contraceptives exclusively to adolescents may be considered to discriminate against those adults without adequate financial resources to purchase contraceptives.

# Resource implications
The higher the costs of an intervention -that is, the more the resources consumed -the more likely a conditional/weak recommendation is warranted.

# T yES o nO
Sustainability of these interventions is likely to be an issue as the costs could be considerable.

# Overall strength of recommendation
Conditional (for the action recommendation)
ii. RECOmmEnDAtiOns  ii. RECOmmEnDAtiOns Question 4.1 Is there evidence that efforts directed at political leaders/planners, including those at the community level, have resulted in the formulation of laws and policies that punish perpetrators of coerced sex or support the reporting of coerced sex involving adolescent girls?
Is there evidence that efforts directed at political leaders/planners, including those at the community level, have resulted in enforcing laws regarding coerced sex involving adolescent girls?
Recommendation for action (combined for 4.1 and 4.2) -Strong recommendation 1. Continue efforts with political leaders, planners and the community to formulate laws and policies that punish perpetrators of coerced sex involving adolescent girls, to enforce these laws and policies in a way that empowers victims and their families, and to monitor their enforcement.
Recommendation for research (combined for 4.1 and 4.2) Undertake research:
- To assess how laws and policies to prevent coerced sex involving adolescent girls have been formulated, enforced and monitored. - To determine the effectiveness of these laws and policies in preventing coerced sex among adolescents.

# Remarks and summary of panel discussion
The systematic review process did not identify any evidence that addressed this question.
The panel observed that efforts to formulate, enforce, and monitor laws and policies are unlikely to be addressed by intervention studies. Panel members agreed that the evaluation of laws and policies requires a different methodology than that used to evaluate interventions for this review.
The panel noted that laws to protect women from sexual violence (including sexually coercive offences) and to provide options for redress have been enacted by two developing countries, India (1,2) and South Africa (3,4). The panel also noted that laws and policies that specifically criminalize the sexual coercion of adolescent girls have recently been adopted in other countries. However, the impact of these laws has not been formally evaluated.
Panel members agreed that laws and policies to reduce coerced sex are important from both rights-based and public health perspectives. The panel recognized that the formulation, enforcement and monitoring of laws and polices will contribute to reducing coerced sex only if individuals and families are aware of them and feel able and willing to collaborate with law enforcement officials to bring perpetrators to justice.
Despite the lack of evidence, the panel concluded that unwanted pregnancies among adolescents, that occur as a result of coerced sex, could be reduced by effective laws and policies to deter sexual coercion and violence. The higher the quality of evidence, the more likely a strong recommendation is warranted.

# o yES o nO
The systematic review process did not identify any eligible studies for inclusion.
uncertainty about the balance of benefits versus harms and burdens (is there uncertainty?)
The larger the difference between the desirable and undesirable consequences, the more likely a strong recommendation is warranted. The smaller the net benefit and the lower the certainty for that benefit, the more likely a conditional/weak recommendation is warranted.

# Remarks and summary of panel discussion
The panel made note of very low quality evidence from one graded study (GRADE Table 11 and GRADE Table 12) ( 5) and moderate quality evidence from another graded study (GRADE Table 13) ( 6) demonstrating that interventions to influence social norms may have a positive effect on attitudes and behaviours to resist sexual coercion.
The panel noted one ungraded study ( 7) that was also used to inform its discussion. Panel members recognized that these interventions yield significant benefits without any perceived harms. They also noted that implementing these interventions may result in social tension as it may challenge existing norms and practices in some communities.
The cost implications of such interventions have not been assessed.
The panel members agreed that interventions to empower girls to resist coerced sex must also be combined with interventions among men and boys to change their behaviours regarding violence and coerced sex. Therefore the panel's recommendation on Question 4.3 should be read alongside its recommendation on Question 4.4. 1. Communication programme involving mass media, small media and interpersonal communication directed at various community members to influence social norms. COMBINED WITH: 2. Teaching and discussion sessions involving small groups of adolescent girls to enhance their ability to resist coerced sex by building their self esteem, by building their life skills in areas such as communication and negotiation, and by improving their links to social networks and their ability to obtain social support.
fAcTOR dEcISIOn EXplAnATIOn lower quality evidence (is there lower quality evidence?)
The higher the quality of evidence, the more likely a strong recommendation is warranted.

# T nO
The graded studies demonstrated positive direct and indirect effects on girls' attitudes and behaviours to resist sexual coercion.
(GRADE Table 11 & 12) (5); GRADE Table 13) ( 6).
uncertainty about the balance of benefits versus harms and burdens (is there uncertainty?)
The larger the difference between the desirable and undesirable consequences, the more likely a strong recommendation is warranted. The smaller the net benefit and the lower the certainty for that benefit, the more likely a conditional/weak recommendation is warranted.

# T nO
Strengthening the ability of adolescent girls to resist coerced sex would contribute to the outcome of reducing too-early pregnancy.
There are no perceived harms.
uncertainty or differences in values (is there uncertainty?)
The greater the variability or uncertainty in values and preferences, the more likely a conditional/weak recommendation is warranted.

# T nO
These types of interventions could result in some social tension as they may challenge existing social norms and practices.

# Resource implications
The higher the cost of an interventionthat is, the more the resources consumed -the more likely a conditional/weak recommendation is warranted.

# T yES o nO
The interventions listed will require resources for planning, implementation and monitoring.

# Overall strength of recommendation
Strong ii. RECOmmEnDAtiOns Question 4.4 Is there evidence that efforts to reduce the use of coercion by males to obtain sex have had an impact?
Recommendation for action -Strong recommendation 1. Implement interventions to engage men and boys to critically assess gender norms and normative behaviours (e.g. gender transformative approaches) that relate to sexual coercion and violence. Combine these with wider interventions to influence social norms on these issues.

# Remarks and summary of panel discussion
The panel made note of very low quality evidence from one graded study (GRADE Table 11 and GRADE Table 12) ( 5) and moderate quality evidence from another graded study (GRADE uncertainty about the balance of benefits versus harms and burdens (is there uncertainty?)
The larger the difference between the desirable and undesirable consequences, the more likely a strong recommendation is warranted. The smaller the net benefit and the lower the certainty for that benefit, the more likely that a conditional/weak recommendation is warranted.

# T yES o nO
These interventions can contribute to decreasing sexually coercive behaviour and thereby contribute to the outcome of reducing tooearly pregnancy.
Interventions to reduce sexual coercion may result in men and boys using alternative strategies to reassume control in sexual encounters.
uncertainty or differences in values (is there uncertainty?)
The greater the variability or uncertainty in values and preferences, the more likely a conditional/weak recommendation is warranted.

# T nO
There were no identified conflicts in values.

# Resource implications
The higher the costs of an intervention -that is, the more the resources consumed -the more likely a conditional/weak recommendation is warranted.

# T yES o nO
The interventions listed will require resources for planning, implementation and monitoring.

# Overall strength of recommendation
Strong ii. RECOmmEnDAtiOns Question 5.1 Is there evidence that efforts directed at policy leaders/planners and community leaders are effective in improving access to safe abortion for adolescents according to existing laws?
Recommendation for action -Strong recommendation 1. Ensure that laws and policies enable adolescents to obtain safe abortion services.

# Recommendation for research
Where laws and policies have been formulated to enable safe abortion services for adolescents, undertake research to assess their enforcement and impact.

# Remarks and summary of panel discussion
The systematic review process did not identify any evidence that addressed this question. The panel observed that intervention studies were unlikely to address the formulation, enforcement and impact of laws and policies to enable safe abortion services for adolescents.
Panel members noted that unsafe abortions contribute substantially to maternal mortality in adolescent and adult women. Further, restrictive legislation increases the likelihood of pregnant women and adolescents having unsafe abortions. The panel concluded that it is likely that the existence of laws and polices that enable adolescents to obtain safe abortion services could reduce unsafe abortion if their formulation is combined with efforts to apply them. Panel members noted that in some communities there may be a conflict of values regarding the legalization of abortion.
The panel recommended the formulation of such laws and policies from both rightsbased and public health perspectives. The higher the quality of evidence, the more likely a strong recommendation is warranted.

# o yES o nO
The systematic review process did not identify any eligible studies for inclusion.
uncertainty about the balance of benefits versus harms and burdens (is there uncertainty?)
The larger the difference between the desirable and undesirable consequences, the more likely a strong recommendation is warranted. The smaller the net benefit and the lower the certainty for that benefit, the more likely that a conditional/ weak recommendation is warranted.

# o yES o nO
Not applicable uncertainty or differences in values (is there uncertainty?)
The greater the variability or uncertainty in values and preferences, the more likely a conditional/ weak recommendation is warranted.
- yES o nO

# Not applicable

# Resource implications
The higher the cost of an intervention -that is, the more the resources consumed -the more likely a conditional/weak recommendation is warranted.
- yES o nO

# Not applicable

# Overall strength of recommendation
Strong (for the action recommendation)
ii. RECOmmEnDAtiOns Question 5.2 Is there evidence that efforts to inform adolescents and other stakeholders about the conditions under which abortions are legal are effective in reducing unsafe abortions among adolescents?
Recommendation for action -Strong recommendation 1. Enable adolescents to obtain safe abortion services by informing them and other stakeholders about:
- the dangers of unsafe methods of interrupting a pregnancy;
- safe abortion services that are legally available; and
- where and under what circumstances these services can be obtained legally.

# Remarks and summary of panel discussion
The systematic review process did not identify any evidence that addressed this question. The panel noted that informing adolescents and other stakeholders about what abortion services are available, and where and under what circumstances they could be obtained legally could reduce unsafe abortion if there are complementary efforts to ensure their provision.
In some settings, some segments of the population could protest the provision of such information.
The panel concluded that such efforts to inform adolescents about abortion services (where legal) are important from both rights-based and public health perspectives. The higher the quality of evidence, the more likely a strong recommendation is warranted.

# o yES o nO
The systematic review process did not identify any eligible studies for inclusion.
uncertainty about the balance of benefits versus harms and burdens (is there uncertainty?)
The larger the difference between the desirable and undesirable consequences, the more likely a strong recommendation is warranted. The smaller the net benefit and the lower the certainty for that benefit, the more likely a conditional/weak recommendation is warranted.

# o yES o nO
Not applicable uncertainty or differences in values (is there uncertainty?)
The greater the variability or uncertainty in values and preferences, the more likely a conditional/weak recommendation is warranted.
- yES o nO

# Not applicable

# Resource implications
The higher the cost of an interventionthat is, the more the resources consumed -the more likely a conditional/weak recommendation is warranted.

# o yES o nO

# Overall strength of recommendation
Strong ii. RECOmmEnDAtiOns Question 5.3 Is there evidence that efforts to reduce barriers are effective in increasing access to and use of safe abortion services among adolescents according to existing laws?
Recommendation for action -Strong recommendation 1. Identify and overcome barriers to the provision of safe abortion services to adolescents.

# Recommendation for research
Undertake research about the feasibility and effectiveness of interventions to reduce barriers to the provision of safe, legal abortion services to adolescents.

# Remarks and summary of panel discussion
The systematic review process did not identify any evidence that addressed this question. The panel noted that where safe abortion services are legally available, identifying and overcoming barriers to their provision and use by adolescents could reduce unsafe abortions. This is because adolescent girls face barriers to obtaining these services even where they are legal and safe.
The panel concluded that efforts to identify and overcome these barriers are important from both rights-based and public health perspectives. The higher the quality of evidence, the more likely a strong recommendation is warranted.

# o yES o nO
The systematic review process did not identify any eligible studies for inclusion.
uncertainty about the balance of benefits versus harms and burdens (is there uncertainty?)
The larger the difference between the desirable and undesirable consequences, the more likely a strong recommendation is warranted. The smaller the net benefit and the lower the certainty for that benefit, the more likely a conditional/weak recommendation is warranted.

# o yES o nO
Not applicable uncertainty or differences in values (is there uncertainty?)
The greater the variability or uncertainty in values and preferences, the more likely a conditional/ weak recommendation is warranted.
- yES o nO

# Not applicable

# Resource implications
The higher the costs of an intervention -that is, the more the resources consumed -the more likely a conditional/weak recommendation is warranted. ii. RECOmmEnDAtiOns Question 5.4 Is there evidence that efforts to increase the availability of post-abortion services are effective in reducing post-abortion mortality and morbidity among adolescents?
Recommendation for action -Strong recommendation 1. Ensure access to post-abortion care by adolescents as a life-saving medical intervention, whether or not the abortion or attempted abortion was legal.

# Recommendation for research
Undertake research to investigate the feasibility and effectiveness of interventions to ensure access to post-abortion care by adolescents.

# Remarks and summary of panel discussion
The systematic review process did not identify any evidence that addressed this question. The panel noted that ensuring access to post-abortion care services for adolescents could reduce maternal mortality. It also recognized that such efforts are important from both rights-based and public health perspectives. Despite the lack of evidence, the panel concluded that interventions to ensure access to post-abortion care by adolescents should be implemented. The higher the quality of evidence, the more likely a strong recommendation is warranted.

# o yES o nO
The systematic review process did not identify any eligible studies for inclusion.
uncertainty about the balance of benefits versus harms and burdens (is there uncertainty?)
The larger the difference between the desirable and undesirable consequences, the more likely a strong recommendation is warranted. The smaller the net benefit and the lower the certainty for that benefit, the more likely that a conditional/weak recommendation is warranted.

# o yES o nO
Not applicable uncertainty or differences in values (is there uncertainty?)
The greater the variability or uncertainty in values and preferences, the more likely a conditional/weak recommendation is warranted.
- yES o nO

# Not applicable

# Resource implications
The higher the costs of an intervention -that is, the more the resources consumed -the more likely a conditional/weak recommendation is warranted. ii. RECOmmEnDAtiOns Question 5.5 Is there evidence that efforts to increase the availability of post-abortion contraceptive services are effective in reducing post-abortion mortality and morbidity among adolescents?
Recommendation for action -Strong recommendation 1. Ensure that adolescents who have had abortions can obtain post-abortion contraceptive information and services, whether or not the abortion was legal.

# Remarks and summary of panel discussion
The systematic review process did not identify any evidence that addressed this question.
The panel concluded that ensuring adolescents who have had abortions are also offered contraceptive information and services could prevent future unintended pregnancies. Despite the lack of evidence, the panel recommended these interventions from both rights-based and public health perspectives. The higher the quality of evidence, the more likely that a strong recommendation is warranted.

# o yES o nO
The systematic review process did not identify any eligible studies for inclusion.
uncertainty about the balance of benefits versus harms and burdens (is there uncertainty?)
The larger the difference between the desirable and undesirable consequences, the more likely a strong recommendation is warranted. The smaller the net benefit and the lower the certainty for that benefit, the more likely a conditional/weak recommendation is warranted.

# o yES o nO
Not applicable uncertainty or differences in values (is there uncertainty?)
The greater the variability or uncertainty in values and preferences, the more likely a conditional/weak recommendation is warranted.
- yES o nO

# Not applicable

# Resource implications
The higher the costs of an interventionthat is, the more the resources consumed -the more likely a conditional/weak recommendation is warranted.

# o yES o nO

# Overall strength of recommendation
Strong ii. RECOmmEnDAtiOns Question 6a.1 Is there evidence that efforts to inform adolescents and other stakeholders about skilled antenatal care are effective in increasing access to and use of skilled antenatal care among adolescents?
Question 6b.1 Is there evidence that efforts to inform adolescents and other stakeholders about the importance of skilled childbirth care are effective in increasing access to and use of skilled childbirth care among adolescents?
Recommendations for action (combined for Q6a.1 and Q6b.1) -Strong recommendations 1. Provide information to all pregnant adolescents and other stakeholders about the importance of utilizing skilled antenatal care. 2. Provide information to all pregnant adolescents and other stakeholders about the importance of utilizing skilled childbirth care.

# Recommendation for research
Undertake research to identify interventions that improve access to and use of services by informing adolescents and other stakeholders about the importance of skilled antenatal and childbirth care for pregnant adolescents.

# Remarks and summary of panel discussion
The systematic review process did not find evidence about the effect of providing adolescents with information to promote access to and use of skilled antenatal care. Nor did the process find evidence about the effect of providing adolescents with information to promote access to and use of skilled childbirth care.
In order to use health services, all pregnant adolescents need information on the importance of quality antenatal and childbirth care. There are no significant harms foreseen. However, unintended harms may result if the increased demand exceeds the availability of these services.
Adolescents have a right to information. There are no conflicts of values regarding the provision of information to adolescents about skilled antenatal and childbirth care.
The interventions listed above will require resources for implementation and monitoring.
The expert panel concluded that, despite the lack of evidence, it is critical to provide "appropriate" (1) information to adolescents and other stakeholders in order to promote access to and use of skilled antenatal and childbirth care. The panel also recognized that providing this information to adolescents is important from both rights-based and public health perspectives. It also noted that, when designing communication and education strategies, the special barriers that adolescents face must be considered. Research is required to identify the most effective information and communication strategies for improving the use of skilled antenatal and childbirth care by adolescents. The higher the quality of evidence, the more likely a strong recommendation is warranted.

# o yES o nO
The systematic review process did not identify any eligible studies for inclusion uncertainty about the balance of benefits versus harms and burdens (is there uncertainty?)
The larger the difference between the desirable and undesirable consequences, the more likely a strong recommendation is warranted. The smaller the net benefit and the lower the certainty for that benefit, the more likely a conditional/weak recommendation is warranted.

# o yES o nO
Not applicable uncertainty or differences in values (is there uncertainty?)
The greater the variability or uncertainty in values and preferences, the more likely a conditional/weak recommendation is warranted.
- yES o nO

# Not applicable

# Resource implications
The higher the costs of an interventionthat is, the more the resources consumed -the more likely a conditional/weak recommendation is warranted.

# o yES o nO

# Overall strength of recommendation
Strong (for the action recommendations)

# Question 6a.2
Is there evidence that changes to health services have an impact on access to and use of skilled antenatal care among adolescents?

# Recommendation for action
No specific intervention is recommended. Please refer to the recommendation for research related to this question.

# Recommendation for research
Undertake research to identify the types of changes to health services that can improve adolescents' access to and use of skilled antenatal care.

# Remarks and summary of panel discussion
The systematic review process did not identify any evidence that addressed this question. The panel recognized that there are evaluations of adolescent-friendly health services in some developing countries. However, these services do not include antenatal care and therefore could not inform the panel's recommendations on this question. The panel members noted, based on their experiences, that certain subgroups of adolescents (for example very young or unmarried adolescents) may face special barriers to accessing care. These barriers must be identified and addressed.
Due to lack of evidence, the panel recommended further research into this question. The higher the quality of evidence, the more likely a strong recommendation is warranted.

# o yES o nO
The systematic review process did not identify any eligible studies for inclusion.
uncertainty about the balance of benefits versus harms and burdens (is there uncertainty?)
The larger the difference between the desirable and undesirable consequences, the more likely a strong recommendation is warranted. The smaller the net benefit and the lower the certainty for that benefit, the more likely a conditional/weak recommendation is warranted.

# Remarks and summary of panel discussion
The systematic review process did not identify any evidence that addressed this question.
The panel noted that birth and emergency preparedness is a critical part of WHO's antenatal care package (1-3). Despite the lack of evidence, the panel concluded that the provision of birth preparedness interventions is important from both rights-based and public health perspectives. The higher the quality of evidence, the more likely a strong recommendation is warranted.

# o yES o nO
The systematic review process did not identify any eligible studies for inclusion.
uncertainty about the balance of benefits versus harms and burdens (is there uncertainty?)
The larger the difference between the desirable and undesirable consequences, the more likely a strong recommendation is warranted. The smaller the net benefit and the lower the certainty for that benefit, the more likely a conditional/weak recommendation is warranted.

# Resource implications
The higher the costs of an interventionthat is, the more the resources consumed -the more likely a conditional/weak recommendation is warranted.
- yES o nO Not Applicable

# Overall strength of recommendation
Strong (for the action recommendation)

# Question 6b.2
Is there evidence that changes to health services have an impact on increasing access to and use of skilled childbirth care among adolescents?

# Recommendation for action
No specific intervention is recommended. Please refer to the recommendation for research related to this question.

# Recommendation for research
Undertake research to identify the types of changes that need to be made to health services in order to improve adolescents' access to and use of skilled childbirth care.

# Remarks and summary of panel discussion
The systematic review process did not identify any evidence that addressed this question.
The panel recognized the lack of evidence available to inform its recommendations on this question. Panel members noted, based on their experiences, that certain subgroups of adolescents (for example the very young, or unmarried adolescents) may face special barriers to accessing care. These barriers must be identified and addressed.
The panel stated that all pregnant adolescents should have access to skilled care at birth in order to improve maternal, perinatal and neonatal outcomes. However, it agreed that an action recommendation on a specific intervention could not be made and therefore called for further research. The higher the quality of evidence, the more likely a strong recommendation is warranted.

# o yES o nO
The systematic review process did not identify any eligible studies for inclusion.
uncertainty about the balance of benefits versus harms and burdens (is there uncertainty?)
The larger the difference between the desirable and undesirable consequences, the more likely a strong recommendation is warranted. The smaller the net benefit and the lower the certainty for that benefit, the more likely a conditional/weak recommendation is warranted.

# o yES o nO
Not applicable uncertainty or differences in values (is there uncertainty?)
The greater the variability or uncertainty in values and preferences, the more likely a conditional/weak recommendation is warranted.
- yES o nO

# Not applicable

# Resource implications
The higher the costs of an intervention -that is, the more the resources consumed -the more likely a conditional/weak recommendation is warranted.
- yES o nO

# Not applicable
Overall strength of recommendation

# Not applicable
ii. RECOmmEnDAtiOns Question 6c.1 Is there evidence that efforts to reduce barriers are effective in increasing access to and use of skilled antenatal, childbirth and postnatal care services among adolescents?

# Recommendation for action
No specific intervention is recommended. Please refer to the recommendation for research related to this question.

# Recommendation for research
Undertake research to identify effective interventions for reducing barriers to accessing and using skilled care for adolescents during antenatal, childbirth and postnatal periods.

# Remarks and summary of panel discussion
The systematic review process did not identify any evidence that was eligible for grading.
The panel noted that adolescents faced multiple barriers to accessing and using skilled care during and after pregnancy. Finances were a well-recognized and significant subset of these barriers. The panel reviewed one ungraded study which addressed this issue (4), which found that a conditional cash transfer (CCT) scheme resulted in increased use of skilled antenatal and childbirth care by a population of women that included adolescents. It demonstrated improvements in neonatal and perinatal mortality, but without any impact on maternal mortality. The panel also noted that the needs of particularly vulnerable subgroups (such as rural, isolated, unmarried or married adolescents) must be identified and addressed.
The panel could not recommend a specific intervention on the basis of available evidence. Research is required to identify and address the barriers faced by adolescents to obtaining skilled antenatal, childbirth and postnatal care. The panel recommended that existing data on cash transfer schemes be disaggregated by age to identify adolescentspecific outcomes. It also recommended research into other interventions including insurance enrolment schemes. The higher the quality of evidence, the more likely a strong recommendation is warranted.
- yES o nO
The systematic review process did not identify any eligible studies for inclusion.
uncertainty about the balance of benefits versus harms and burdens (is there uncertainty?)
The larger the difference between the desirable and undesirable consequences, the more likely a strong recommendation is warranted. The smaller the net benefit and the lower the certainty for that benefit, the more likely a conditional/weak recommendation is warranted.

# o yES o nO
Not applicable uncertainty or differences in values (is there uncertainty?)
The greater the variability or uncertainty in values and preferences, the more likely a conditional/weak recommendation is warranted.
- yES o nO

# Not applicable

# Resource implications
The higher the costs of an interventionthat is, the more the resources consumed -the more likely a conditional/weak recommendation is warranted.

# o yES o nO

# Overall strength of recommendation

# Not applicable

# Question 6c.2
Is there evidence that efforts to tailor antenatal, childbirth and postnatal care services specifically to adolescents are effective in improving maternal and infant outcomes among adolescents?

# Recommendation for action
No specific intervention is recommended. Please refer to the recommendation for research related to this question.

# Recommendation for research
Undertake research to identify effective interventions for tailoring antenatal, childbirth and postnatal care services to adolescents.

# Remarks and summary of panel discussion
The panel considered low quality evidence from one graded study to inform its recommendation (GRADE Table 14 (5). The study intervention combined facilitybased antenatal care with home visits during the last trimester and postnatal period by community-based health educators. This intervention resulted in improvements in some health outcomes for adolescents.
The health benefits of these interventions are clear for adolescent mothers and their children, with no ascertainable harms or burdens. These interventions are consistent with the goal of improving health outcomes for adolescent mothers. However, these interventions may encounter resistance in some communities because of social norms regarding adolescent sexuality and adolescent pregnancy.
Given the limitations of the study, the panel decided to focus on the need for further research into these interventions and the need to evaluate such interventions in different sociocultural contexts. The higher the quality of evidence, the more likely a strong recommendation is warranted.

# T yES o nO
The graded (low quality) study assessed access to standard antenatal care, including scheduled home visits by community-based health educators supervised by trained personnel (nurses, midwives), as well as postnatal scheduled home visits (up to 12 visits) by trained and supervised community based health educators (GRADE Table 14 (5). The evidence demonstrated improvements in maternal outcomes such as anaemia, overweight and underweight as a result of the intervention. The evidence also demonstrated improvements in infant outcomes such as infant underweight.
uncertainty about the balance of benefits versus harms and burdens (is there uncertainty?)
The larger the difference between the desirable and undesirable consequences, the more likely a strong recommendation is warranted. The smaller the net benefit and the lower the certainty for that benefit, the more likely a conditional/weak recommendation is warranted.

# o yES o nO
Not applicable uncertainty or differences in values (is there uncertainty?)
The greater the variability or uncertainty in values and preferences, the more likely a conditional/weak recommendation is warranted.
- yES o nO

# Not applicable

# Resource implications
The higher the costs of an intervention -that is, the more the resources consumed -the more likely a conditional/weak recommendation is warranted.

# Recommendation for research
Undertake research to identify interventions in order to expand the availability of and access to BEmOC and CEmOC for adolescents.

# Remarks and summary of panel discussion
The systematic review process did not find any evidence that was eligible to address this question.
Basic emergency obstetric care and comprehensive emergency obstetric care are life-saving interventions that are included in current WHO guidelines (6,7). The panel noted that, despite the lack of available evidence, these interventions should be provided to adolescents from both rights-based and public health perspectives. It noted that when delivering BEmOC and CEmOC, it is essential to address the special barriers for adolescents with respect to abortion-related complications, as well as other complications such as obstructed labour and anaemia.
Despite the lack of evidence, the panel recommended the expansion of access to BEmOC and CEmOC for all populations including adolescent women. The panel also recommended further research to identify specific strategies to expand these services for adolescents. lower quality evidence (is there lower quality evidence?)
The higher the quality of evidence, the more likely a strong recommendation is warranted.

# o yES o nO
The systematic review process did not identify any eligible studies for inclusion.
uncertainty about the balance of benefits versus harms and burdens (is there uncertainty?)
The larger the difference between the desirable and undesirable consequences, the more likely a strong recommendation is warranted. The smaller the net benefit and the lower the certainty for that benefit, the more likely a conditional/weak recommendation is warranted.

# o yES o nO
Not applicable uncertainty or differences in values (is there uncertainty?)
The greater the variability or uncertainty in values and preferences, the more likely a conditional/weak recommendation is warranted.
- yES o nO

# Not applicable

# Resource implications
The higher the costs of an intervention -that is, the more the resources consumed -the more likely a conditional/weak recommendation is warranted.      CD005215.  2. 'Community randomized' means that locations were randomly allocated to be experimental or control sites. No details provided on how randomization was completed and participants were not blinded. Analyses presented here are post-hoc analyses -the published paper did not provide any comparisons of the intervention and control groups.
iii: APPEnDix: gRADE tAblEs 2. 'Community randomized' means that locations were randomly allocated to be experimental or control sites. No details provided on how randomization was completed and participants were not blinded. Analyses presented here are post-hoc analyses -the published paper did not provide any comparisons of the intervention and control groups.
iii: APPEnDix: gRADE tAblEs  4. The primary outcomes of the trial were the impact of the interventions on the biological outcomes of HIV incidence and herpes simplex 2 incidence as well as knowledge and reported attitudes to sexual behaviour, however coerced sex was not an included outcome. The question on sexual attitudes included in the outcomes did not explicitly address coerced sex. Consequently, the trial does not directly address impact of interventions on coerced sex.
- 95% confidence interval as reported in the published paper, likely to be error in presentation. 6. Paper reports that no statistical comparison were made as the number of cases in each group was too small (<10) to justify comparison. 7. For this outcome, RR and absolute effect are calculated for standard activities vs. intervention.
iii: APPEnDix: gRADE tAblEs  The WHO has articulated the definition of health and the importance of legislative and regulatory frameworks to support that definition. Within the framework of WHO's definition of health as a state of complete physical, mental and social well-being, and not merely the absence of disease or infirmity, reproductive health addresses the reproductive processes, functions and system at all stages of life. Implicit in this is the right to be informed of and to have access to safe, effective, affordable and acceptable methods of fertility regulation of their choice, the right of access to appropriate health care services that enable women to go safely through pregnancy and childbirth, and provide couples with the best chance of having a healthy infant. The WHO Global Reproductive Health Strategy emphasizes the importance of legislative and regulatory frameworks that support and facilitate universal and equitable access to sexual and reproductive health services. It notes that it may often be necessary to remove existing legal and policy barriers that impede the use of life-saving interventions and other necessary services. The political, legal and regulatory environments are key determinants of the availability, quality, and accessibility of health services. Further, the human rights principles of participation, non-discrimination and accountability are central to an equitable, democratic process that guides the elaboration of supportive laws and policies.
There are continued challenges in achieving the Millennium Development Goals (MDGs). That is, adolescents face a disproportionate burden of disease. Although adolescents aged 10-19 years account for 11% of all births worldwide, they account for 23% of the overall burden of disease (disability-adjusted life years) due to pregnancy and childbirth. In addition, adolescents face unique barriers to health services. Many countries have laws that prohibit people under 18 from accessing sexual and reproductive health services without parental/spousal consent, effectively denying access to many sexually active young people.
These challenges to adolescent health have far-reaching consequences for global health. Nearly 50% of the world's population is under 25 with 20% (more than 1.3 billion people) representing younger adolescents (aged 10 to 19). In a number of countries in sub-Saharan Africa, the population under age 15 is five-times that of those over 55. In many developing countries young people make up 25-30% of the population; in Japan and France it is 13% and 14%, in China, 16% 1. About 85 per cent of the world's adolescent population lives in low and middle income countries 2.
Adolescent health outcomes are also characterized by disparities by economic status. Poorer adolescents are more likely to get pregnant, more likely to have health problems during pregnancy and delivery, and least likely to have skilled care at birth. Recent research shows that in many countries, inequality has become more accentuated in the last 15 years, and that the fertility rate has actually increased among the poorest adolescents in many countries 3 with adolescent girls from the poorest one fifth of the population four times more likely to become pregnant than those in the richest one fifth. Poorer young women are also less likely to have their births attended by a skilled health worker, with the richest young women are two to eight times more likely to have their births attended by a medical professional 4.. Adolescence represents a key stage in development and critical opportunity for ensuring successful transition to adulthood. Poor sexual and reproductive health outcomes can often be traced to adolescence, when most people become sexually active. 5 Educational achievement, skills developed and decision-making around sexual behaviour and childbearing therefore have profound effects, on the lives of adolescents as well as their families, communities and the generations that follow.
In 2009, the Child and Adolescent Health (CAH) Department of WHO initiated a systematic review on 'Preventing too-early pregnancies and poor reproductive outcomes among adolescents in developing countries'. The topics addressed in the systematic reviews include early marriage, coerced sex, unsafe abortions (and related deaths), prevention of early pregnancy among adolescents, access and use of contraceptives, and access to skilled care during pregnancy, childbirth and post-partum.
The review was conducted in response to requests from policy makers and reproductive health programme managers who work with adolescents in low-and middle-income countries. These key stakeholders are increasingly concerned about high rates of adolescent pregnancy and its related outcomes, and want to know the most effective means by which to provide adolescents with the services and information they need. The systematic review, therefore, forms the evidence-base for the development of the forthcoming guidelines.
CAH conducted the review in collaboration with the Departments of Reproductive Health and Research (RHR) and Making Pregnancy Safer (MPS). Key partners for developing the systematic reviews included technical partners such as AGI, ICRW, UNFPA, FHI, Population Council, and Centro Rosarino de Estudios Perinatales (CREP) as well as USAID, UNFPA and IPPF.  iv: AnnEx 2 -Report of the expert panel guidelines document will include the recommendations, grade profiles and summary tables of the evidence that could not be put into GRADE.
The purpose of the November 2010 meeting was to present the summaries of evidence distilled from a series of systematic reviews for six key outcomes related to morbidity and/or mortality associated with too early pregnancy, in order to (1) comment on the evidence used, (2) comment on the interpretation of evidence, and (3) agree on the final recommendations, taking into account risks and benefits values and preferences.
They key expected outputs of the meeting were to (1) provide evidence-based recommendations for each outcome; (2) identify key research gaps relevant to each outcome, and (3) agree on key elements of a plan to disseminate the new guidance and to identify key partners for this purpose.
The overall aim of the consultation was to make recommendations on the prevention of too-early pregnancy in recognition of the associated negative health and social consequences as well as international treaty documents that cite the right to 'free and full' consent to a marriage (Universal Declaration of Human Rights), the right of protection from child marriage (Convention on the Elimination of all Forms of Discrimination against Women) and stipulate that all necessary action, including legislation, be taken to specify a minimum age for marriage The meeting was opened by Dr. Elizabeth Mason, Director of CAH and Acting Director MPS.
All participants received a conflict of interest form to be completed prior to the meeting. Following an explanation of the declaration of interest process, each participant was asked to stand and make a declaration of interest (declaring a conflict of interest or no conflict of interest). The consultants (see Annex-Participant List-SR Consultants) that participated in the literature review declared their participation in the review of the evidence and therefore abstained from further commenting on the evidence for articulating the recommendation(s).
The summary of the evidence was presented for each of the six outcomes. This included a brief narrative presentation of the results of the systematic reviews, including GRADE table profiles and summaries of evidence. Additionally, all relevant documents related to the systematic reviews and individual articles were provided for the expert panel's reference during the meeting. The discussion, therefore, focused on the recommendations, with changes based on group comment recorded electronically in real time. In formulating recommendations and rating its strength, the panel was instructed to weigh four main factors: (1) quality of evidence (2) balance of benefits versus harms and burdens 6 (3) differences in values 7 (4) and resource implications. 8 6 The larger the difference between the desirable and undesirable consequences, the more likely a strong recommendation. The smaller the net benefit and the lower certainty for that benefit, the more likely is a conditional/weak recommendation 7 The greater the variability or uncertainty in values and preferences, the more likely conditional or weak recommendation warranted.
The higher the costs of an intervention -that is, the more resources consumed -the more likely is a conditional/weak recommendation warranted.
purpose of the meeting Expected outputs health, social and rights basis of the meeting methodology and process for meeting iv: AnnEx 2 -Report of the expert panel Group agreement was requisite for re-formulating the proposed recommendations. The definition of group agreement or consensus that was applied was: majority agree; those that disagree do no feel strongly; and all would have a chance to express their opinion. If consensus could not be reached, a vote could be taken.

# Cross-cutting Themes in Panel Discussion of Recommendations:
Observations on the methodology - Limitations of study design -many systematic reviews and/or articles were excluded either from screening and/or review based on the inclusion criteria of the methodology (i.e. the review had no language restrictions; the key words used include adolescents and the primary terms from the outcomes and key questions; and geographic settings by World Bank income grouping). Even fewer systematic reviews were GRADE eligible. Therefore the final number of studies or systematic reviews that informed the recommendations were often a small proportion of studies found through multiple search strategies. Given this disconnect between the level of existing research and the level of evidence needed to inform recommendations, there was a plea from the panel to address this in recommendations for future research.
- Special challenges for evaluation. The challenges implicit in evaluating multicomponent interventions was raised across outcomes. The types of interventions that address the outcomes of interest are often multi-pronged and situated within comprehensive programming. Therefore, many of the evaluations of interventions did not explicitly assess one aspect or strategy of the interventions against the outcomes of interest. The panel suggested that the recommendations for future research address this through proposing methodologies and/or that future guidelines and recommendations with special challenges to evaluation be considered in the eligibility criteria.
- Limitations of methodology to assess effectiveness of policy-related intervention.
Since the effectiveness of legal and/or policy interventions (formulation of laws/ policies and/or enforcement) was considered as part of the systematic review, the panel suggested that future efforts identify an alternative methodology and/or data sources to perform such an assessment. Alternative data sources and methods that expand beyond the peer-review literature and grey literature of public health and social science research to include legal and law enforcement sectors were suggested. Additionally, it was suggested that the outcomes of policy/legal interventions, where they exist, be documented periodically to advance evidence-based understanding on this topic.
- Challenges of multi-component interventions often address multiple outcomes. However, attributing any one component of the intervention to changes in a discrete outcome presents an important challenge to the evaluation design.
- Robustness of the study findings may be questionable as several of the findings reported were secondary outcomes of the studies reviewed. All studies base their sample size estimates on the main study objective. For studies where the outcomes examined were not the primary study objectives, the reported estimates of effect are likely to be less precise.

# Possibilities for future secondary analysis in order obtain further evidence - Identify possibilities of conducting an analysis of sub-population of adolescents.
Where intervention studies have included the outcomes of interest and included decision making process used in the meeting iv: AnnEx 2 -Report of the expert panel women and men. In addition to disaggregating data by age, highlighting the possibility of further disaggregation by marital status was suggested, given its significance as important driver of vulnerability and/or protection in many socio-cultural contexts.
- Education as a variable for further analysis needs to be further broken down. The group identified the need to better understand the specific strategies and drivers of effectiveness in education interventions with respect to outcomes of interest (i.e. life skills education versus basic scholastic education, versus comprehensive sexuality education). The group discussed and suggested that, where possible, secondary analysis of education interventions considering the affect of distinct, targeted strategies versus education as a broad concept. Additionally, the group suggested that education quality be a factor that is considered in analysis related to outcomes, not coverage alone.
Based on the synthesis of the evidence, including (1) quality of evidence (2) balance of benefits versus harms and burdens 9 (3) differences in values 10 (4) and resource implications 11 the panel suggested recommendations for each outcome. The summary of the recommendations that emerged from the meeting discussion are included below. Note, these are the recommendations that have been circulated to the panel for final comment. The final recommendations will be included in the Guidelines document.

# REcOmmEndATIOnS fOR AcTIOn
On interventions to address individual and community level determinants of tooearly pregnancy and negative reproductive health outcomes
- Interventions to inform and empower girls should be intensified in relevant contexts, in combination with interventions to influence family and community norms to delay marriage.
- Interventions should be undertaken with the aim of influencing family and community norms to support delayed age of marriage of girls under 18.
On interventions to address wider societal determinants of too-early pregnancy and negative reproductive health outcomes
- Efforts to increase educational opportunities for girls, through formal and non-formal channels should be prioritized.
- Efforts should be made with political leaders, planners and the community to formulate and enforce laws to prohibit marriage of girls before the age of 18 years.
The larger the difference between the desirable and undesirable consequences, the more likely a strong recommendation. The smaller the net benefit and the lower certainty for that benefit, the more likely is a conditional/weak recommendation 10 The greater the variability or uncertainty in values and preferences, the more likely conditional or weak recommendation warranted. 11 The higher the costs of an intervention -that is, the more resources consumed -the more likely is a conditional/weak recommendation warranted. - Further research should be undertaken in order to determine the feasibility and effectiveness of economic incentives to adolescents girls and/or families as a means of delaying age of marriage in specific contexts and evaluate the longer-term impact

# Overview of

# REcOmmEndATIOnS fOR AcTIOn
On interventions to address individual and community level determinants of tooearly pregnancy and negative reproductive health outcomes
- Target school retention for girls in primary school, with a special emphasis on secondary school settings.
- Combined interventions including curriculum-based sexuality education 12 together with contraceptive promotion should be offered to adolescents to reduce pregnancy rates.
- Post-partum and post-abortion contraception promotion interventions, through multiple home visits and/or clinic visits, should be offered to adolescents to reduce second pregnancy.
On interventions to address wider societal determinants of too-early pregnancy and negative reproductive health outcomes
- Efforts should continue to target key stakeholders to impact adolescent pregnancy prevention through strategies that address the proximal determinants of this outcome (such as information and skills building, individual behaviour change, sexuality education and other aspects of a supportive community and policy environment).

# iv: AnnEx 2 -Report of the expert panel

# REcOmmEndATIOnS fOR fuRThER RESEARch
On laws and policies - Further research is needed to better understand the effect of education availability (formal and non-formal and exploring education as a proxy for sexuality education), on adolescent pregnancy prevention, considering potential mitigating factors such as socio-economic and/or marital status. - Further research should be pursued in order to address relative effectiveness of intervention in various settings (in school/out of school) and populations.
- Further research should be undertaken to identify, specify and evaluate the feasibility and effectiveness interventions to involving men (adolescents and adults) in decisions related to contraceptive use by partners as well as themselves.
- Further research should be undertaken to ascertain the feasibility and impact of reducing contraceptive costs specifically to adolescents.

# On interventions to address wider societal determinants of too-early pregnancy and negative reproductive health outcomes
- Further research should be undertaken to identify, specify and evaluate interventions to influence community attitudes to support adolescents' access to contraceptives.

# iv: AnnEx 2 -Report of the expert panel

# REcOmmEndATIOnS fOR AcTIOn
On interventions to address individual and community level determinants of tooearly pregnancy and negative reproductive health outcomes
- Interventions should be undertaken to influence community members to support access to contraceptives for adolescents.
- Expand interventions to improve health service delivery to adolescents, including the training of health workers; improving aspects of facilities and commodity availability and actions in the community to ensure acceptability and improve demand, as a means to improve adolescents access to and use of contraceptive information and services, including emergency contraception.
- Efforts to reduce the costs of contraceptives to adolescents should be undertaken.
- Interventions, in particular, curriculum based comprehensive sexuality education should be expanded in order to provide accurate information and education about contraceptives to adolescents.
On interventions to address wider societal determinants of too-early pregnancy and negative reproductive health outcomes
- Efforts should be made with political leaders, and planners to formulate laws and policies to increase access to contraceptives services and information, including emergency contraceptives to adolescents.

# REcOmmEndATIOnS fOR fuRThER RESEARch
On laws and policies - Further research should be undertaken to improve the understanding of interventions that result in the formulation of laws and policies which increase access to contraceptives services and information, including emergency contraceptives to adolescents.

# On interventions to address individual and community level determinants of tooearly pregnancy and negative reproductive health outcomes
- Further research should be undertaken to identify, specify and evaluate the feasibility and effectiveness of interventions to improve availability of hormonal contraceptives over the counter to adolescents.
- Further research should be pursued in order to address relative effectiveness of intervention in various settings (in school/out of school) and populations.
- Further research should be undertaken to identify, specify and evaluate the feasibility and effectiveness interventions to involving men (adolescents and adults) in decisions related to contraceptive use by partners as well as themselves.
- Further research should be undertaken to ascertain the feasibility and impact of reducing contraceptive costs specifically to adolescents. - Efforts should be continued to formulate laws and policies that punish perpetrators of coerced sex, to enforce them in a way that empowers victims and their families, and to monitor their enforcement.

# REcOmmEndATIOnS fOR fuRThER RESEARch
On laws and policies - Further research should be undertaken to assess how such laws and policies have been formulated, how they have been enforced, how their enforcement has been monitored, and what this has resulted in, using methods and materials appropriate to this subject. - Efforts should be made to ensure access by adolescents to post abortion care as a life-saving medical intervention, whether or not the abortion or attempted abortion was legal or illegal.
- Efforts should be made to ensure that adolescents who have obtained post abortion care services can obtain contraceptive information and services.
On interventions to address wider societal determinants of too-early pregnancy and negative reproductive health outcomes
- Efforts should be continued to ensure that laws and policies enable adolescents to obtain safe abortion services.

# REcOmmEndATIOnS fOR fuRThER RESEARch
On laws and policies - Further research should be undertaken to assess how laws and policies that enable adolescents to obtain safe abortion services have been formulated, how they have been put into effect, and what this has resulted in, using methods and materials appropriate to this subject.

# On interventions to address individual and community level determinants of too-early pregnancy and negative reproductive health outcomes
- Further research should be undertaken to investigate the feasibility and effectiveness of efforts to ensure access of adolescents to post abortion care.
On interventions to address wider societal determinants of too-early pregnancy and negative reproductive health outcomes
- Further research should be undertaken to investigate the feasibility and effectiveness of interventions to identify and overcome barriers to the provision and utilization of abortion services.

# OuTcOmE 5
Reduce unsafe abortion among adolescents iv: AnnEx 2 -Report of the expert panel

# REcOmmEndATIOnS fOR AcTIOn
On interventions to address individual and community level determinants of too-early pregnancy and negative reproductive health outcomes
- Information about the importance of utilizing skilled ANC should be provided to all pregnant adolescents and key relevant populations.
- Information about the importance of utilizing a skilled attendant at childbirth should be provided to all pregnant adolescents and key relevant populations.
- Birth and emergency preparedness is a key component of WHO ANC Guidelines2,3 and should be consistently promoted in ANC strategies for pregnant adolescents (at the household, community, and service settings).
On interventions to address wider societal determinants of too-early pregnancy and negative reproductive health outcomes
- Expand the availability and access to basic emergency obstetric care (BEMOC) and comprehensive emergency obstetric care (CEMOC).

# REcOmmEndATIOnS fOR fuRThER RESEARch
On laws and policies - Further research should be undertaken to identify specific intervention strategies to expand availability and access to BEMOC and CEMOC to adolescents. - Further intervention research should be undertaken to determine the effect of various strategies to inform the different key populations about ANC for adolescents in order to improve its access and use.
- Further research should be undertaken to determine the effect of various intervention strategies to inform the different key populations about skilled childbirth for adolescents in order to improve its access and use.
- Further research should be undertaken to identify effective interventions related to the types of changes to health services needed to improve access and use of ANC to adolescents.
- Further research should be undertaken to identify interventions that address specific aspects needed for birth and emergency preparedness for adolescents, focussing on intermediate outcomes (such as increased use of skilled care during pregnancy, childbirth and post natal) in addition to distal outcomes such as pregnancy-related morbidity and mortality.
- Further research should be undertaken to identify effective interventions, including the types of changes to health services needed to improve access and use of skilled childbirth for adolescents.
- Further research should be undertaken to identify intervention strategies to tailor antenatal, childbirth, and postnatal care services specifically to address adolescents taking into account varying contexts and characteristics of existing services and the heterogeneity of adolescents.
On interventions to address wider societal determinants of too-early pregnancy and negative reproductive health outcomes
- Further research should be undertaken to identify effective strategies to reduce barriers in increasing access to and use of skilled antenatal, childbirth, and post natal care services among adolescents. Considering the heterogeneity of adolescents, strategies will likely need to vary, targeting specific barriers and addressing structural determinants of access.
iv: AnnEx 2 -Report of the expert panel
Ann Wagner, International Center for Research on Women (ICRW) 41 articles were reviewed and 14 were identified as appropriate for full inclusion in the systematic review, with an additional 8 studies retained for information even though the study design did not include control groups. No studies were deemed eligible for the GRADE process. Information in the 14 studies with the most robust evaluations was used to inform the discussion and develop recommendations.

# Interventions on laws and policies
The systematic review process did not identify any eligible studies (based on the inclusion criteria) that demonstrated interventions targeting political leaders/planners, including those at the community level, had either resulted in the formulation of laws and policies to make marriage for girls below age 18 illegal and/or were effective in enforcing laws prohibiting marriage for girls below age 18.
The panel observed that efforts to formulate laws and policies, enforce them and monitor their enforcement are highly unlikely to be addressed by intervention studies. Some members of the panel cautioned that laws alone would not necessarily lead to the desired outcome, as enforcement is often the issue even where laws exist. Thus, the recommendation combined the formulation and enforcement elements. Additionally, the nature of enforcement in relation to successful outcomes needs to also be understood. For example, enforcement of laws could have unintended harmful consequences, e.g. the jailing of parents contravening laws, thereby endangering the livelihood and well-being of families.
Further, in this discussion on policy related interventions, the panel underscored the limitations of the methodology to identify effective interventions. There was a sense that considerable work has been done in this area, with success in formulating/changing laws. Therefore there was the suggestion to adopt more flexible methods for defining effective interventions. There was also the suggestion to document the process in countries that have passed recent laws to further understand actions taken to stimulate the formulation of laws related to early marriage.
Despite lack of eligible evidence on interventions that target political leaders/planners on the outcome of reducing marriage before age 18, given the rights that are at stake as well as the known multiple adverse outcomes of early marriage, the panel concluded that (1) continued efforts were needed to promote the existence of laws prohibiting marriage as an important measure to prevent too-early pregnancy and that research could further these efforts; The panel also suggested that (2) further research should be undertaken to improve the understanding of interventions which result in the formulation of laws, how they have been enforced, including potential unintended harmful consequences of enforcement and how their enforcement has been monitored.

# Interventions that address community level determinants
There is some evidence that efforts to influence family and community norms concerning marriage are effective, although few programmes address family and community norms exclusively. Family and community norm change is almost always addressed in combination with more individual-level efforts; therefore, it is impossible to differentiate the effect of this strategy over others. Alim (2007) is the only study to detailed remarks by outcome: OuTcOmE 1 Reduce marriage before the age of 18 years iv: AnnEx 2 -Report of the expert panel look at a programme to evaluate only family/community awareness efforts, but there was no control group in the study to determine its effectiveness. More specifically, the studies which were included in the review showed a positive direct and indirect effect on community and family members' attitudes related to early marriage. (Brady 2007, Erulkar & Muthengi 2009, Kanesathasan 2008). However, the methodological issues were: lack of control group, non-randomized sample selection, lack of significance tests, etc., and lack of specificity in interventions that make it difficult to draw conclusions (Alim 2007; UNICEF 2008).
Changes in social norms are essential in delaying the age at marriage and while this may threaten entrenched views and cause controversy, the panel maintained that benefits outweigh potential harms. The precise costs and sustainability prospects for these interventions have not been established and cannot be compared with other interventions (such as economic incentives).
The panel concluded that interventions should be undertaken with the aim of influencing family and community norms to support delayed age of marriage of girls under 18.

# Interventions that Provide Economic Incentives for Families
There was some evidence that economic incentives for families are effective in delaying marriage of girls under 18 (Baird 2009; Duflo 2007; Arends-Kuenning & Amin 2000); however, all of the studies were subject to some limitations study design, concerns about balance of benefits and potential harm, and sustainability (Baird et al. 2009;Duflo,2007). The Baird (2009) study showed that providing cash incentives and support with school fees did decrease proportion of marriage among girls who were not in school at baseline, but the study did not differentiate by age among participants ranging from 15 to 22. It is unclear if it had a significant effect on girls under the age of 18. Duflo (2007) showed that girls who received free uniforms were 12% less likely to be married than girls in other schools; however, the finding was only statistically significant at the 90% level. The Arends-Kuenning & Amin (2000) study evaluated the impact of a scholarship programme, but there was no control group.
The discussion focused on the harms (safety and security challenges), resource intensiveness and challenges inherent in these types of interventions. That is, the group noted that based on the data, It is unclear whether girls who receive financial incentives directly are at increased risk of harm from others. The resource and sustainability implications are not yet clear, though some cost-effectiveness studies have begun to study conditional cash transfer programmes more generally.
Additionally, the panel noted the increasing trend in use of economic incentives to stimulate social change, including attitudes towards early marriage.
The panel concluded that further research should be undertaken in order to determine the feasibility and effectiveness of economic incentives to adolescents girls and/or families as a means of delaying age of marriage in specific contexts and evaluate the longer-term impact.

# Interventions that influence individual-Level determinants Inform and Empower Adolescents
There is reasonably strong evidence to suggest that efforts to inform and empower adolescents are effective in delaying marriage among girls under age 18. The main form iv: AnnEx 2 -Report of the expert panel that these efforts take is in life skills (N=7), reproductive health information (N=5), and sports-based knowledge and information (N=2). One study showed that a 1-year course to inform and empower girls led to a increase in median age of marriage and a decrease in proportion of girls married in the intervention area (compared to no change in control area); however, the study was subject to selection bias, and moreover, these activities were provided in combination with other interventions and activities -including outreach to parents (Pande et al 2006). Another study showed that a programme to improve girls' knowledge of key health and rights issues, including early marriage, led to change in attitudes about ideal age of marriage and lower marriage rates among participants; however, this programme also included other components and was subject to selection bias of participants; therefore, the robustness of the evaluation is somewhat limited (Brady et al 2007). Finally, the Disha programme in India that provided youth-friendly reproductive health services to youth ages 14 to 24 increased knowledge on legal age of marriage and changed attitudes toward ideal age of marriage, but the programme included many other components related to skills and community support, and there is not evidence to show change in girls' marriage behaviour (Kanesathasan et al 2008).
In summary, programmes that include a component that work directly with girls to inform and empower them tend to show the greatest effect in changing attitudes and behaviour related to marriage; however, the quality of the evidence is low. The strength of these studies is also limited by selection bias of participants, and the fact that they are usually implemented and evaluated in combination with other components -as part of a multi-component intervention. The panel noted the evidence of effectiveness of various interventions to influence girls' attitudes towards early marriage. Despite weak evaluation design and the inability to precisely determine relative effectiveness of specific interventions, the panel concluded that the potential benefit exceeds such technical concerns as well as any related to potential harm.
The panel highlighted that it may be challenging for girls to act on the new information and skills in the absence of a supportive environment. Challenging social norms in some contexts could lead to backlash against the girl. Therefore, it stressed the importance of adhering to the ecological model with interventions that combine targeting individual girls in addition to targeting their social environment (i.e. families and communities) in order to have the best chance for changing outcomes. Further, since information and empowerment approaches can take many forms, no general conclusions were possible to posit for resource implications.

# The panel concluded that: (1) interventions to inform and empower girls should be intensified in relevant contexts, in combination with interventions. to influence family and community norms to delay marriage.; and
(2) that further research should be undertaken in order to inform the feasibility and strategies for scale-up of these interventions.

# iv: AnnEx 2 -Report of the expert panel

# Expanded availability of formal and non-formal education for girls
There is minimal evaluation data to suggest that programmatic efforts that expand availability of education for individual girls have delayed age of marriage (Brady et al. 2007, CREPHA 2002, Gandhi 2006). One study showed that girls and their families who received a cash incentive to return to school did reduce the proportion of marriage in this age group, an effect that was not realized for girls who were already in school at baseline (Baird et al 2009). While the quality of evidence of interventions that expand the availability of education for girls is low, its importance and association with positive social, economic and health outcomes led the panel to its recommendations. Specifically, the panel noted the fundamental right of adolescents to education as well as the population-level data related to increasing years of education, higher age at marriage and better reproductive health behaviours and outcomes. Increasing girls' access to education has important economic and social benefits apart from increasing the age of marriage.
In addition to considering the evidence base and quality of evidence, the panel discussed possible harms and resource implications of making a recommendation for this type of intervention. In discussing of possible harms, like any gender-transformative strategy (challenging prevailing gender norms), there is the possibility of backlash or resistance by families and communities. Further the resource implications will vary dramatically, depending on the type of educational intervention (i.e., non-formal education or expansion of the formal school system).
The panel concluded that (1) efforts to increase educational opportunities for girls, through formal and non-formal channels should be prioritized; and that (2) further research should be undertaken in order to assess the impact of improved educational availability and enrolment on age of marriage.

# Expanding Livelihoods Opportunities
While livelihoods were a component in 7 of 14 programmes, there was no programme that tested the effect of livelihood programmes alone. The panel noted that there was limited evidence on interventions to improve the livelihoods of adolescent girls to delay marriage. In addition, some panel members noted that there were considerable challenges in implementing the livelihoods component.
The panel noted possible harms associated with girls' participation in livelihood programmes, including safety and security challenges whereby they become targets of violence and/or are seen as threats to the cultural norms. Such programmes could also raise expectations of participants' and their families' of earning money, which may not always be fulfilled. Finally, the panel noted that it is possible that income-generating activities can introduce disincentives for girls to go to school. Further, the resource implications will depend greatly on the type and scope of the intervention (e.g. financial literacy, vocational training savings and loan activities). However, the importance of protecting very young adolescent girls from labour, improving their capacity to earn, and the consequential individual, social and economic benefits, override potential harm. Interventions that address community level determinants 13 All of the intervention studies in this review targeted either girls or adolescent girls. Several interventions were multifaceted (Oringanje 2010) and some targeted additional audiences such as boys, adult males, parents and community members. None of the studies reviewed explicitly targeted policy makers and decision makers. Many interventions were described as community-based.
While multiple audiences were sometimes included in the studies found during the review, there was no way to attribute any effect on "reducing pregnancy among girls under 20" to efforts directed at a particular target group. Therefore, the panel could not conclude that efforts directed at specific population segments had an effect in and of themselves. However the panel acknowledged the importance of better understanding what types of targeted intervention strategies are effective and with which groups in order to prevent early pregnancy.

# The panel concluded that (1) efforts should continue to target key stakeholders to support adolescent pregnancy prevention through strategies that address the proximal determinants of this outcome (such as information and skills building, individual behaviour change, sexuality education and other aspects of a supportive community and policy environment); and that (2) further research is required to determine the effectiveness of the types of interventions to reduce pregnancy among girls under the age of 20, taking in account socio-cultural context, by key relevant target population groups.

# Interventions that address individual-level determinants
Improve the economic situation of girls Population-based research reflects a strong association between socio-economic status (SESand adolescent birth rates. Only one study linking economic situation of girls with early pregnancy prvention was identified for inclusion in the review. The study (Conditional Cash Transfer-CCT trial in Malawi, Baird et al., 2009) demonstrated a relationship between financial incentives (cash transfer), school retention and pregnancy rates. It showed that direct payments to the families of female secondary school students can reduce adolescent pregnancy rates. However, the paper reflecting this finding was part of larger, broader intervention. Therefore it is not clear whether CCT in and of itself, as one component of the intervention, could be linked to desired pregnancy prevention outcomes. The panel also highlighted the need for research demonstrating the evidence-based link between adolescent pregnancy and economic betterment, including employment.
In the context of discussing the study, the panel also noted that sometimes keeping girls in school is used in parallel or posited as a proxy for improving the economic situation of girls. However, it was noted that one's economic situation may or not be improved by staying in school.

# iv: AnnEx 2 -Report of the expert panel
The panel concluded that further research is needed to better understand the relationship between economic status (SES), employment, school-status, and other intermediate-level outcomes and mediating factors with respect to adolescent birth rates.

# Expanded availability of formal and non-formal education for girls and/or school retention
Overall, the importance of education in long-term outcomes was agreed upon. However, a better understanding of the specific strategies to do this is needed. Keeping girls in school is important in and of itself, based on the rights framework. Thus, the panel strongly endorsed the need for a recommendation while acknowledging the limited existing research linked to reducing adolescent pregnancy (Harden 2006).
The panel identified the need to better understand the specific strategies and drivers of effectiveness in education interventions with respect to outcomes of interest (i.e. life skills education versus basic scholastic education, versus comprehensive sexuality education). The group discussed and suggested that, where possible, secondary analysis of education interventions considering the affect of distinct, targeted strategies versus education as a broad concept. Additionally, the group suggested that education quality be a factor that is considered in analysis related to preventing early pregnancy, not coverage alone.
The panel also suggested that possibilities of conducting future secondary analysis of sub-population of adolescents be identified. Where intervention studies have included the outcomes of interest and included women and men. In addition to disaggregating data by age, highlighting the possibility of further disaggregation by marital status was suggested, given its significance as important driver of vulnerability and/or protection in many socio-cultural contexts. For example, in South Asia, associations with delayed pregnancy are stronger among married adolescents. However, there is a large information-gap for unmarried adolescents in these contexts. Another suggested area of research that was suggested was around school retention among already pregnant adolescents -after pregnancy and/or delivery, and on the special education and psychosocial intervention strategies, in low and middle income countries, for supporting school retention among adolescents.

# The panel concluded that recommendations be combined for interventions related to increasing school exposure (through expanded availability of formal and non-formal education for girls as well as school retention interventions). Specifically, the panel concluded that stakeholders should (1) target school retention for girls in primary school, with a special emphasis on secondary school settings; that (2) further research is needed to better understand the effect of education availability (formal and nonformal and exploring education as a proxy for sexuality education), on adolescent pregnancy prevention, considering potential mitigating factors such as socio-economic and/or marital status; and that (3) further research is needed with respect to both the effect of targeted education retention interventions and policies (including support for adolescent mothers), with key related population groups, on reducing second pregnancy/delaying pregnancy in adolescents.

# Sexuality education programmes for adolescent boys and girls
With respect to sexuality education and pregnancy prevention, there was one systematic review found. While the systematic review (Oringaje, 2009) included developing iv: AnnEx 2 -Report of the expert panel countries, in addition to developed countries, there were few studies from developing countries and little evidence from those studies. Additionally, the exclusion of trials with high loss to follow-up further lowered the pooled measure of intervention effect.
In the discussion about sexuality education as it relates to reducing early pregnancy, the topics raised include ways to integrate key elements of sexuality education into skills-building curriculum (including sexual negotiation skills for girls, exploring the role mothers); ways strengthen current sexuality education to prevent early pregnancy (importance of contraceptive provision); and the need for further research.
In terms of addressing the need for further research on the affect of sexuality education on reducing early pregnancy, the panel noted the importance of context specific evaluations of curriculum-based sexuality education. Additionally, the group agreed that curriculum-based sexuality education should not refer exclusively to schoolbased settings, though schools are most commonly the setting in which such curriculumbased sexuality education is currently taking place. 14 together with contraceptive promotion should be offered to adolescents to reduce pregnancy rates.

# The panel concluded that combined interventions including curriculum-based sexuality education

# Secondary Outcome-Reducing Repeat Pregnancies Postpartum and post-abortion contraception to reducing repeat pregnancy
The small evidence base suggests that programmes with multiple postpartum contacts can improve contraceptive use and reduce repeat pregnancy rates in adolescents. Additionally, the quality of the evidence is very low (GRADE Profile, Lopez et al., 2009), with unclear methods, small sample sizes, and short follow-up periods.
Related to discussing participation in an educational setting (whether formal or informal), there was a discussion about social exclusion as an important consideration in ability to access education during and post pregnancy and thereby relating to prevention second pregnancy. In developed as well as some middle-income countries, there is high correlation between adolescent pregnancy and social exclusion.
The panel concluded that post-partum and post-abortion contraception promotion interventions, through multiple home visits and/or clinic visits, should be offered to adolescents to reduce second pregnancy.

# Social support programmes to reducing repeat pregnancy
The group discussed the importance of establishing and testing definitions of social support (as in working with communities and families) within different socio-cultural contexts. For this type of intervention, no action recommendation is being made not only because of the lack of evidence, but also because the definition of social support is unclear, while prior recommendations and related key questions refer to specific, existing services.
The panel, therefore, concluded that further research is required to define the interventions/actions related to social support, their feasibility and effectiveness in reducing repeat pregnancies iv: AnnEx 2 -Report of the expert panel

# Presenter: Donna McCarraher, Family Health International-FHI

# Panel Remarks: Interventions on laws and policies
None of the reviewed eligible studies found examined efforts directed at political leaders/ planners, including those at the community level, to increase adolescents' access to contraceptive services and information. However, the panel acknowledged the utility of laws and policies, with adolescent-specific provisions, to improve access to contraceptive information and services. The panel also agreed that the evaluation of laws and policies (formulation and/or enforcement) requires a different methodology than the one applied in this review; and further suggested that findings on policy/legal interventions should be documented periodically to advance evidence-based understanding on this topic. Specifically, in weighing the possible benefits versus harms, the panel concluded that benefits outweighed any possible harms; that is, laws and policies favourable of adolescents access to contraceptives ease service delivery. The loss of political capital in advocating for policy/legal action in a sensitive, perhaps controversial subject was mentioned as a possible harm.

# The panel concluded that (1) efforts are made with political leaders, and planners to formulate laws and policies to increase access to contraceptives services and information, including emergency contraceptives to adolescents; and that (2) research be undertaken to improve the understanding of interventions which result in the formulation of such laws and policies.

# Interventions that address community level determinants
No eligible studies were found in graded or ungraded reviews and in individual studies including actions in the communities, therefore it is difficult to determine the contribution of actions in communities; no independent effect has been found.
The panel noted the limited evidence specific addressing interventions to influence community attitudes towards contraceptive availability for adolescents. Community acceptance was noted as a key barrier and/or driver for improving access to contraction for adolescents. Additionally, resources invested in advocating attitudinal changes of community members are not without cost, but precise estimates of cost of interventions are not available

# The panel concluded that (1) interventions should be undertaken to influence community members to support access to contraceptives for adolescents; and that (2) further research should be undertaken to identify, specify and evaluate interventions to influence community attitudes to support adolescents' access to contraceptives.

# Improvements in health services increasing access (including emergency contraception)
The panel noted the limited eligible studies reflecting the contribution of improved health service delivery to increased contraceptive use.
Nevertheless, the panel noted the overall importance of adolescents' access to health services, including, but not limited to, contraceptive information (and addressing the barriers to contraceptive provision such as provider attitudes), for current and future fertility regulation and contraceptives.

# Interventions that make contraceptive methods, including emergency contraception, available over-the-counter
The panel noted the limited evidence available to address this question. However, it noted that, in many instances, over the counter provision of condoms was common and that this can improve access compared to static health service provision 15.
However, the panel did not make a recommendation for action, noting a variety of questions and concerns in the absence of data: the accuracy and thoroughness of information provided about hormonal contraceptives, including emergency contraceptives; the unknown adverse affects of not requiring a prescription; the potential to perpetuate stigma and create further barriers if pharmacists reflect negative attitudes.
Therefore, the panel noted the importance of future research, especially exploring drivers and factors related to acceptability of contraceptive provision through pharmacists or vendors, including how acceptability relates to the increased potential for income generation.

# The panel concluded that further research should be undertaken to identify, specify and evaluate the feasibility and effectiveness interventions to improve availability of hormonal contraceptives over the counter to adolescents.

# Access to accurate information and sexuality education
The systematic review (Oringanje) included a limited number of studies from developing countries, although of low quality. Studies from developed countries indicated curriculum based sexuality education increased contraceptive use among sexually active adolescents were downgraded.
In discussing harms or burdens, difference in values and resource implications, the panel agreed that are no ascertainable harms or burdens based on this type of interventions. Additionally, studies have shown that CBSE does not increase sexual initiation. The acceptability of sexuality education varies considerably and is influenced by socio-cultural contexts. While costing studies are under way, but there are no results as yet. Therefore, there are likely to be considerable costs in sustaining and ensuring wide coverage of good quality programmes
The panel concluded that (1) interventions, in particular, curriculum based comprehensive sexuality education should be expanded in order to provide accurate information and education about contraceptives to adolescents; and that (2) further research should be pursued in order to address relative effectiveness of intervention in various settings (in school/out of school) and populations.

# Male involvement
The panel noted the limited number of eligible studies demonstrating improved condom use through targeted interventions to transform gender attitudes among adolescent boys.

# iv: AnnEx 2 -Report of the expert panel
Therefore, the group agreed to include the Project H data that shows an increase in male condom use by men and boys as the basis for the action recommendation.
The panel discussed the strategic role of interventions to encourage male "autonomous" condom use as well as to influence the attitudes of men to support the use of contraceptives by their partners.
In discussing potential harms and burdens of male involvement strategies to improve contraceptive use, there was discussion around the definition of "male involvement" and the assumption that "male involvement" is inherently positive for adolescent girls. The panel noted that given the covert nature of contraceptive use among women in some countries, male involvement could potentially harm women's autonomous use of contraceptives. There was agreement that much of this depends on the socio-cultural context.
The panel concluded that further research should be undertaken to identify, specify and evaluate the feasibility and effectiveness interventions to involving men (adolescents and adults) in decisions related to contraceptive use by partners as well as themselves.

# Reducing the financial cost of contraceptives
The panel noted the cost is frequently a barrier for adolescents given their limited financial resources and the limited evidence indicating the effectiveness of interventions to reduce costs. However, the sustainability of such interventions needs further exploration.
The health benefits of contraception to prevent unsafe and/or unwanted pregnancy in adolescents outweigh the burden associated administrative costs and real costs of subsidising contraceptives. Sustainability of these interventions is likely to be an issue. Improving access to contraceptives for adolescents continues to be a challenge in some socio-cultural contexts where social norms do not acknowledge adolescent sexuality as a part of health and wellbeing.
The panel concluded that (1) efforts to reduce the costs of contraceptives to adolescents should be undertaken; and that (2) further research should be undertaken to ascertain the feasibility and impact of reducing contraceptive costs specifically to adolescents.

# Presenter: Althea Anderson, Population Council

# Panel Remarks: Interventions on laws and policies
The systematic review process did not identify any eligible studies that demonstrated effectiveness of interventions in contributing to this outcome. Note: only two cases were identified (LCWRI 2007;LCWRI 2008; Republic of South Africa 2007; Republic of South Africa 2010) in which developing countries have passed specific laws to protect women from sexual violence, which included sexually coercive offences, and that provide options for redress. At this time, the impact of these laws has not been formally evaluated. The panel made note of other countries that have recently adopted laws and policies that specifically punish the sexual coercion of adolescent girls. However, the panel observed that efforts to formulate laws and policies, enforce them and monitor their enforcement are highly unlikely to be addressed by intervention studies.

# OuTcOmE 4
Reduce coerced sex among adolescents iv: AnnEx 2 -Report of the expert panel Despite the lack of evidence, the panel discussed a variety of topics related to legal interventions to reduce coerced sex: the importance of laws and policies (existence, monitoring and enforcement) to prevent coerced sex; the need to identify alternative methods to evaluate the impact of laws and policies on coerced sex and other sexual and reproductive health outcomes; the need to document legal/policy interventions periodically to advance evidence-based understanding on this topic.
The panel concluded that (1) efforts be continued to formulate laws and policies that punish perpetrators of coerced sex, to enforce them in a way that empowers victims and their families, and to monitor their enforcement; and that (2) Further research should be undertaken to assess how such laws and policies have been formulated, how they have been enforced, how their enforcement has been monitored, and what this has resulted in, using methods and materials appropriate to this subject.

# Interventions that influence individual-Level determinants Interventions that empower adolescent girls
The studies which were included in the review show that interventions to build the self esteem of adolescent girls; to build their life skills in areas such as communication and negotiation; to improve their links to social networks and their ability to obtain social support in combination with interventions to create supportive social norms have positive direct and indirect effects on attitudes and behaviours to resist sexual coercion (Askew et al. 2004;Kim et al. 2001;Nkwe 2009;). However, the quality of the evidence is low. Despite this, the panel concluded that the potential benefits of skills building and empowerment far outweigh any possible risks. The interventions listed will require resources for the planning, implementation and monitoring.
The panel concluded that interventions to build the self-esteem of adolescent girls; to build their life skills in areas such as communication and negotiation; to improve their links to social networks and their ability to obtain social support, should be carried out to build girls' ability to be better linked to and better able to draw support from social networks in their communities. These interventions should be combined with interventions to create supportive social norms.

# Interventions that target men
The studies which have been included in the review show that interventions aimed at challenging and transforming gender norms that relate to sexual coercion and violence have positive direct and indirect effects on adolescent boys' attitudes and behaviours related to sexual coercion (Askew; Kim; Nkwe; Ross). However, the quality of the evidence is low.
The panel discussed harms or burdens, difference in values and resource implications related to interventions that target men in order to reduce coerced sex among adolescents. The panel agreed that the potential benefits of male involve of this far outweigh any possible risks. That is, engaging men and boys to critically assess gender norms that relate to sexual coercion and violence, and to influence wider social norms can contribute to decreasing sexually coercive behaviour thereby contributing to the outcome of preventing too-early pregnancy. It was noted, however, that interventions to reduce sexual coercion may result in men and boys using alternative strategies to iv: AnnEx 2 -Report of the expert panel reassume control in sexual encounters. Additionally, the interventions referred to would require resources for the planning, implementation and monitoring.
The panel concluded that interventions to engage men and boys to critically assess gender norms (e.g. gender transformative approaches) that relate to sexual coercion and violence, combined with interventions to empower adolescent girls and those that influence wider social norms, should be carried out to reduce the sexual coercion of adolescent girls.
Presenter: Akin Bankole, Alan Guttmacher Institute-AGI

# Panel Remarks: Interventions on laws and policies
The panel observed that efforts to formulate laws and policies, apply them and determine the effects of their application are unlikely to be addressed by intervention studies. The panel also observed that it is likely that the existence of laws and polices that enable adolescents to obtain safe abortion services could reduce unsafe abortion if their formulation is combined with efforts to put them into effect. It was agreed that the formulation of such laws and policies would contribute to meeting the needs and fulfilling the rights of adolescent girls.
Therefore, panel concluded that (1) Efforts be continued to ensure that laws and policies enable adolescents to obtain safe abortion services; and that (2) further research should be undertaken to assess how such laws and policies have been formulated, how they have been put into effect, and what this has resulted in, using methods and materials appropriate to this subject.

# Interventions that address community level determinants Awareness among target population groups16 about conditions under which abortions are legal
The systematic review process did not identify any eligible studies that linked targeted information interventions for key populations to the outcome. The panel recognized that it is likely that informing all the stakeholders in the community about what abortion services are available, and where and under what conditions they could be obtained legally could reduce unsafe abortion if there are complementary efforts to ensure their provision. The panel also concluded that such efforts will contribute to meeting the needs and fulfilling the rights of adolescent girls. The panel is unable to comment on the resource implication, since there were no interventions defined.
The panel concluded that alongside efforts to formulate laws and policies that enable adolescents to obtain safe abortion services, efforts must be made to inform all the stakeholders in the community about the following issues: - What safe abortion services are available - Where and under what conditions they could be obtained legally. 16 Population groups include: Community: leaders, members; Policymakers, decision makers; Families: parents and mothers-in-law; Adolescents: couples, boys, girls, males, females; and the General population.

# OuTcOmE 5
Reduce unsafe abortion amoung adolescents iv: AnnEx 2 -Report of the expert panel

# Interventions targeting barriers to access
While the systematic review process did not identify any eligible studies that linked interventions that target barriers to access and the outcome, the panel decided on making a recommendation for action, recognizing the following: where safe abortion services are available, identifying and overcoming barriers could improve access and use of safe abortion services thereby to reducing unsafe abortion; the needs and rights of adolescent girls; the principles of the overall WHO recommendations on safe abortion 17.
The panel concluded that (1) alongside efforts to formulate laws and policies that enable adolescents to obtain safe abortion services and efforts to inform all the stakeholders in the community about what safe abortion services are available, and where and under what conditions they could be obtained legally, efforts must be made to identify and overcome barriers to their provision (by health workers) and their utilization (by adolescents); that (2) Further research should be undertaken to investigate the feasibility and effectiveness of interventions to identify and overcome barriers to the provision and utilization of abortion services.

# Secondary Outcomes Increase availability of post-abortion services to reduce post-abortion mortality and morbidity
While the systematic review process did not identify any eligible studies that linked increased availability of post-abortion services to reduced post-abortion morbidity and mortality, the panel decided on making a recommendation for action recognizing the following: ensuring the access of adolescents to post abortion care services could serve as a life-saving measure; the needs and rights of adolescent girls.
The panel concluded that (1) efforts be should be made to ensure access by adolescents to post abortion care as a life-saving medical intervention, whether or not the abortion or attempted abortion was legal or illegal; and that (2) Further research should be undertaken to investigate the feasibility and effectiveness of efforts to ensure that access of adolescents to post abortion care.

# Expand availability of post-abortion contraceptive services to reducing post-abortion mortality and morbidity
While the systematic review process did not identify any eligible studies that linked increased availability of post-abortion contraceptive services to reduced post-abortion morbidity and mortality, the panel decided on making a recommendation for action recognizing: the needs and rights of adolescent girls and the WHO. Medical Eligibility Criteria for Contraceptive Use, 2008 update. The criteria state that (1) women may start hormonal contraception at the time of surgical abortion, or as early as the time of administration of the first pill of a medical abortion regimen; and (2) following medical abortion, an intrauterine device may be inserted when it is reasonably certain that the woman is no longer pregnant.
The panel concluded that efforts should be made to ensure that adolescents who have obtained post abortion care services can obtain contraceptive information and services.

# iv: AnnEx 2 -Report of the expert panel
Presenter: Guillermo Carroli, Centro Rosarino de Estudios Perinatales (CREP)

# Panel Remarks:
Interventions that address community level determinants Targeting particular population segments 18 While the systematic review process revealed limited existing research linking information provision through community mobilization and sensitization with use of ANC, childbirth care, and/or post-natal care the panel made a recommendation for action in recognition of: the right to information; the special adolescent need for information given the myriad barriers they face with respect to access to care (including ANC and childbirth care);
The panel discussed harms or burdens, difference in values and resource implications related to community-based interventions to increase ANC, childbirth care, and/ or post-natal interventions. No harm was foreseen, although with increased demand for services, appropriate quality of care must be in place. In certain socio-cultural contexts, considerations for specific access to care barriers for sub-populations of adolescents (e.g. unmarried adolescents, street youth, and other marginalized groups) were mentioned, in addition to considerations of service availability. The panel agreed that targeted information interventions, including community mobilization efforts, reflect cost implications. However the specific costs were not possible to assess or further comment on.
Given the limited existing research, the panel also discussed recommendations for further research, including a focus on identifying how best to provide information to adolescents, in addition to key relevant populations.
The panel concluded that (1) information about the importance of utilizing skilled ANC should be provided to all pregnant adolescents and key relevant populations; (2) information about the importance of utilizing a skilled attendant at childbirth should be provided to all pregnant adolescents and key relevant populations; (3) intervention research should be undertaken to determine the effect of various strategies to inform the different key populations about ANC for adolescents in order to improve its access and use; and that (4) intervention research should be undertaken to determine the effect of various strategies to inform the different key populations about skilled childbirth for adolescents in order to improve its access and use.
Change in health services and increased access and use of skilled ANC There were no eligible studies found during the systematic review process that linked 'change in health services' to increased use of skilled ANC.
The discussion focused on special barriers to ANC for adolescents, including youth friendly services and provider attitudes; mobility (married adolescents in some sociocultural contexts often have restricted freedom to independently navigate their context); and young age (10)(11)(12)(13)(14). The panel agreed that these special barriers be considered, in addition to information as a barrier to ANC. 18 Population groups include: Community: leaders, members; Policymakers, decision makers; Families: parents and mothers-in-law; Adolescents: couples, boys, girls, males, females; General population The panel concluded that further intervention research should be undertaken to identify the types of changes to health services needed to improve access and use of ANC to adolescents.

# Interventions that address individual-level determinants
Birth preparedness and pregnancy-related outcomes Given the evidence on birth preparedness as an effective intervention in improving neo-natal and peri-natal outcomes, the panel was able to make a recommendation for action. Specifically, birth preparedness is an intervention of the WHO ANC package of care, based on the multi-centered RCT 19 20 that demonstrates the effectiveness of the package of ANC in improving neo-natal and peri-natal outcomes. Additionally, some community-based studies, including birth and complication preparedness show improved access and use of skilled ANC and childbirth.
The panel discussed harms or burdens, difference in values and resource implications related to birth preparedness interventions. The panel noted that there were no harms or burdens or difference in values but that there may be costs related to interventions for birth and complication preparedness at the community-level. 21,22 and should be consistently promoted in ANC strategies for pregnant adolescents (at the household, community, and service settings); and that (2) Intervention research should be undertaken to identify specific aspects needed for birth and emergency preparedness for adolescents, focussing on intermediate outcomes (such as increased use of skilled care during pregnancy, childbirth and post natal) in addition to distal outcomes such as pregnancy-related morbidity and mortality.

# The panel concluded that (1) birth and emergency preparedness is a key component of WHO ANC Guidelines
Change in health services use of skilled childbirth care Since there were no eligible studies found in the systematic review process that linked 'change in health services' to increased use of skilled childbirth care, the panel noted the need for further research.
The panel concluded that intervention research should be undertaken to identify the types of changes to health services needed to improve access and use of skilled childbirth for adolescents.

# Target and reduce barriers and increased use of skilled antenatal, childbirth, and post natal care services
One study identified in the systematic review process, with an analysis disaggregated by age, demonstrated the increased use of skilled antenatal, childbirth, and post natal care services through reducing financial barriers (Lim, 2010). The study extracted data from household surveys and showed an increased odds ratio for financial schemes and an iv: AnnEx 2 -Report of the expert panel increase in antenatal care, in facility births and skilled birth attendance and reduced odds for peri-natal and neonatal deaths in adults and adolescent mothers.
The panel highlighted priorities for future research, including: the importance of conducing further secondary analysis of existing data from conditional cash transfer schemes (or voucher schemes) (which have been carried out in Nepal, Cambodia, Bangladesh, Indonesia, Honduras, Mexico among other countries); and assessing how enrollment in an insurance scheme could improve access to antenatal, childbirth and/ or post natal care services. The group also noted that research should not only focus on financial barriers, but also address the multitude of additional barriers adolescents face with respect to accessing antenatal, childbirth and post natal care. Therefore research should also consider the special barriers to health-seeking behavior, education, employment, health insurance, alternative models of care, provider attitudes, and quality of care standards specific to adolescents, among others. Additionally, substantial efforts should be directed at targeting most vulnerable (poorest of the poor, geographically/ rural, isolated, younger ages, and other disenfranchised groups).
The panel concluded that intervention research should be undertaken to identify effective strategies to reduce barriers in increasing access to and use of skilled antenatal, childbirth, and post natal care services among adolescents. Considering the heterogeneity of adolescents, strategies will likely need to vary, targeting specific barriers and addressing structural determinants of access.

# Tailoring antenatal, childbirth, and postnatal care services to improve maternal and infant outcomes
The systematic review identified one study (Aracena, 2009) that met the inclusion criteria, assessing home visits as a form of tailored adolescent intervention for last trimester and post natal care, in addition to antenatal and standard in-facility care and reflected increased use. Specifically, the study addressed access to standard ante-natal care, including scheduled home visits by community-based health educators supervised by trained personnel (nurses-midwives), including post natal scheduled home visits (up to 12 visits) by trained and supervised community based health educators. (Aracena 2009). The findings are consistent with reviews and studies including (Olds &Kitzman (1990 and 2004) Larson (1980), Korfmacher, Kitzman and Olds (1998), Cumsille and Ramirez (1999) Olds et al (2002,2004). However, the quality of the evidence was GRADED Very Low.
Given the limited research findings in low and middle income countries, and the high resource implication of including a recommendation for expanded services, the panel decided to focus on the need for further research to identify effective interventions that influence maternal and peri-natal and child health outcomes. Specifically, given the various and complex access issues for adolescents, and their heterogeneous nature, within varying socio-cultural contexts, it was discussed that research could focus whether "tailoring" standard services is sufficient and/or whether additional support (home visits) be included as part of the recommended package for adolescents. Existing efforts in developing countries to tailor maternal and infant care for adolescents should also be evaluated to better inform programmatic and policy approaches.

# Expanding availability of basic emergency obstetric care and comprehensive emergency obstetric to improve maternal and infant outcomes
Basic emergency obstetric care and comprehensive emergency obstetric care are lifesaving interventions. Therefore adolescents have the right to ensured access. Given the high proportion of adolescent maternal death attributable to abortion related complications in many developing countries, it is essential that basic emergency obstetric care and comprehensive emergency obstetric care address the special barriers for adolescents with respect to abortion related complications.
In addition to special barriers, the unique vulnerabilities of adolescents was also mentioned as an important consideration for intervention design. For example, monitoring of quality maternal health standards during pregnancy and childbirth and postnatal care, is important to ensure quality of care but also avoid abuse of procedures (e.g. C-sections).
The panel concluded that (1) availability and access to basic emergency obstetric care (BEMOC) and comprehensive emergency obstetric care (CEMOC) should be expanded; and that (2) intervention research should be undertaken to identify specific efforts to expand availability and access to BEMOC and CEMOC to adolescents.

# Next Steps:
(1) CAH-WHO will prepare a draft of the recommendations that emerged from the meeting and circulate to the panel for final inputs before including in the Guidelines document.

# (2) CAH-WHO will finalize Guidelines/Recommendations report and submit to the WHO Guidelines Review Committee (GRC). (3) Based on the FCI-WHO presentation on the Guidelines dissemination plan,
WHO work with FCI to finalize the publication and disseminate.
iv: AnnEx 3 -key questions by outcome 2.5. Is there evidence that efforts to provide postpartum and post-abortion contraception are effective in reducing second pregnancies among adolescents?
- 6. Is there evidence that social support programs are effective in reducing second pregnancies during adolescence?
- 1. Is there evidence that efforts directed at political leaders/planners, including those at the community level, have resulted in the formulation of laws and policies that increase access to contraceptive services and information for adolescents?
- 2. Is there evidence that efforts directed at political leaders/planners, including those at the community level, have resulted in the formulation of laws and policies that increase access to emergency contraception for adolescents?
- 3. Is there evidence that efforts directed at community members and leaders are effective in increasing access to contraceptives for adolescents? AnnEx 3 -key questions by outcome iv: AnnEx 3 -key questions by outcome 3.4. Is there evidence that efforts to improve health services are effective in increasing access to contraceptive information and services (including emergency contraception) for adolescents?
- 5. Is there evidence that efforts to make contraceptive methods, including emergency contraception, available over-the-counter are effective in increasing the access to contraceptives by adolescents?
- 6. Is there evidence that efforts to provide accurate information and education about contraceptives to adolescents are effective in increasing contraceptive use among adolescents?
- 7. Is there evidence that efforts to involve males in contraceptive decisions 'by the couple' are effective in increasing contraceptive use among adolescents?
- 8. Is there evidence that efforts to reduce the financial cost of contraceptives for adolescents are effective in increasing contraceptive use among adolescents?
- 1. Is there evidence that efforts directed at political leaders/planners, including those at the community level, have resulted in the formulation of laws and policies that punish perpetrators of coerced sex or support reporting of coerced sex involving adolescent girls?
- 2. Is there evidence that efforts directed at political leaders/planners, including those at the community level, have resulted in enforcing laws regarding coerced sex involving adolescent girls? 4.3. Is there evidence that efforts directed at adolescent girls to resist coerced sex have an impact?
- 4. Is there evidence that efforts to reduce the use of coercion by males to obtain sex have had an impact?
- 1. Is there evidence that efforts directed at policy leaders/planners and community leaders are effective in improving access to safe abortion for adolescents according to the existing law?
- 2. Is there evidence that efforts to inform adolescents and other stakeholders about the conditions under which abortions are legal are effective in reducing unsafe abortions among adolescents?
- 3. Is there evidence that efforts to reduce barriers are effective in increasing access to and use of safe abortion services among adolescents according to existing laws?
- 4. Is there evidence that efforts to increase the availability of post-abortion services are effective in reducing post-abortion mortality and morbidity among adolescents? 5.5. Is there evidence that efforts to make available post-abortion contraceptive services are effective in reducing post-abortion mortality and morbidity among adolescents? In the review, analysis and selection of the programme and policy evaluation reports identified, interventions addressing early marriage were defined as those fulfilling at least one of the following criteria:
- Includes in the description a specific aim to address or prevent early marriage of girls;
- Includes as part of the programme intervention or policy strategy deliberated activities to address the established causes and consequences of early marriage; or
- Includes in their evaluation some attempt to measure change in early marriagerelated behaviour (e.g. actual early marriage, practices concerning officiating at early marriages, acceptance of marriage offers for girls under age 18) OR attitudes concerning early marriage among relevant stakeholders (e.g. girls at risk of child marriage, parents, community leaders, religious leaders, policymakers, etc.) due to an intervention or other intentional activity.
WHO initially provided 6795 citations from its search of international databases, including 19 systematic reviews. Citations were initially screened and classified by title into one of two categories: not relevant or possibly relevant. Abstracts of the citations classified as possibly relevant were examined in a second round of screening and were further categorized into two categories: not relevant or possibly relevant. The third round of review consisted of examining full-text documents for their basic relevance; this process determined if the activities described in the document referenced an intervention that addressed child marriage in any way, and whether any evaluation of the intervention was attempted. The documents were again classified into not relevant or possibly relevant categories. These documents were then reviewed in detail to determine if they were appropriate for inclusion in the systematic review. The same process was conducted for the search results from WHO and regional databases, such as Regional Office for the Eastern Mediterranean (EMRO) and Latin American and Caribbean Health Sciences (LILACS). WHO initially provided 88 citations from these databases. A wide range of articles, reviews of the literature, and grey literature on early marriage, including an International Center for Research on Women (ICRW) report (1) and a 2007 ICRW scan of interventions on child marriage (2), to identify additional interventions were also examined. A general online search was then conducted for these referenced interventions to determine if they had been evaluated, and attempted to determine -through additional online search -whether they had indeed been evaluated. If it could not be determined whether the intervention had been evaluated or if a referenced evaluation could not be located, staff at the relevant organizations was contacted by email. A general online search using Google with different combinations of keywords related to each of the sub-questions listed above for Outcome 1 was also conducted. This search yielded documents on additional interventions and a few evaluations, which were then reviewed in a process identical to that outlined in Step 1 above. Several organizations were contacted for suggestions on other relevant interventions.
All documents identified in these steps were reviewed in detail to determine if they were appropriate for inclusion in the systematic review. In this final step, 41 articles were reviewed and 14 were identified as appropriate for full inclusion in the systematic review, with an additional eight evaluations retained for information even though the study design did not include control groups. Of citations obtained from the citations WHO provided and WHO databases, as well as through the steps that were undertaken, the 19 that were ranked as not relevant typically addressed one of the following without reference to a specific intervention:
- The prevalence and/or determinants of child marriage within a particular context.
- Adverse sexual and reproductive health behaviours and outcomes associated with child marriage (unrelated to an intervention).
During the study reviews, the relevant data was abstracted from the included articles into an Excel spreadsheet and submitted to WHO, along with electronic versions of the included articles. No studies were deemed eligible for the GRADE process used by WHO. Information in the 14 studies with the most robust evaluations was used to inform the discussion and develop recommendations.
Several different modalities were used to implement the reviewed interventions, such as group formation among girls at risk of early marriage, peer education and counselling, awareness-raising among parents and/or at the community level, and/or some level of engagement with community leaders or other decision-makers or influential residents.
One intervention (3) used was tested for efficacy of a participatory approach to develop and implement the interventions.  A number of evaluations provided little if any information on the selection of intervention sites (e.g. Better Life Options Program in India ( 4)). Few of the reviewed interventions used random selection to determine the study/intervention sites or the control sites. However, a few selected the overall geographic region purposively but then randomly selected villages/communities and/or participants from within that overall region (e.g. Malawi Conditional Cash Transfer Program (5)).
Many interventions, such as the Kishori Abhijan programme in Bangladesh (6), were located at sites where the implementing nongovernmental organization had a presence. Several of the reviewed interventions intentionally targeted areas where the infrastructure was more developed (e.g. Nepal Participatory Project (3)) while others, such as the Ishraq program in Egypt (7) targeted areas with poor infrastructure or other indicators of socioeconomic need.
The majority of interventions (13 of 14) measured changes in early marriage behaviour in the programme area compared to a control area; for example, a study compared the proportion of girls marrying during the intervention period in the intervention area and the control area (4). Few evaluations (6 of 14) measured changes in attitudes towards or knowledge about early marriage, even though those were common goals/objectives Among the 14 studies included in Table A4-1, the following limitations were identified: - No randomization of treatment or control sites.

# Geographic location
- The control group was not always comparable to the intervention group (e.g. Ishraq program (7). Given the many potential influences on girls' age at marriage, the inclusion of a comparable control group is essential to support claims of impact.
- Very few evaluations incorporated multivariate analyses or included statistical significance tests in bivariate analyses. The two next most common components among the 14 evaluated interventions included activities to change norms among parents of at-risk girls or at the community level (N=6) and to educate adolescents about sexual and reproductive health or family life education (N=5). Other components included micro-credit, financial support for girls' education (in cash or kind), creating safe spaces for young women to gather and socialize, teacher training, offering sports and physical activity, creating more youthfriendly reproductive and sexual health services, and legal reform.
In addition to the 14 studies, which included control groups, eight studies with no control group were also examined. Among these eight studies, the most common components included training in sexual and reproductive health or family life education, livelihoods training, non-formal or general education, and activities to change community norms concerning early marriage. Many interventions addressed more than one relevant audience (e.g., girls, parents, community leaders, religious leaders). Only a single evaluation of a law change appeared in the results of the literature search or Internet search.
Two of the evaluations that lacked control groups did not specify outcomes with enough detail to be included in this analysis/count. Secondary pregnancy prevention 2.5. Is there evidence that efforts to provide postpartum and post-abortion contraception are effective in reducing second pregnancies among adolescents? 2.6. Is there evidence that social support programmes are effective in reducing second pregnancies during adolescence?
The WHO literature searches found two systematic reviews (8,9) that assessed interventions to prevent pregnancy among adolescents in developing countries. Only the review could be entered into GRADE (8).
A Cochrane review included randomized trials only, most of which were conducted among poorer socioeconomic population segments in developed countries (8). This review showed that a variety of interventions were effective in reducing the unintended pregnancy rate among adolescents over medium-and long-term follow-up. The impact on secondary behavioural factors was less consistent. It further concluded that combination interventions (ones that incorporated educational and contraceptive aspects) were most effective in preventing unintended pregnancy, particularly when trials with high attrition were excluded. However, inference was limited by the lack of biological outcome data, variability in populations studied, and the paucity of comparisons of different interventions. The GRADE evidence profiles for different outcomes included in the review are shown in Tables 1 and 2 (see Section 3 for tables).
The WHO literature search found one systematic Cochrane review (10) on postpartum interventions to prevent repeat pregnancy among adolescents and women. This review included three randomized control trials examining postpartum interventions in developing countries, but only one included pregnancy as an outcome (10). As the Syrian study followed women at four months postpartum, it would be difficult to observe an effect in that short time frame. Considering trials in both developing and developed countries, three of four interventions with multiple contacts had a favourable impact on contraceptive use and repeat pregnancy. The authors concluded that the longer-term interventions are promising and not necessarily more   3.
The WHO literature search found five possibly relevant systematic reviews (11-15) that focused on high-income countries (the United States of America and the United Kingdom). These reviews are summarized in Table 4.
Three of these reviews contained meta-analyses that concluded that interventions are effective in reducing pregnancy (13,15) and repeat pregnancy (11). But the interventions evaluated in these reviews were diverse. Harden and colleagues examined early childhood and youth development programmes (13). Franklin et al reported on sex education programmes (including abstinence-centred and more comprehensive sex education with information on contraception) delivered in both schools and communities (15). The majority of the interventions in the review by Corcoran et al. were hospital-based; 25% involved home visits and 38% were comprehensive and included case management, referral and individual counselling (11). All three meta-analyses evaluated the quality of the studies included, but their evaluation criteria differed. The three meta-analyses share constraints common to most such efforts: failure to include relevant research, incomplete presentation of results and inability to secure data from original authors (11,13,15).
The two other publications were systematic reviews. DiCenso et al. reported no effect of primary prevention strategies in reducing pregnancy (12). It included studies of school-based sex education (some peer-led and others linked with health facilities), abstinence programmes (school-and community-based), and multifaceted (sex education coupled with service opportunities) interventions. However, they rated 7 of the 11 reviewed studies as poor quality. One study reported reduced pregnancy rates in the multifaceted intervention arm (education plus service opportunities) (16). The review by Moos et al. included three studies that focused on adolescents (14). Only one of those ascertained pregnancies, but the effect of clinic-based counselling was unknown because pregnancy data were not presented by group.
Additional publications and unpublished reports that were identified described interventions in less-developed countries to prevent adolescent pregnancies, but were not included in the systematic reviews. The reports that could be entered in GRADE appear in Tables 5a to 5e. Reports that could not be included in any systematic reviews nor could be GRADE-d are listed in Table 6, and more detailed assessments of their features, outcomes and quality appear in Table 7.
Lessons learned and resulting recommendations can and should incorporate data from rigorous randomized control trials and from well-conducted observational studies. Quality research upon which to make concrete recommendations should feature suitable control groups and ascertain biological outcomes. Information was compiled from Cochrane systematic reviews, systematic reviews that could not be GRADE-d, as well as stronger observational studies that were not included in reviews. Greater importance was placed: on randomized control trials than observational study results; on findings from developing country settings; and on pregnancy outcome data rather than contraceptive uptake or intentions. The synthesis indicated that multifaceted interventions (combination of contraceptive and educational interventions) lower the rate of adolescent unintended pregnancy.
iv: AnnEx 4 -search results by outcome 3.1. Is there evidence that efforts directed at political leaders/planners, including those at the community level, have resulted in the formulation of laws and policies that increase access to contraceptive services and information for adolescents? 3.2. Is there evidence that efforts directed at political leaders/planners, including those at the community level, have resulted in the formulation of laws and policies that increase access to emergency contraception for adolescents? 3.3. Is there evidence that efforts directed at community members and leaders are effective in increasing access to contraceptives for adolescents? 3.4. Is there evidence that efforts to improve health services are effective in increasing access to contraceptive information and services (including emergency contraception) for adolescents? 3.5. Is there evidence that efforts to make contraceptive methods, including emergency contraception, available over-the-counter are effective in increasing the access to contraceptives by adolescents? 3.6. Is there evidence that efforts to provide accurate information and education about contraceptives to adolescents are effective in increasing contraceptive use among adolescents? 3.7. Is there evidence that efforts to involve males in contraceptive decisions 'by the couple' are effective in increasing contraceptive use among adolescents? 3.8. Is there evidence that efforts to reduce the financial cost of contraceptives for adolescents are effective in increasing contraceptive use among adolescents?

# Summary of limitations of studies
Many studies measured condom use, though condoms are not the most effective pregnancy prevention methods (but necessary for HIV/STI prevention). A range of definitions and/or indicators for condom use was applied in the studies (at last sex, always, etc). It is important to note that the validity of self-reported condom use is questionable. Many studies were HIV focused, and therefore the relevance for inclusion was questionable, given the focus of the key questions on prevention of early pregnancies and poor reproductive health outcomes. Additionally, the precision of parameter estimates were questionable given that condom use is the secondary outcome and not a primary outcome.

# OuTcOmE 3
Increasing the use of contraception by adolescents at risk of unintended pregnancy ScOpE: Key questions Search strategy and review iv: AnnEx 4 -search results by outcome 4.1. Is there evidence that efforts directed at political leaders/planners, including those at the community level, have resulted in the formulation of laws and policies that punish perpetrators of coerced sex or support reporting of coerced sex involving adolescent girls? 4.2. Is there evidence that efforts directed at political leaders/planners, including those at the community level, have resulted in enforcing laws regarding coerced sex involving adolescent girls? 4.3. Is there evidence that efforts directed at adolescent girls to resist coerced sex have an impact? 4.4. Is there evidence that efforts to reduce the use of coercion by males to obtain sex have had an impact?
In the review, analysis and selection of programmatic interventions and policies related to sexual coercion the following were the eligibility criteria: - programmes or policies with a primary or secondary aim of addressing sexual coercion of adolescent girls;
- inclusion as part of programme intervention or policy strategy, of activities to address the causes and consequences of sexual coercion using public debate, critical reflection or explicit discussion of how gender norms may impact sexual behaviour (programme interventions or policy strategies could take the form of group educational activities, mass media campaigns, policy messages or institutional practices designed for adolescent girls and boys); and
- an evaluative measure of attitude changes among adolescent girls and boys on the acceptability of sexual coercion, behavioural changes among adolescent girls as they relate to sexual coercion, or behavioural changes among adolescent boys engaging in sexually coercive practices.
Multiple sources that were referenced in the literature search included:
- A review of sex without consent: young people in developing countries (17)
- WHO EndNote web and regional databases
- Formal literature search of electronic databases - Adolescent sexual and reproductive health field and policy experts.
The following electronic bibliographic databases were searched: Cochrane Library, PubMed, EMBASE, Popline, Lilacs, EMRO, and African Index Medicus (AIM). Searches were performed using keyword, MESH, and subject heading mapping. Pubmed was searched using all terms including but not restricted to adolescence or childhood or teenaged and combining them with all words relating to coerced sex or rape. Truncation was used where appropriate. This search was then combined with a search listing of all low-and middle-income countries (using subject headings as well as free text). The PubMed terms and strategy were translated into appropriate strategies for the other Citations ranked as not relevant were typically descriptive in nature and addressed one of the following topical areas:
- the prevalence of sexual violence within a particular geographic location;
- adolescents' awareness of sexual coercion;
- adverse sexual and reproductive health behaviours and outcomes associated with sexual violence/coercion (unrelated to an intervention);
- improving delivery of quality health services for survivors of sexual coercion;
- reviews of interventions addressing child sexual abuse or rape.

# Excluded studies and reports
In the final phase of analysis, studies and reports considered possibly relevant were excluded for the following reasons:
- lack of a direct/indirect measure of adolescent sexual coercion;
- not an intervention or not evaluated;
- did not include target population;
- measured perceived social norms vs personal attitudes.
Key findings from original research were evaluated for attitudinal and behavioural outcomes on reducing adolescent sexual coercion. The results of the literature search were used to develop a summary of findings including study design, study quality, consistency of effects across studies, and directness of study measures to reducing adolescent sexual coercion.

# Search results

# Irrelevant studies and reports
Analysis strategy iv: AnnEx 4 -search results by outcome
The literature searches conducted found no systematic reviews that directly assessed attempts to impact the occurrence of coerced sex among adolescents. There was only one published article found which directly addressed the four questions listed above, specifically questions 4.3 and 4.4. Most literature focused on a review of the occurrence of coerced sex and consequences. Four articles and two policies were identified which related to the questions above in that they provided an assessment of programmes directed at sexual behaviour and attitudes among adolescents. A study, which implemented interventions in Kenyan communities, included the occurrence of coerced sex as an outcome (18). Post-hoc analyses that compared sexual coercion outcomes between intervention and control sites indicate a positive impact of the intervention on girls reporting sexual coercion as well as boys' sexually coercive behaviours between the first intervention arm (site A) and the control site (site C). However these results should be interpreted with caution. A comparison between the second intervention arm (site B) and the control site (site C) showed an opposite effect for some outcomes. Additionally, the reported observations for each outcome were relatively small. The three remaining studies (Soul City Botswana, 19,20) did not directly assess the impact of interventions used on coerced sex. However, the interventions in the referred studies address changing adolescent girls' and boys' attitudes related to sexual coercion which may have an indirect effect on girls' ability to resist unwanted sexual encounters as well as in preventing sexually coercive behaviours among boys. Therefore, these studies are indirectly applicable to the outcome of reducing sexual coercion of adolescent girls.

# Summary of evidence
iv: AnnEx 4 -search results by outcome 5.1. Is there evidence that efforts directed at policy leaders/planners and community leaders are effective in improving access to safe abortion for adolescents according to the existing law? 5.2. Is there evidence that efforts to inform adolescents and other stakeholders about the conditions under which abortions are legal are effective in reducing unsafe abortions among adolescents? 5.3. Is there evidence that efforts to reduce barriers are effective in increasing access to and use of safe abortion services among adolescents according to existing laws? 5.4. Is there evidence that efforts to increase the availability of post-abortion services are effective in reducing post-abortion mortality and morbidity among adolescents? 5.5. Is there evidence that efforts to make available post-abortion contraceptive services are effective in reducing post-abortion mortality and morbidity among adolescents?
The following electronic bibliographic databases were searched: Cochrane Library, PubMed, EMBASE, Popline, LILACS, EMRO, and AIM. Searches were performed using keyword, MESH and subject heading mapping. PubMed was searched using all terms including but not restricted to adolescence or childhood or teenaged and combining them with all words relating to unsafe abortion. Truncation was used where appropriate. This search was then combined with a search listing all low-and middleincome countries (using subject headings as well as free text). The PubMed terms and strategy were translated into appropriate strategies for the other databases. Case reports, comments, editorials, conferences, legal cases or legislation, newspaper articles and patient education handouts were excluded. Additionally, all years and languages were included.

# iv: AnnEx 4 -search results by outcome