Adolescent pregnancy in India: multilevel insights into distribution, determinants and socioeconomic inequalities.

Background: Adolescent pregnancy is a major public health issue, as it has a higher incidence of adverse pregnancy outcomes. It also affects the physical and psychosocial well-being of the adolescent mother. This study aims to estimate the distribution, determinants, rural-urban disparities and socioeconomic inequalities of adolescent pregnancy during 2019-2021 in India. Methods: We analysed data from the fifth round of the nationally representative cross-sectional survey (National Family Health Survey (NFHS-5), 2019-2021) using STATA V.18. We assessed the prevalence of adolescent pregnancy with respect to various factors using bivariate analysis and the correlates by nested multilevel logistic regression model and reported an adjusted OR with a 95% CI. We have used Concentration Index to assess the socioeconomic inequalities across the wealth index and education status. The positive value of the Concentration Index refers to the concentration of inequalities towards wealthier and higher education status, while the negative values refer to the concentration of inequalities towards poorer and lower education status, respectively. Results: A total of 122 480 adolescent girls aged 15-19 years were respondents in this study. The mean age of the respondents was 16.9 years, with an SD of 1.40, with 78% being from rural areas and 13% being married. The overall prevalence of adolescent pregnancy was 6.68%. Across the wealth index from poorest to richest, the risk of adolescent pregnancy shows a declining trend. The factors that determined adolescent pregnancy were age at marriage/cohabitation <18 years (AOR 3.87, 95% CI 3.70 to 3.99), illiteracy (AOR 1.28, 95% CI 1.16 to 1.35), an age gap of over 5 years with a partner (AOR 1.37, 95% CI 1.23 to 1.49), domestic violence (AOR 1.19, 95% CI 1.16 to 1.24), the North-East region (AOR 1.46, 95% CI 1.31 to 1.53), smoking/tobacco use (AOR 2.46, 95% CI 2.26 to 2.45), alcohol consumption (AOR 1.77, 95% CI 1.31 to 1.97) and lack of access to a healthcare centre (AOR 1.15, 95% CI 1.04 to 1.23). Exposure to media (AOR 0.82, 95% CI 0.76 to 0.87) and having health insurance (AOR 0.87, 95% CI 0.81 to 0.92) reduced the prevalence of teenage pregnancy. The highest prevalence of adolescent pregnancy was in Tripura (21.8%) and the lowest in Ladakh (0%). Teenage pregnancy was more concentrated among the poor (-0.055) and in urban areas (-0.061) than in rural areas (-0.045). Inequalities across education status were concentrated more towards lesser education (-0.040), which was even higher in rural (-0.044) than urban (-0.021) areas. Conclusions: Adolescent pregnancy affects nearly 7 of every 100 girls aged 15-19 years in India, with greater risks among the poor, less educated and rural populations. Retaining girls in school and expanding access to higher education are critical for prevention. Strict enforcement of the legal minimum marriage age of 18 years can reduce early unions and narrow spousal age gaps. Universal access to contraceptives, protection from sexual abuse and domestic violence and promotion of adolescent-friendly media programming by government and organisations are essential to reduce disparities.