Prevalence and determinants of repeat pregnancy among adolescent girls in selected health areas of the Limbe Health District of Cameroon: A community-based cross-sectional study

Repeat pregnancy is a significant public health concern due to its association with adverse maternal and child health outcomes. Understanding the factors contributing to repeat pregnancy is crucial for developing effective interventions and improving reproductive health services. This study aims to provide valuable insights into the prevalence and determinants of repeat pregnancy in the Limbe Health District, which can inform targeted interventions and policies to reduce its occurrence and improve reproductive health outcomes. This was a community-based cross-sectional study carried out in selected health areas of the Limbe Health District from February to June 2023 among 394 teenagers. A multistage sampling technique was used to enroll participants. A structured questionnaire was used to collect data. The principal investigator collected data and the data was entered using kobo collect. The data was analyzed using the Statistical Package for Social Sciences Version 26. Descriptive statistics such as mean and standard deviation were used to summarize data. A logistic regression model was used to identify determinants of teenage pregnancy at p<0.05. The mean age was 15.5±2.6. Of the 394 teenagers, 167 (42.4%) were within the age group 17-19 years and 358 (90.9%) were single. Less than half, 190 (48.2%) had attended secondary school and 317 (80.5%) were Christian. The prevalence of repeat pregnancy was 12.2%. Seaport health area recorded the highest individual prevalence of repeat pregnancy at 16.6% and the Bojongo health area recorded the lowest individual prevalence was at 6.4%. Factors identified associated with repeat pregnancy were age group 17-19 (AOR=12.6[95%CI: 1.51-105.48], p=0.019), being married (AOR=12.82[95%CI:3.55-46.30], P<0.001), Being a smoker (AOR=3.39[1.25-9.21], p=0.017), consuming alcohol (AOR=2.60[95%CI: 0.8-8.4], p=0.025) and dating older people (AOR=2.90[1.20-7.04], p=0.018). This study revealed a repeat pregnancy prevalence of 12.2%. Factors associated with repeat pregnancy include marital status, smoking status, age and alcohol consumption. These findings highlight the need for targeted interventions and support for individuals at risk of repeat pregnancies.


INTRODUCTION
Teenage pregnancy is a global public health concern with significant social, economic and health implications (Kaphagawani and Kalipeni, 2017).Repeat pregnancy among teenagers, defined as a subsequent pregnancy following a previous one in girls <20 years poses even greater challenges (Norton et al., 2017).It not only exacerbates the existing negative consequences associated with teenage pregnancy but also increases the risk of adverse outcomes for both the mother and the child (Maravilla et al., 2019).Repeat pregnancy is known to affect around 18% of adolescent mothers in the USA (Gavin et al., 2013), Europe (Rowlands, 2010) and Australia (Lewis et al., 2010).While much research has been done on repeat pregnancy in Europe, America and Australia, the current research is unable to clearly establish its magnitude in developing countries such as Cameroon.
Understanding the prevalence and determinants of repeat pregnancy among teenagers is crucial for developing effective interventions to address this issue (Alukagberie et al., 2023).
Studies have shown that repeat pregnancies among teenagers are not uncommon.A study conducted by (Dee et al., 2017) found that approximately 20% of teenage mothers experience a repeat pregnancy within two years of their first birth (Dee et al., 2017).Similarly, a study by Jones et al. reported that 23% of teenage mothers in the United States had a repeat pregnancy within two years (Martinez et al., 2011).These findings highlight the need to investigate the prevalence of repeat pregnancy among teenagers in the Limbe Health District.This need is further supported by the fact that, very little found in literature on repeat pregnancy in Cameroon as a whole and the Limbe Health District in particular.
Several factors contribute to the high prevalence of repeat pregnancy among teenagers.One important determinant is the lack of comprehensive sexual education (Mejia et al., 2021).Research by Kirby et al. (2017) suggests that teenagers who receive comprehensive sexual education are less likely to engage in risky sexual behaviors and have a lower likelihood of experiencing repeat pregnancies.Additionally, socioeconomic factors such as poverty, limited access to healthcare services, and low educational attainment have been identified as significant determinants of repeat pregnancy among teenager (Ganchimeg et al., 2014).
Furthermore, peer influence and social norms play a crucial role in shaping teenagers' sexual behaviors.A study by Santelli et al. (2017) found that teenagers who perceive their peers as engaging in risky sexual behaviors are more likely to experience repeat pregnancies.
The Limbe Health District, Cameroon is an important area for studying the prevalence and determinants of repeat pregnancy among teenagers.Many health areas of the district face unique challenges, including limited access to healthcare services, high poverty rates, and cultural norms that may influence teenagers' sexual behaviors.Understanding the specific factors contributing to repeat pregnancy in this context is crucial for developing targeted interventions to address the issue.This study therefore set to close this gap by examining the prevalence and determinants of repeat pregnancy in the selected health areas of the Limbe health district of Cameroon.

Research designs
A community-based cross-sectional study was carried out in four selected health areas of the Limbe Health District.A cross-sectional study was used since prevalence was the main outcome and the participants were met only once.

Study area
The study was carried out in the Limbe Health District of the South West Region of Cameroon from November 2022 to September 2023.

Geographical situation
The Limbe Health District is one of the 18 health districts found in the South West Region.The district is situated in the tropical rainforest of the Congo Basin.
The Limbe Health District has many local communities where few girls have access to education.It is the calmest and least affected district by the current crisis affecting the Northwest and Southwest Regions of Cameroon.It has experienced influx of population since 2017 when the crisis became so violent.In additional to having many local communities where not many girls have access to education, it is a host of many internally displaced persons including young girls because of its relative calmness in term of the crisis as compared to the other cities within the North West and Southwest Regions.

Study population
The study population included teenage girls aged 10-19 years living in selected health areas of the Limbe Health District.

Sample size determination
The sample size was obtained using the formula for estimation of the confidence interval for a proportion since our major outcome is the prevalence of teenage pregnancy.*Corresponding author.E-mail: chrisantuseweh@gmail.com.Tel: +237681759260.
Author(s) agree that this article remain permanently open access under the terms of the Creative Commons Attribution License 4.0 International License ( ) Where, n=Number of participants (least sample size needed); Z=the standard normal value corresponding to a significance criterion of 0.05 (95), = 1.960; e=Amount of error we will tolerate = ± 5%; P=Pre-study estimate of the prevalence of teenage pregnancy = 5.2% (Gabriel et al., 2020).

=78
n= 78 participants.The sample size was made up to 394 participants to increase the strength of the study.

A multi-stage sampling technique was used
Stage 1: A cluster sampling technique was used where all the eight health areas of the district were treated as clusters.
Stage 2: A simple random sampling technique was employed to select four out of the eight health areas in the Limbe Health District.
Here, all eight health areas were written on pieces of paper and folded to look the same.Four of those papers were randomly picked without replacement.The selected health areas which were Mabeta, Seaport, Bojongo, and Idenau were included in the study.Stage 3: A probability proportionate to size sampling technique was then used to know the number of participants to select from each selected health area.Stage 4: A systematic sampling technique was finally employed to select teenagers from the selected communities to meet up with the 394 participants' sample size.Here, houses with adolescent girls in the selected communities were numbered with the help of a community health worker.The interval size, k for each community was calculated by dividing the total number of participants (households with adolescent girls) by the proportionate sample size in each community.A household with an adolescent girl was chosen at random and subsequent households were chosen after the interval size, k to meet up the proportionate sample size of each community.
The proportion of adolescent girls selected from the various communities was determined (Table 1).

Inclusion criteria and exclusion criteria
Teenage girls living in the Lim/be health district whose parents gave assent and those were severely ill during the time of data collection.

Data collection tools
A pre-tested structured questionnaire was used to collect data.This questionnaire was divided into different sections according to the different objectives.

Pre-testing of questionnaires
A pre-test was carried out in the Buea Health District at the Tole Health Area.This was to test the validity of the questionnaire, its reliability and applicability during data collection.Also, pre-testing of the questionnaire before data collection helped to remove inconsistencies and repetitions.Amendments were made in some questions where necessary after the pre-testing.

Data collection
The data collection was done by the principal investigator using structured questionnaires.Most of the questions were coded into binary responses to ease data analysis and were closed ended.The questionnaires were in English and were self-administered by the teenagers who could read and write.For those who could not read and write, the responses of the teenagers were administered in the questionnaires by the data collector.The participants from all health areas were adequately informed about the study with the help of an information sheet and detail verbal explanation where necessary.Participants were enrolled in the study only after approved assent from the adolescents and consent from their parents, indicating their willingness to allow their children participate in the study.They were informed that they reserve the right to withdraw from the study at any time.Confidentiality of the participants was guaranteed by not using names on the questionnaires and by explaining to the participants how the questionnaires were handled.Each questionnaire only had had a file number, which was useful to the investigator alone during data analysis.

Data management
Questionnaires were properly checked for proper completion on collection from the participants and incomplete questionnaires were discarded.The questionnaires administered every day were safely stored in a cupboard accessible only by the principal investigator until data collection was complete.The data was keyed in using the kobo collect toolbox and an excel file generated from the kobo toolbox was then imported into SPSS version 26 for analysis.The questionnaires were kept in a locked cupboard in case needed for reference.

Data analysis
Data was analyzed using the Statistical Package for the Social Sciences (SPSS) software version 26 and presented in the form of tables and charts.Continuous variables such as age were described using summary statistics such as means and standard deviations.Categorical variables such as educational level and marital status were described using frequency tables and pie charts.
The prevalence of repeat pregnancy was gotten by dividing the number of teen girls who had experienced repeat pregnancy by the total population under investigation.
Simple logistic regression analysis was used to determine association between repeat pregnancy and categorical variables like, education and profession.Predictors in the simple logistic regression bivariate analysis with P<0.2 were taken to the multiple logistic regression analysis to finally identity factors associated.
Multiple logistic regression was used to identify the factors associated with repeat pregnancy from the bivariate analysis at 95% confidence level (P<0.05).

Ethical consideration
Ethical clearance was obtained from the Faculty of Health Sciences 0.1893 3.84 × 0.493 = 0.0025 Institutional Review Board of the University of Buea.This was after reviewing the protocol that was submitted to this board to ensure safe scientific procedures were used in collecting the data and ethics was respected.
Administrative authorizations were obtained from the Department of Public Health of BIAKA University Institute of Buea, South West Regional Delegation of Public Health and Limbe District Health Services before data collection.Informed consent was gotten from the guardians of the teenage girls and assent was given by the teenage girls before participating in the study.

Socio-demographic and life style characteristics
Regarding socio-demographic and lifestyle characteristics of teenagers (Table 2), their mean age was 15.5±2.6.Of the 394 teenagers who took part in the study, about 167 (42.4%) were within the age group 17-19 years and 358 (90.9%) were single.One hundred and ninety (48.2%) had attended secondary school and 317 (80.5%) were Christian.Eighty-four (21.3%) were living with their parents and 311 (78.9%) were internally displaced persons.

Life style characteristics
More than half of the participants 275 (69.8%) had never smoked and 372 (94.4%) average monthly income was below 25000 FCFA.A majority of the participants 261 (66.2%) were alcohol consumer and for 276 (70.1%) both parents were still alive.Two hundred (50.8%) reported not keeping late night or going for clubbing in the night and 251 (63.7%) reported having lived with their parents in the same room when of age 10+ years.As shown in Table 3, 313 (79.4%) reported not dating older people and above half 212 (53.8%) were watching pornographic videos.Two hundred and fourteen 214 (54.3%) had been sexually abused in the past and 226 (57.4%) reported they could leave and go back home anytime they wanted.Two hundred (50.8%) had a family history of teenage pregnancy and 259 (65.7%) reported they had never had multiple sex partners.Two hundred and thirty (58.4%) had been educated on the use of contraceptive to prevent pregnancy.

Prevalence of repeat pregnancy among teenagers in the Limbe Health District
Concerning the distribution of the prevalence of repeat pregnancy by the different health areas, of the 145 girls recruited from the seaport health area, 24 (16.6%) reported having experienced repeat pregnancy.Twelve (16.0%) of the 75 recruited from the Edenau health area and 7 (7.3%) of the 96 from Mabeta had experienced repeat pregnancy.Seaport health area therefore recorded the highest proportion of teenage girls who had experienced repeat pregnancy (Figure 1).

Overall prevalence of repeat pregnancy in the selected health areas
The overall prevalence of repeat pregnancy documented in this study was 48 (12.2%) (Figure 2).

Factors associated to repeat pregnancy in the bivariate analysis
At the level of the bivariate analysis using simple logistic regression model, ten factors were found associated to repeat pregnancy at p<0.05.These factors were: Age group, marital status, religion, person living with, internally displaced persons, smoking status, monthly income, keep late night, dated old people and had multiple sex partners (Table 4).

Factors associated to repeat pregnancy in the multivariate analysis
At the level of multivariate analysis after controlling for confounders, five factors were finally identified as significant predictors of repeat pregnancy (Table 5).These factors were: Age group, marital status, smoking status, alcohol consumption and dated old people.In fact, the odds of a teenager experiencing repeat pregnancy with the age group 17-19 was 12.6 (95%CI: 1.51-105.48,P=0.019) times more than the odds of a teenage girl within the age group 11-13 experiencing repeat pregnancy.Married teenage girls were more likely to   experience repeat pregnancy as compared to their unmarried counterparts (AOR=12.82,(95%CI: 3.55-46.39),P<0.001).Teen girls who were current smokers were more likely to experience repeat pregnancy as compared to those who had never smoked (AOR=3.39(95%CI: 1.25-9.21),P=0.017).Teen girls who were current alcohol drinkers were more likely to experience repeat pregnancy as compared to those who were nondrinkers (AOR=2.6 (95%CI: 0.8-8.4),p=.025).Finally, those who reported dating older men were more likely to experience repeat pregnancy as compared to those who were not dating older men (AOR=2.90(95%CI: 1.20-7.04),P=0.018).

Prevalence of repeat pregnancy among teen girls
In the study conducted in selected health areas of the Limbe health district in Cameroon, it was found that the prevalence of repeat pregnancy among teenagers was  12.2%.This finding is significant as it sheds light on the issue of repeat pregnancies in this specific population.
The identified prevalence suggests that a considerable proportion of teenagers in the study area experience repeat pregnancies, which may have implications for their health and well-being (Nang-Bayi et al., 2021).This prevalence rate calls for urgent attention and the implementation of targeted interventions to address the underlying factors contributing to repeat pregnancies among teenagers.This proportion of teenagers showed to have experience repeat pregnancy in this area is concerning and could negatively affect the attainment of the sustainable development goal 3: Health and wellbeing for all (Tsalis et al., 2020).This is because, pregnancy among teenagers have been shown to have adverse health effects on the both the mother and the baby.These consequences could further be worsened in more than one pregnancy (repeat pregnancy) among teenage girls (Mekonnen et al., 2019).The prevalence documented in this study is higher than the 42.6% reported by Ana and her colleagues in Caruaru, Pernambuco in 2017 (Albuquerque et al., 2017).It is also lower than the 20% reported in a study by Pattarawala and colleagues in 2017 (Talungchit et al., 2017) and the 19.9% reported by Desiree et al in 2019 in South Africa (Govender et al., 2019).The observed differences in the prevalence of repeat pregnancy between this study (12.2%), the study in South Africa (20%), and the study in Caruaru, Pernambuco (42.6%) can be attributed to several factors.Firstly, variations in the study populations might have played a role.This study included teens girls from 10 to 19 years unlike the others that included older teens.The younger teens included in this study must have contributed to the lower prevalence of teenage pregnancy reported in this study (Gabriel et al., 2020).Differences in demographics, socioeconomic status, cultural practices, and access to healthcare services can influence the likelihood of repeat pregnancies.
Additionally, variations in the sample sizes could have contributed to the differences.The study used a larger sample size than that of Ana and her colleagues.The larger sample size might have contributed to the differences observed in the different studies.Differences in the time period during which the studies were conducted might also have an impact, as societal norms and contraceptive practices can change over time.Furthermore, variations in the availability and utilization of contraceptive methods can contribute to differences in repeat pregnancy rates (Ribas, 2021).

Determinants of repeat pregnancy among teen girls
At the level of multivariate analysis after controlling for confounders, five factors were finally identified as significant predictors of repeat pregnancy.These factors were: Age group, marital status, smoking status, alcohol consumption, and dated old people.Married teen girls were more likely to experience repeat pregnancy as compared to their unmarried counterparts.Several factors contribute to married teen girls being more likely to experience repeat pregnancy compared to their unmarried counterparts.Firstly, marriage often brings about increased sexual activity and less consistent use of contraception, leading to a higher risk of unintended pregnancies (Wasswa et al., 2020 ).Additionally, societal pressure and expectations within marriage may discourage the use of contraception or family planning methods.Moreover, married teen girls may have limited access to comprehensive sexual and reproductive health education and services, further increasing their vulnerability to repeat pregnancies (Okine and Dako-Gyeke, 2020).These factors collectively contribute to the higher likelihood of married teen girls experiencing repeat pregnancy compared to their unmarried counterparts (Jibril and Kibru, 2020).
Teen girls that were smokers were more likely to experience repeat pregnancy.There are several reasons why teen girls who smoke are more likely to experience repeat pregnancy compared to their non-smoker counterparts.Firstly, smoking is often associated with engaging in risky behaviors, including unprotected sexual activity, which increases the chances of unintended pregnancies (Jibril and Kibru, 2020).Additionally, smoking may be linked to a higher likelihood of substance abuse, which can impair judgment and decision-making regarding contraception use (Ely et al., 2020).Furthermore, smoking can have detrimental effects on fertility and reproductive health, potentially increasing the difficulty of preventing pregnancies.These factors collectively contribute to the higher likelihood of teen girls who smoke experiencing repeat pregnancy compared to their non-smoker counterparts.Teenagers who reported drinking alcohol were more likely to experience repeat pregnancy as compared to their counterparts who reported not drinking alcohol.This could be due to the following.Firstly, alcohol consumption can impair judgment and decision-making, leading to engaging in risky sexual behaviors and increased chances of unintended pregnancies (Kusunoki and Barber, 2020).Additionally, alcohol use may be associated with a higher likelihood of engaging in unprotected sexual activity, further increasing the risk of pregnancy.
Teenage girls who reported dating older people were more likely to experienced repeat pregnancy as compared to those who did not.This could be because, firstly, power imbalances may exist in relationships with older partners, leading to limited control over contraceptive use and decision-making (Kusunoki and Barber, 2020).Older partners may exert pressure or influence to engage in unprotected sexual activity, increasing the risk of unintended pregnancies.

Conclusion
This study revealed a repeat pregnancy prevalence of 12.2%.Several factors were identified associated with repeat pregnancy, including marital status, smoking status, age, and alcohol consumption.These findings highlight the need for targeted interventions and support for individuals at risk of repeat pregnancies.

Figure 1 .
Figure 1.Distribution of repeat pregnancy prevalence by health areas.

Figure 2 .
Figure 2. Prevalence of repeat pregnancy among teenagers in the Limbe Health District.

Table 1 .
Proportion of adolescent girls selected from each community.

Table 2 .
Socio-demographic variables of teenagers in Limbe Health District.

Table 3 .
Life style variables of teenagers in Limbe Health District.

Table 4 .
Factors associated to repeat pregnancy at the bivariate analysis (simple logistic regression).

Table 5 .
Factors associated to repeat pregnancy in the multivariate analysis (multiple logistic regression).