Accelerators for improved health among adolescent mothers in South Africa: HIV and violence prevention, sexual reproductive health and education success

Background: 30% of girls in Africa are mothers, facing high risk for negative health and educational outcomes. We aimed to identify services with the potential to reduce multiple simultaneous risks for adolescent mothers, described by the UN as ‘development accelerators’. Methods: Adolescent mothers (n=1044) from South Africa completed questionnaires between 2017/2019 and 2020/2023, assessing mental health, HIV risks, violence victimisation, education access and hypothesised ‘accelerators’. We used multivariable random effects regression models, adjusting for covariates. Predicted probabilities (marginal effects) were estimated to determine how each identified accelerator, and their combinations, influence the probability of each outcome, offering improved interpretability into the impact of the accelerators. Results: Three ‘accelerators’ showed protective associations against multiple risks: Food security was associated with reductions in age disparate/transactional sex (OR 0.56, 95% CI (0.42, 0.74)); no contraception use (OR 0.42, 95% CI (0.29, 0.60)); no school enrolment or work engagement (OR 0.46, 95% CI (0.32, 0.67)) and low self-efficacy (OR 0.62, 95% CI (0.46, 0.83)). Non-violent parenting was associated with reductions in suicidality (OR 0.20, 95% CI (0.10, 0.39)); mental health distress (OR 0.44, 95% CI (0.31, 0.64)); transactional/age disparate sex (OR 0.62, 95% CI (0.45, 0.87)); intimate partner violence (OR 0.27, 95% CI (0.14, 0.52)); and sexual violence (OR 0.21, 95% CI (0.10, 0.44)). Respectful clinics were associated with reductions in mental health distress (OR 0.65, 95% CI (0.46, 0.92)); low self-efficacy (OR 0.43, 95% CI (0.33, 0.58)) and condomless sex (OR 0.46, 95% CI (0.35, 0.61). When all three accelerators—compared with none—were provided, risks were greatly lowered. For example, suicidality from 13% to 2%; intimate partner violence from 22% to 5% and sexual violence from 11% to 1%. Conclusions: This real-world, longitudinal cohort design study identifies services with accelerator impacts that protect adolescent mothers against multiple risks. These can be realised through improved reach of existing services to include adolescent mothers: economic support including government cash transfers, parenting programmes and adolescent-responsive healthcare.