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Systematic review
Use of contraceptives, empowerment and agency of adolescent girls and young women: a systematic review and meta-analysis
  1. Zohra S Lassi1,2,
  2. Komal Abdul Rahim3,4,
  3. Alexandra Maria Stavropoulos2,
  4. Lareesa Marie Ryan2,
  5. Jyoti Tyagi5,
  6. Bisi Adewale6,
  7. Jaameeta Kurji7,
  8. Soumyadeep Bhaumik8,9,
  9. Salima Meherali6,
  10. Moazzam Ali10
  1. 1 School of public health, Faculty of health and medical sciences, The University of Adelaide, Adelaide, South Australia, Australia
  2. 2 Robinson Research Institute, University of Adelaide, Adelaide, South Australia, Australia
  3. 3 Dean's Office, Medical College, Aga Khan University, Karachi, Pakistan
  4. 4 Center of Excellence in Trauma and Emergencies, Aga Khan University, Karachi, Pakistan
  5. 5 George Institute of Global Health, New Delhi, India
  6. 6 University of Alberta, Edmonton, Alberta, Canada
  7. 7 School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
  8. 8 Meta-Research and Evidence Synthesis Unit, Health Systems Science, George Institute of Global Health, New Delhi, India
  9. 9 George Institute for Global Health, Faculty of Medicine and Health, University of New South Wales (UNSW Sydney), Sydney, New South Wales, Australia
  10. 10 Department of Sexual and Reproductive Health, World Health Organization, Geneva, Switzerland
  1. Correspondence to Dr Moazzam Ali, Department of Sexual and Reproductive Health, World Health Organization, Geneva, Switzerland; alimoa{at}who.int

Abstract

Introduction The evidence on adolescent empowerment, which involves access to personal and material resources for reproductive autonomy and economic equity, is limited. This systematic review assesses the use of contraceptives in empowering and strengthening the agency and vice versa among adolescents and young women.

Methods We ran the searches in six electronic databases: Cochrane Database of Systematic Reviews (CDSR) and the Cochrane Central Register of Controlled Trials (CENTRAL), The Campbell Library, MEDLINE (PubMed), EMBASE, Cumulated Index to Nursing and Allied Health Literature (CINAHL) and Web of Science. The methodological quality of studies was assessed using ROBINS-I and ROB-II tools as appropriate. Meta-analysis was performed using Review Manager 5.4.

Results Forty studies that assessed the impact of empowerment on contraceptive use were included. Of these, 14 were non-randomised studies for intervention (NRSIs), and the remaining 26 were randomised controlled trials (RCTs). The results from RCTs show a significant effect of the sexual and reproductive health empowerment in increasing ever use of contraception (RR 1.22; 95% CI 1.02, 1.45; n=9; I²=77%; GRADE: Very Low), and insignificant effect on unprotected sex (RR 0.97; 95% CI 0.74, 1.26; n=5; I²=86%; GRADE: Very Low) and adolescent pregnancy (RR 1.07; 95% CI 0.61, 1.87; n=3; I²=36%; GRADE: Very Low). None of the studies assessed impact of contraceptive use on empowerment.

Conclusions Empowerment of adolescents and young women certainly improves contraceptive use in the immediate or short-term period. However, more robust studies with low risk of bias, longer-term outcomes, and impact of contraceptive use on empowerment and agency-strengthening are required. To increase contraceptive use uptake, tailored policies and delivery platforms are necessary for youth in low- and middle-income countries.

  • adolescent
  • contraception behavior
  • Contraceptive Agents, Female
  • family planning services
  • Reproductive Health
  • Reproductive Health Services

Data availability statement

All relevant data is included in the review. Not Applicable.

http://creativecommons.org/licenses/by-nc/4.0/

This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.

https://doi.org/10.1136/bmjsrh-2023-202151

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    WHAT IS ALREADY KNOWN ON THIS TOPIC

    • Empowerment interventions focusing on sexual and reproductive health positively influence the short-term increase in contraceptive utilisation among adolescents and young women.

    WHAT THIS STUDY ADDS

    • There is a notable paucity of empirical evidence elucidating the impact of contraceptive utilisation on the empowerment and agency of adolescents and young women. This research gap necessitates further in-depth investigation. This study fills the gap by assessing the impact of empowerment on contraceptive use and vice versa.

    HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE OR POLICY

    • Additional research endeavours are imperative to understand how empowerment is conceptually framed, subjectively perceived and methodologically assessed within diverse cultural milieus. This underscores the critical importance of contextual comprehension in designing and implementing empowerment interventions.

    • It is incumbent on the research community to prioritise conducting more robust studies characterised by diminished bias risks. Such investigations should place a particular emphasis on investigating the protracted ramifications of contraceptive utilisation in bolstering the empowerment and agency of adolescents and young women.

    Introduction

    Adolescents (aged 10–19 years) and young people (aged 10–24 years) comprise a quarter of the world population, about 1.8 billion, mostly in South Asia, East Asia and Africa.1 Globally, approximately 15% of adolescent girls give birth before the age of 18 years,2 with up to 45%3 to 48%4 of these pregnancies being unintended. Unintentional adolescent pregnancies can threaten their community status, increase violence risk, and hinder education, employment and independence opportunities, diminishing their agency.1

    Empowerment entails women’s control over resources, self-reliance, decision-making and choice. This control can be defined in terms of earnings and expenditures, self-reliance, decision-making and choice, with women having the final say in various issues and having the choice to choose their spouse or be consulted.5 Empowerment can be measured through various methods, including analysing available resources, examining women’s decision-making agency and examining achievement. Changes in women’s resources can influence their choices due to other factors. Decision-making agency is based on women’s responses to roles, while achievement highlights inequalities in decision-making capacity. These measures are triangulated to capture empowerment.5

    Unintended pregnancies significantly affect adolescent girls and offspring’s health, particularly in low- and middle-income countries (LMICs) alike.6 Maternal conditions, for instance, are the second most common cause of mortality among teenage girls (7 per 100 000 live births) and contribute significantly to the overall burden of disease in this population (disability-adjusted life years (DALYs): 507 per 100 000 population).2 Globally, lack of access to contraceptives contributes to unintended pregnancies.7 Unintended pregnancies and lack of empowerment negatively impact health, socioeconomic status and adolescent girls' education, agency, community stigma and increased violence risk.8 Lack of education and early pregnancy in adolescent girls leads to reduced agency and lower status, particularly unmarried pregnant girls who face an increased risk of violence from partners and male relatives.9

    Despite significant focus on sexual and reproductive health (SRH) regulations, national efforts should prioritise creating supporting environments for contraceptive use, addressing social barriers.10 11 Greater attention is needed to foster enabling environments for contraceptive use, as supply-side efforts are insufficient in addressing the “relational and social barriers faced by women and couples”.12 It has been argued that a more insightful understanding of the constraints imposed by structural environments within which women and girls exercise agency is required.13 Contraceptive use by married or unmarried girls can enhance education, economic opportunities and decision-making abilities. Self-efficacy is crucial in negotiating contraceptive use with partners, representing empowerment.14 15 Individual empowerment encompasses various domains, such as health, social, economic, political, educational and spiritual, and is not achieved solely through agency, knowledge and an enabling environment.16

    The complex link between adolescent contraceptive use and empowerment warrants a comprehensive evaluation. Interventions should target both contraceptive use and empowerment outcomes, with long-term monitoring. This systematic review adopts a bidirectional approach, examining how contraceptives empower adolescents and vice versa (figure 1).

    Figure 1
    Figure 1

    Conceptual framework on family planning and empowerment of adolescents.

    Methodology

    The protocol is registered with PROSPERO (CRD42022331194). We have followed the 2020 Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.17

    Search strategy and databases

    The search strategy was guided by the PICOS (Population, Intervention, Comparator, Outcome, Study Designs) provided but was not restricted by the outcome to retain a broader search. No date or language restrictions were applied. The logic grid adapted for all databases is presented in online supplemental appendix 1.

    Supplemental material

    We ran the searches in the following databases: Cochrane Database of Systematic Reviews (CDSR) and the Cochrane Central Register of Controlled Trials (CENTRAL) in the Cochrane Library, the Campbell Library, MEDLINE (PubMed), EMBASE, Cumulated Index to Nursing and Allied Health Literature (CINAHL) and Web of Science. Additionally, we searched for non-indexed, grey literature using organisational websites reported in online supplemental appendix 2. We searched the bibliography of all included studies and relevant systematic reviews to identify any missing papers. The final search date was 20 October 2023.

    Supplemental material

    Eligibility criteria

    We included the studies that met the criteria detailed below.

    Types of studies

    The study included experimental studies with a control/comparison arm, including clinical and randomised controlled trials (cRCTs/RCTs), non-randomised studies for intervention (NRSIs), including quasi-randomised controlled trials (q-RCTs), controlled before-after (CBA), and interrupted time series (ITS) studies.18 Exclusions included observational studies, historic control/comparison arm, cohort, cross-sectional studies, case reports, opinions, editorials, commentaries, letters, conference abstracts and systematic reviews.

    Participants

    The study included interventions for adolescents and young women aged 10–24 years, including studies with disaggregated data and outcomes for both sexes. Studies with broader age groups included, but not segregated data, were considered separately in subgroups.

    Interventions/exposure

    We included studies on interventions/strategies that aimed to increase the use of contraceptives or empowerment or agency in adolescents and young women.

    The study defined contraceptive use as using modern contraceptives like pills, implants and condoms. Interventions included education, promotion and provision of these contraceptives through community, school and technological platforms, involving teachers, parents, peers and community/outreach workers.19

    Empowerment, as per our definition, comprises three interconnected dimensions: resources, agency and achievements.20 Resources encompass material and human assets facilitating choice. Agency involves defining and pursuing goals, employing diverse strategies like bargaining, negotiation, deception, manipulation, subversion and resistance, individually and collectively. Resources and agency combined result in capabilities that drive achievements.

    Outcomes

    For each outcome, we reported sex-disaggregated data if available, or else the outcomes, including both sex (male and female), were also included. The primary outcomes of the studies assessing the impact of the empowerment on contraceptive use included modern contraceptives, unprotected sex and adolescent/teenage pregnancy. Secondary outcomes included discussions with partners on condom use, refusal to sex, access to healthcare services, gender empowerment and receiving education or income.

    The primary outcomes of the study assessing the impact of contraceptive use on empowerment were broadly categorised into educational, employment, social, reproductive autonomy and general autonomy outcomes (details in online supplemental appendix 3).

    Supplemental material

    Data collection and analysis

    Selection of studies

    Search results were exported into EndNote, de-duplicated and uploaded into Covidence,21 a web-based systematic review software, for screening. Two review authors independently screened for the potential inclusion of all titles/abstracts/full texts, and discrepancies were resolved by consensus or by contacting a third reviewer. Reasons for exclusion were recorded (online supplemental appendix 4). A PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) 2020 flow diagram was used to record the numbers (figure 2).

    Supplemental material

    Figure 2
    Figure 2

    PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) flow diagram.

    Data extraction

    In a standardised data collection form, data were extracted for key variables, including study characteristics and outcomes. Two review authors independently extracted data, and discrepancies were resolved through discussion until consensus had been achieved or by consulting a third reviewer where required. We extracted data on the following study characteristics (table 1):

    Assessment of methodological quality

    View this table:
    Table 1

    Data extraction of included studies

    Two authors carried out quality assessments independently using the updated Cochrane Risk of Bias tool, ROB-II,22 for RCTs/cRCTs and ROBINS-I for NRSIs.23

    Data synthesis and measure of treatment effect

    The review analysed various empowerment strategies and interventions, including different study designs. Subgroup analysis was conducted for study design and other characteristics. A meta-analysis was conducted where two or more studies were pooled. Results were presented as summary risk ratios (RRs) with 95% confidence intervals (95% CIs) for dichotomous outcomes and mean differences (MDs) for continuous outcomes. The statistical method used was generic inverse variance (GIV) to account for clustering. A random-effects model was used to account for expected heterogeneity in study settings, exposures, comparisons, and outcomes across studies.

    Assessment of heterogeneity

    The study assessed statistical heterogeneity using I2 and χ2 tests, and visually inspecting forest plots. Based on prior clinical knowledge, the study expected clinical and methodological heterogeneity. To explain observed heterogeneity, participants were empowered differently, and subgroup analyses were conducted on primary outcomes. Subgroup analysis involved stratifying groups and testing for differences based on:

    • Study design (eg, NRSI, RCT/cRCT)

    • Age groups (adolescents, young adults, or a combination of the two)

    • Sex (aggregated data for both sexes or separated data for females)

    • Platform for delivery (community, school, technology)

    • Setting (regions based on WHO regions).

    Assessment of reporting biases

    For outcomes including more than 10 studies, we created and examined a funnel plot to explore possible small-study and publication biases.

    GRADE and evidence profiles

    We constructed GRADE Evidence profiles for the use of contraceptive outcomes as per the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) criteria.24 The study evaluates the risk of bias, directness of evidence, heterogeneity, precision of effect estimates, and publication bias within a study. It rates the certainty of evidence for key outcomes as high, moderate, low, or very low. For non-randomised studies, the quality of evidence was graded based on effect magnitude, dose–response relationship, and plausible confounding factors.

    Results

    Description of studies

    The database search identified 8571 papers, with 1130 additional sources identified. After removing duplicates, 7234 papers were screened for title and abstract. After 240 articles were screened for full texts, 40 studies were eligible for data synthesis. All studies assessed the impact of empowerment on contraceptive use, with no studies examining the impact of contraceptive use on empowerment. Refer to online supplemental appendix 5 for the characteristics of the included studies.

    Supplemental material

    We excluded 160 studies from 171 records at the full-text screening stage. The PRISMA flow diagram outlines the complete set of reasons for exclusion. A complete set of excluded studies with reasons can be found in online supplemental appendix 4.

    Of the 40 studies, 14 were NRSIs,25–38 11 were RCTs39–49 and 15 were cRCTs.50–64 Some 29 studies targeted adolescents26 27 29 30 32 35–37 40–42 44–48 50–53 55 57–64 and 11 targeted adolescents and young adults.25 28 31 33 34 38 39 43 49 54 56 Of all the studies, 32 targeted both genders25–35 37 40–42 44 46 47 50–62 64 and 8 included females only.36 38 39 43 45 48 49 63 Of the 32 studies targeting both genders, 13 provided segregated data for females.27 28 33 34 37 41 53 54 56–58 60 64 The studies on empowerment and strengthening of the agency were further classified as SRH empowerment and behavioural skills25–36 38–45 47 50–61 64 and multidimensional SRH empowerment.37 46 48 49 62 63 The delivery platforms included school,25 26 29 32 34 35 37 42 46 50–53 55 57 58 60–62 community,27 28 30 31 33 36 38 39 41 44 47–49 54 56 59 63 64 digital43 and clinic.45 The outcomes reported in the included studies are detailed in table 2.

    View this table:
    Table 2

    Reported outcomes from the included studies

    A detailed quality assessment for NRSIs and RCTs/cRCTs are mentioned in table 3 and figure 3, respectively. Briefly, among the NRSIs, 2 were high-risk of bias,27 30 6 studies had some concerns25 29 34–37 and the remaining 6 were low-risk of bias studies.26 28 31–33 38 Of the RCTs/cRCTs, 7 studies were rated as high-risk of bias,40 41 54 60 61 63 65 12 had some concerns39 43 44 46–48 50 53 57–59 64 and 7 studies were low-risk of bias.42 45 49 51 52 55 62

    View this table:
    Table 3

    ROBINS-I tool for assessing quality of non-randomised studies for intervention (NRSIs)

    Figure 3
    Figure 3

    ROB-II for assessing quality of clinical and randomised controlled trials (cRCTs/RCTs). D1: Randomisation process; D2: Deviations from the intended interventions; D3: Missing outcome data; D4: Measurement of the outcome; D5: Selection of the reported result.

    Impact of empowerment on contraceptive use

    SRH empowerment and behavioural skills

    A total of 34 studies provided SRH empowerment.25–36 38–45 47 50–61 64 Of these, 13 were NRSIs,25–36 38 8 were RCTs39–45 47 and 13 were cRCTs.50–61 64 Some 24 studies were reported on adolescents only26 27 29 30 32 35 36 40–42 44 45 47 50–53 55 57–61 64 and 10 were reported on adolescents and young adults.25 28 31 33 34 38 39 43 54 56 The studies were conducted in the African region,25–28 31 34 35 50 52 54 56–58 64 regions of America,29 30 32 36 39–45 47 51 53 55 59 61 Western Pacific33 60 and South Asian region.38

    Randomised controlled trials (RCTs)
    Any contraceptive usage

    Nine studies reported any contraceptive usage.39 43 45 52 53 55 56 58 64 The confidence in the effect estimate is limited in showing a significant impact of the intervention in increasing any modern contraceptive use (RR 1.22; 95% CI 1.02, 1.45; n=9; Heterogeneity: χ2 p=<0.00001; I²=77%; GRADE: Very Low) (figure 4).

    Figure 4
    Figure 4

    Sexual and reproductive health empowerment on any contraceptive use.

    There is uncertainty about the impact of the intervention on the mean number of contraception use44 51 in the last 1–3 months (MD −0.02; 95% CI −0.03, –0.01; 2 studies; Heterogeneity: χ2 p=0.58; I²=0%; GRADE: Very Low). One study reported insignificant use of emergency contraception (RR 1.41; 95% CI 0.95, 2.10).53

    Unprotected sex

    Five studies reported unprotected sex.40 42 47 50 64 There is uncertainty about the insignificant impact of the intervention in reducing the frequency of unprotected sex (RR 0.97; 95% CI 0.74, 1.26; n=5; Heterogeneity: χ2 p=<0.00001; I²=86%; GRADE: Very Low).

    Adolescent pregnancy

    Three studies reported adolescent pregnancy.43 55 56 There is uncertainty about the insignificant impact of the intervention on adolescent pregnancy (RR 1.07; 95% CI 0.61, 1.87; n=3; Heterogeneity: χ2 p=25; I²=36%; GRADE: Very Low).

    Discussion with partners on condom use

    One study reported discussion on condom use with partners.39 There is a probable significant impact of the intervention in increasing discussion with partners on condom use (RR 1.60; 95% CI 1.28, 2.00).

    Refuse unsafe sex

    Three studies reported refusal of unsafe sex.39 41 53 The effect estimate showed no impact in refusing unsafe sex (RR 1.00, 95% CI 0.96, 1.04; n=3; Heterogeneity: χ2 p=0.07; I² = 55%).

    Accessed to healthcare services

    Four studies reported access to healthcare services.43 55 58 64 The effect estimate showed an insignificant impact of intervention in increasing uptake of healthcare services (RR 1.11; 95% CI 0.88, 1.40; n=4; Heterogeneity: χ2 p=0.02; I² = 66%).

    Gender empowerment

    One study reported gender empowerment.64 The results showed an insignificant impact of intervention in increasing gender empowerment (RR 1.17; 95% CI 0.97, 1.42).

    Refer to table 4 for the subgroup analysis of SRH empowerment and behavioural skills for RCTs/cRCTs.

    View this table:
    Table 4

    Subgroup analysis of sexual and reproductive health empowerment and behavioural skills for clinical and randomised controlled trials (cRCTs/RCTs)

    Non-randomised studies for intervention (NRSIs)
    Any contraceptive usage

    Any contraceptive usage was defined as any modern contraceptive use or ever-used contraceptive.25–28 30 31 33–35 38 The confidence in the effect estimate is limited in showing a significant impact of the intervention in increasing any modern contraception use (RR 1.14; 95% CI 1.02, 1.27; n=10; Heterogeneity: χ2 p=<0.00001; I²=92%; GRADE Certainty: Very low). There was no publication bias as indicated from the funnel plot (figure 5).

    Figure 5
    Figure 5

    Funnel Plot for Publication Bias of SRH Empowerment Any Contraceptive Usage (NRSI).

    Unprotected sex

    One study reported unprotected sex.29 There is uncertainty on the effect estimate showing an insignificant impact of the intervention in reducing unprotected sex (RR 0.70; 95% CI 0.44, 1.12; GRADE Certainty: Very Low).

    Adolescent pregnancy

    Two studies reported adolescent pregnancies.29 30 There is uncertainty on the effect estimate showing an insignificant impact of the intervention in reducing adolescent pregnancy (RR 0.39, 95% CI 0.06, 2.64; n=2; Heterogeneity: χ2 p=0.0005; I²=92%; GRADE Certainty: Very low).

    Joint decision to use contraception

    One study reported a joint decision to use contraception.33 There is moderate confidence in the effect estimate showing a potentially significant impact of the intervention in increasing joint decision to use contraception (RR 1.07; 95% CI 1.00, 1.14; GRADE Certainty: Moderate).

    Discussion on condom use

    One study reported discussion on condom use.31 There is uncertainty in the results showing an insignificant impact of the intervention in increasing discussion on condom use (RR 1.48; 95% CI 0.18, 2.54; GRADE Certainty: Very Low).

    Access to healthcare services

    One study reported access to healthcare services.31 There is confidence in the results showing a significant impact of the intervention in increasing access to healthcare (RR 3.89; 95% CI 1.90, 7.93; GRADE Certainty: High).

    Multidimensional empowerment

    A total of six studies provided multidimensional empowerment.37 46 48 49 62 63 Of these six studies, four were RCTs,46 48 49 62 one a cRCT,63 and one an NRSI.37 Five studies reported on adolescents only,37 46 48 62 63 and one reported on adolescents and young adults.49 The studies were conducted in the African region46 48 49 62 63 and in the regions of America.37

    Randomised controlled trials (RCTs)
    Any contraceptive usage

    Three studies provided estimates for any contraceptive usage.46 48 63 There is uncertainty about the effect of intervention in increasing uptake of contraception (RR 1.10; 95% CI 1.00, 1.20; n=2 studies; Heterogeneity: χ2 p=0.94; I²=0%; GRADE Certainty: Very Low).48 63 The results from another study that reported mean contraceptive usage showed an insignificant difference in contraceptive usage in the intervention and control group (MD 0.03; 95% CI −0.18, 0.24).46

    Adolescent pregnancy

    Two studies reported adolescent pregnancy.48 63 There is uncertainty in the effect estimate showing an insignificant impact of the intervention on reducing adolescent pregnancy (RR 0.82; 95% CI 0.62, 1.08; n=2; Heterogeneity: χ2 p=0.001; I²=81%; GRADE Certainty: Very Low).

    Received own income

    One study reported receiving income after the intervention.48 The results showed an insignificant impact of the intervention in increasing own income generation (1.06; 95% CI 0.81, 1.37).

    Received education

    One study reported receiving education.63 The results showed an insignificant impact of the intervention on receiving education (RR 0.94; 95% CI 0.89, 1.01).

    Non-randomised studies of intervention (NRSIs)
    Any contraceptive usage

    One study reported any contraceptive usage.37 There is uncertainty in the results showing an insignificant impact of the intervention on using a condom in the last sex in females only study (RR 1.19; 95% CI 0.97, 1.45; GRADE Certainty: Very Low).

    Adolescent pregnancy

    One study reported adolescent pregnancy.37 There is uncertainty in the results showing a significant effect of the intervention on preventing adolescent pregnancy among females (RR 0.48; 95% CI 0.24, 0.98; GRADE Certainty: Very low).

    Access to healthcare services

    One study reported access to healthcare services.37 There is uncertainty on the effect estimates showing that females insignificantly accessed healthcare services (RR 1.15; 95% CI 0.96, 1.37; GRADE Certainty: Very Low).

    Impact of contraceptive use on empowerment

    There were no studies that assessed the impact of contraceptive use on empowerment.

    Discussion

    This review focuses on studies that assessed the impact of empowerment on contraceptive use. Of 40 studies, 34 provided SRH empowerment with behavioural skills and 6 provided multidimensional empowerment. The pooled estimates showed a significant impact on increasing the use of modern contraceptives and a non-significant reduction in unprotected sex. A significant difference was observed in contraceptive use across different regions and delivery platforms. The intervention also improved communication with partners and combined decision-making on contraceptive use. However, the evidence is limited, and the GRADE certainty of these studies is low and of very low quality. Multidimensional empowerment could potentially improve the overall uptake of modern contraceptives. The low-GRADE certainty is due to high risk of bias, statistical heterogeneity and precision in the studies. Despite these issues, there is suggestive evidence that empowerment may be positively associated with improved contraceptive uptake.

    Our findings are consistent with an earlier review that showed a significant impact of SRH empowerment on increasing adolescent knowledge of SRH and the use of contraception.66 67 A Cochrane review found school-based interventions effectively prevent unintended pregnancies but found inconclusive evidence on contraceptive use and sexually transmitted infection (STI) prevention.68 Our review included studies that empowered adolescents and young adults at individual or group levels. The literature suggests that group-based interventions are more effective in improving SRH outcomes, such as the prevention of HIV and STIs.69 Earlier reviews underscored that studies did not report the longer-term outcomes of the use of contraceptives on empowering girls and young women.70 71 Our review also did not report any long-term impact of empowerment on contraceptive use.

    Our review found that empowerment interventions primarily targeted SRH with limited focus on multidimensional empowerment. Community norms play a vital role, but barriers include resource scarcity, monitoring limitations and insufficient government collaboration.72 Interventions aimed at changing societal norms, building capacity, and financial means are crucial for enhancing contraceptive use among younger populations. Strengthening economic and health domains is integral to empowerment, but only one study targeted both. Economic empowerment has shown beneficial impacts on married adult women.73

    Empowerment, a concept that differs across cultures and settings, is crucial for understanding its impact on adolescents' use of contraceptives. In an ideal world, cross-country comparisons of empowerment or undertaking qualitative evidence synthesis (QES) are possible with a measure validated in various settings or regions. However, studies have not consistently defined or measured empowerment. Despite this, school-based programmes are effective in empowering adolescents in SRH, including the use of contraceptives.74 75 However, the literature also suggests that the effectiveness of school-based empowerment is amplified when these are linked to communities.76 77 Our included studies were also conducted in community-based settings. Community-based SRH empowerment strategies are prioritised over school-based ones, as WHO defines adolescent-friendly services as accessible, acceptable, equitable, appropriate and effective for various youth subpopulations.78

    This systematic review used a comprehensive search strategy across multiple databases, excluding language and date restrictions. It examined publication bias in outcomes from 10 or more studies. However, potential biases include missing evidence from unpublished studies and the likelihood of publishing studies with statistically significant positive findings. The review also found four potential studies on trial registries, which may be included in future updates.79–82

    The review explored empowerment’s link with contraceptive use in adolescents and young people but lacked evidence on how on contraceptive use affects empowerment. Multidimensionality of empowerment complicates overall improvement. Most studies focused on Africa and the Americas, suggesting varied perceptions. Cross-region comparisons and studies from regions are needed. Adolescent-focused studies highlight their unique needs. Evidence quality varied, with limitations like insufficient randomisation and self-reported data. Long-term effects of empowerment on contraceptive use remain unclear due to study limitations and a focus on short-term outcomes.

    Conclusions

    This review highlights the impact of empowerment on adolescent and young adult contraceptive use, boosting uptake and decision-making. Tailored programmes and policies for LMIC youth are crucial. Rigorous evaluation with consistent measures is vital. Future research should focus on long-term outcomes, agency and achievement-related measures. Increased accessibility to empowerment programmes is crucial for enhancing contraceptive use in resource-limited settings, especially for out-of-school adolescents. Assessing agency outcomes can inform informed decision-making. Further research is necessary in South Asia, the Gulf and Europe.

    Data availability statement

    All relevant data is included in the review. Not Applicable.

    Ethics statements

    Patient consent for publication

    Ethics approval

    Not applicable.

    Acknowledgments

    The authors gratefully acknowledge comments and suggestions from the WHO Technical Advisory Group (TAG) consisting of (listed in alphabetical order): Dr Ann Biddlecom; Dr Harriet Birungi, Professor Herbert Peterson, Dr Iqbal Shah, Dr James Kiarie, Professor John Cleland, Dr John Townsend, Dr Manala Makua and Professor Sonalde Desai. We would like to specially acknowledge the support and guidance of Dr James Kiarie (WHO) throughout the process of completing the project. They thank him for his efforts. The authors acknowledge the support of the United States Agency for International Development ( USAID) who provided input on the research questions. USAID did not participate in the data abstraction, analysis or interpretation or the decision to submit this article for publication. The analysis, interpretation, write up and decision to submit the article was coordinated by the UNDP-UNFPA-UNICEF-WHO-World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Department of Sexual and Reproductive Health and Research, WHO. All authors were consultants and one author is a staff member.

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    Supplementary materials

    Footnotes

    • X @Drjyotityagi, @Moazzam2000

    • Collaborators NA.

    • Contributors ZSL: conceptualisation, project administration, methodology, software, formal analysis, investigation, data curation, writing – original draft. KAR: project administration, methodology, software, formal analysis, investigation, data curation, writing – original draft. AMS: writing – review and editing. LMR: writing – review and editing. JT: writing – review and editing. BA: writing – review and editing. JK: writing – review and editing. SB: writing – review and editing. SM: writing – review and editing. MA: conceptualisation, methodology, software, formal analysis, data curation, review. MA is a guarantor of the work.

    • Funding This study received support from the USAID consolidated grant 7200GH21IO00005.

    • Disclaimer The named authors alone are responsible for the views expressed in this publication and do not necessarily represent the decisions or the policies of the UNDP-UNFPA-UNICEF-WHO-World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP) or the World Health Organization (WHO).

    • Competing interests None declared.

    • Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.

    • Provenance and peer review Not commissioned; externally peer reviewed.

    • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.