World Health Organization · 2025 edition
GRADE evidence tables and systematic review methodology for interventions to prevent child marriage and improve contraceptive access among adolescent girls.
- Issuer
- World Health Organization
- Edition
- 2025 edition
- Audience
- Guideline Development Group members, systematic reviewers, programme planners, researchers, and policymakers requiring detailed evidence grading and study-level data
- Evidence
- GRADE-rated evidence synthesis of RCTs, quasi-experimental and observational studies; certainty ranged from very low to moderate across outcomes
- Reviewed
- 15 Oct 2026 · GMJ
What this guideline says
GMJ summary
This web annex provides the complete evidence base—GRADE tables, Evidence-to-Decision frameworks, and systematic review methods—supporting WHO’s 2025 guideline on preventing early pregnancy among adolescents in low- and middle-income countries. The evidence synthesis covers nine PICO questions on child marriage prevention (empowering girls, engaging parents and community, incentives, education, economic interventions, laws, leader mobilization, supporting married girls, and adolescent participation) and eight PICO questions on contraceptive access (social norms change, self-care, financial barriers, digital interventions, leader engagement, service quality, enabling laws, and adolescent participation).
For child marriage, evidence shows moderate certainty that skills-building interventions (life skills, sexual and reproductive health education, livelihoods training) reduce marriage before age 18 by 20–53%, conditional cash transfers linked to education reduce marriage by 24–31%, and school subsidies or fee waivers increase schooling by 0.67–1.68 years and delay marriage by 0.34–2.8 years. Evidence on contraceptive use among adolescents is more limited, with low to moderate certainty that multi-component social norms interventions combining home visits and group discussions increase modern contraceptive use (OR 4.53, 95% CI 1.60–12.87) and use at last sex (RR 1.26, 95% CI 1.06–1.50).
The document includes 17 detailed GRADE evidence tables with over 60 studies, notes that many multi-component interventions could not isolate specific effective elements, and highlights substantial heterogeneity across settings. Several interventions showed impact only among subgroups (younger vs. older adolescents, urban vs. rural) or were not sustained long-term.
Key points
For clinicians — doses and thresholds as stated in the guideline
- Life skills, SRHR education and livelihoods interventions reduced child marriage by 20–31% in the education arm (OR 0.693, P ≤0.001) and gender-rights arm (OR 0.695, P ≤0.001) and by 25–30% in multi-skill interventions (AHR 0.70–0.75, P <0.01).
- Conditional cash transfers tied to school attendance reduced marriage before age 18 by 24% at 4.5 years post-programme (−8.9 percentage points, P <0.01) and sustained reductions in pregnancy and fertility among school dropouts.
- Unconditional cash transfers reduced marriage likelihood by 44% at two years (−7.9 percentage points, P <0.05) and pregnancy by 27%, but effects were not sustained two years after programme end except in the conditional transfer arm.
- School fee elimination increased years of schooling by 0.67–1.68 years, delayed marriage age by 0.34–2.8 years, and in Rwanda and Zambia reduced marriage before 18 by 5–19 percentage points; effects were larger for secondary vs. primary fee removal.
- Multi-component social norms interventions (home visits, group discussions, peer education) increased any modern contraceptive use (additional 17.9%, 95% CI 5.3–30.5, P =0.005) and contraceptive use at last sex (RR 1.26, 95% CI 1.06–1.50).
- Community mobilization with SRHR education among married adolescents increased contraceptive demand (OR 1.49, P <0.01), contraceptive use (OR 3.84, P <0.001), and knowledge of fertile days (OR 2.97, P <0.001).
- Impact of laws setting minimum marriage age at 18 was inconsistent: significant reductions in child marriage observed only in Nepal and Tajikistan immediately post-implementation and not sustained; no effect in Benin, Bhutan, Kazakhstan or Mauritania; differential urban/rural impact in Ethiopia.
- Empowerment programmes increased self-efficacy scores by 0.31 points (95% CI 0.02–0.6), girls' mobility and freedom scores, and contraceptive self-efficacy by 8.3–10.6 percentage points (P <0.05), though many did not translate into measurable reductions in child marriage.
Impact of conditional financial incentives on child marriage (PICO 1.3, outcome 1, RCTs)
Table extracted from the guideline
| Study/Setting | N | Intervention | Result on child marriage | Certainty |
|---|---|---|---|---|
| Baird et al. Malawi CCT | Not stated | Conditional cash transfer | No significant impact at 2 years (−1.2 percentage points, SE 0.024) | Moderate |
| Austrian et al. Kenya | Not stated | Violence prevention + education (VE) | −6.2 percentage points (95% CI −11 to −2), P <0.01 | Moderate |
| Baird et al. Malawi CCT sustained | Not stated | CCT 2 years post-programme | Sustained significant reduction in marriage incidence | Moderate |
| Buchmann et al. Bangladesh | 15,576 | CCT for ≥2 years | 24% reduction in marriage before age 18 (−8.9 percentage points, P <0.01) at 4.5 years | Moderate |
| Özler et al. Liberia GE+ | Not stated | Cash incentive + empowerment | 46% less likely to be married (−3.6 percentage points); GE+ reduced marriage >50% | Moderate |
Source: World Health Organization, Guideline on preventing early pregnancy and poor reproductive outcomes among adolescents in low- and middle-income countries – Web Annex: Evidence base. Reproduced in summary form.
From the guideline
Verbatim
“The average programme effect in the community was significant with adjusted hazard ratio 0.75 (95% CI: 0.60–0.92; P = 0.007) for education, 0.72 (95% CI: 0.59–0.88; P = 0.001) for gender, and 0.70 (95% CI: 0.56–0.87; P = 0.001) for livelihoods relative to those living in control arm villages.”
Editor’s perspective
Why this matters for Georgia and the region
Prof. Giorgi Pkhakadze, MD, MPH, PhD
Editor-in-Chief, Georgian Medical Journal · Chair, Public Health Institute of Georgia · WHO consultant, health and migration
As someone who has worked on adolescent health strategy in Georgia and the region, I find the evidence on conditional social transfers particularly relevant. Georgia's Targeted Social Assistance programme reaches approximately 10% of the population but is not currently conditioned on school attendance beyond basic enrolment; the sustained impact shown here—24% reduction in marriage before 18 at 4.5 years post-intervention—suggests we should pilot secondary-school-linked conditions in high-risk regions like Kvemo Kartli and Samtskhe-Javakheti. I would stress to Georgian colleagues the importance of the multi-component approach: empowerment programmes that combined life skills, SRHR education and livelihoods training showed 20–31% reductions, whereas single-component interventions were inconsistent. The implementation caveat is significant: many studies could not isolate which intervention elements drove impact, effects varied markedly by setting and age group (often benefiting younger but not older adolescents), and in our context intensive family and community engagement will be essential given that individual empowerment alone showed limited effectiveness. Georgia's relatively strong civil registration and health information systems position us well to rigorously evaluate adapted interventions, which this evidence base makes clear is necessary before scale-up.
ORCID 0000-0001-7609-4515 · Perspective written for the GMJ Guidelines Library, 15 Oct 2026
Applicability
Georgia and the South Caucasus
Georgia has made substantial progress in adolescent health—early marriage (before age 18) affects approximately 14% of women aged 20–24 (UNICEF 2021), lower than many LMICs in this evidence base but still significant in rural areas and among internally displaced populations. The country’s 2017–2030 national adolescent health strategy prioritizes life-skills education and youth-friendly health services. This evidence supports scaling conditional social protection linked to secondary school retention (Georgia’s Targeted Social Assistance programme could be adapted), integrating SRHR and gender-equality content into the national school curriculum (currently limited), and ensuring contraceptive access for unmarried adolescents (legal since 2007 but patchy in practice). National programmes should note that in the Caucasus context, family and community engagement components will be essential—individual empowerment interventions alone showed inconsistent effects—and that urban-rural disparities in both marriage age and service access require targeted approaches. Georgia’s relatively strong health information systems and civil registration can support monitoring, but measuring social norms change and attributing causality remain methodological challenges as noted throughout this evidence base.
Questions this guideline answers
Quick answers
Which interventions have the strongest evidence for reducing child marriage?
Moderate-certainty evidence supports three intervention types: (1) multi-component empowerment programmes combining life skills, SRHR education and livelihoods training (20–31% reduction); (2) conditional cash transfers tied to school attendance (24% reduction sustained 4.5 years post-programme); and (3) elimination of secondary school fees (5–19 percentage point reduction, 0.67–1.68 additional years of schooling). Single-component interventions and laws alone showed inconsistent effects.
Do unconditional cash transfers work as well as conditional transfers for delaying marriage?
Unconditional cash transfers reduced marriage by 44% and pregnancy by 27% during the two-year intervention period, but effects were not sustained two years after programme end (moderate certainty). In contrast, conditional transfers tied to school attendance produced sustained effects on marriage, pregnancy and fertility, but only among girls who had already dropped out of school at baseline. The choice depends on programme goals and whether sustaining school enrolment is feasible.
What evidence exists for improving contraceptive use among adolescents?
Low to moderate certainty evidence shows multi-component social norms interventions (home visits plus group discussions) increased any modern contraceptive use by 17.9 percentage points (OR 4.53) and use at last sex (RR 1.26). Among married adolescents, community SRHR education increased contraceptive demand (OR 1.49) and current use (OR 3.84). Evidence is limited by few studies, multi-component designs that cannot isolate active elements, and lack of longer-term follow-up.
Do laws setting minimum marriage age at 18 reduce child marriage?
Evidence is very low certainty and inconsistent. Laws showed significant reductions in child marriage only in Nepal and Tajikistan immediately post-implementation (not sustained in later cohorts), no effect in Benin, Bhutan, Kazakhstan or Mauritania, and differential impact by urban/rural location in Ethiopia. Legal reform appears necessary but insufficient without enforcement, complementary social norm change, and economic alternatives for families. In high-norm areas of Ethiopia, the effect was statistically insignificant despite being larger in magnitude.
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- Issuer
- World Health Organization
- Type
- Guideline
- Edition
- 2025 edition
- Status
- Current
- Published
- 2025-04-23
- Languages
- English
- Scope
- Evidence synthesis (GRADE tables, Evidence-to-Decision frameworks, systematic review methodology) for 17 PICO questions on preventing child marriage and improving contraceptive access among adolescents aged 10–19 in LMICs
- Audience
- Guideline Development Group members, systematic reviewers, programme planners, researchers, and policymakers requiring detailed evidence grading and study-level data
- Licence
- CC BY-NC-SA 3.0 IGO
- Evidence
- GRADE-rated evidence synthesis of RCTs, quasi-experimental and observational studies; certainty ranged from very low to moderate across outcomes
- Record history
- Created 15 Oct 2026 · updated 15 Oct 2026 · next check Apr 2027
Web Annex. Evidence base. In: WHO guideline on preventing early pregnancy and poor reproductive outcomes among adolescents in low- and middle-income countries. Geneva: World Health Organization; 2025. https://doi.org/10.2471/B09322.GMJ Guidelines Library records are original summaries written by the GMJ editorial team from the issuer’s published document and reviewed by a physician. They do not replace the full guideline. The document is the copyright of its issuer and is linked, not hosted. Spotted an error or a newer edition? Tell the Guidelines Desk.
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