As the fastest-moving global public health crisis during this century, the COVID-19 pandemic is causing significant mortality and morbidity and creating daunting health and socioeconomic challenges. The restrictive measures that have been put in place by many countries to contain the spread of the virus may negatively affect access to essential sexual and reproductive health (SRH) services, particularly by adolescents living in low- and middle-income countries (LMICs) and fragile settings [1]. Young people are especially affected by the closure of social spaces, including schools, community centers, and health clinics, where many of them receive comprehensive education on SRH and services. Past epidemic outbreaks have shown that disruptions in education are extremely harmful to young people, especially girls, in terms of not only lost earnings and education but also increased vulnerability to gender-based violence, early marriages, unintended pregnancy, and female genital mutilation [2].

Globally, approximately 1.8 billion people are between the age of 10 and 19 years, and 90% of them live in low- and middle-income countries (LMICs). Low- and middle-income-earning countries are countries that are considered either as low-income-earning countries or both low and high middle-income-earning countries. According to the World Bank, low-income economies are countries with a Gross National Income (GNI) per capita of USD 1025 or less, and middle-income economies (low and high middle-income countries) are those with a GNI per capita between USD 1026 and USD 12,375, using the World Bank Atlas method [3]. Thus, all countries with a GNI per capita of USD 1025 or less to USD 12,375 using the World Bank Atlas method can be classified as low- and middle-income-earning countries. Many adolescents from LMICs, particularly girls, are vulnerable to poor SRH and experience early and unintended pregnancy, unsafe abortions, sexual violence, and sexually transmitted infections. These adolescents already faced significant barriers in accessing essential SRH information and services before the COVID-19 crisis [4]. Lockdowns and the diversion of medical resources have led millions of women and girls to be forced to carry unwanted pregnancies or risk unsafe abortions [5]. In addition, a low level of access to SRH information and services has resulted in increased teenage pregnancies throughout the world but more so in many LMICs [6]. Potential disruption of the supply and the production of contraceptives also leads to teenage pregnancies in LMICs. In addition, the redeployment and unavailability of medical staff and breakdown of SRH services have also affected the availability and accessibility of family planning services [7,8]. According to the Guttmacher Institute (2020), disruptions in access to contraceptive services and disruptions in prevention programs may lead to 13 million more child marriages over the next decade in LMICs [2,9].

Limited access to youth-friendly healthcare services was reported in various countries during the COVID-19 pandemic. In Kenya, some adolescents (17%) complained of not being able to go to their regular clinic for medical care, and others (3%) reported not being able to get their medication refills. More specifically, 2% of adolescents aged 15 to 19 years were not able to access medication refills, whereas 8% of adolescents reported missing antiretroviral therapy (ARVs) for 2 or more days in a row in the last 30 days [15].

In addition, many older girls reported ignoring and not being able to access the needed SRH services during the pandemic, such as modern contraceptive and family planning services [18]. Adolescents in Cote d’Ivoire also reported difficulty accessing contraceptives due to disruptions to clinic hours and outreach, which was attributed to an increased rate of adolescent pregnancies [14]. Accessing and purchasing menstrual hygiene products was another issue reported by adolescents amid COVID-19. In Lebanon, access to supplies for menstrual management was also a concern among refugee girls, who either resorted to borrowing menstrual products from local stores or using pieces of cloth at home [14].

2.2. School Closure and Increased Rates of Early Marriages

A study conducted in three different countries, including Ethiopia, Cote d’Ivoire, and Lebanon, reported mixed findings on the risks of child marriage amid the COVID-19 pandemic [14]. In Lebanon, two of the adolescent Palestinian girls became engaged during the lockdown, while other adolescent girls mentioned postponing their marriage due to economic crisis, resulting in lower marriage rates [14]. Similar findings were reported by both Palestinian and Lebanese boys, who perceived the pandemic and resulting economic challenges as a major barrier to their marriage. On contrary, the marriage rate was perceived to be higher among Syrian girls as marriage to a Syrian girl in comparison to a Lebanese girl is considered cheaper as they carry a high dowry with them upon marriage [14]. Moreover, both adolescent girls and boys in Ethiopia were pressurized to get married as school closure coincided with the traditional wedding season in three of the six communities where the study took place. Even daughters in their early adolescence were forced to get married because of the limited presence of local authority officials and schoolteachers, who otherwise would cause hindrances in early child marriages. In addition, adolescent boys who previously attended secondary schools were also under pressure to get married during the stay-at-home restrictions [14].

2.3. Sexual or Intimate Partner Violence during COVID-19

The frequency of intimate partner violence rose amid this pandemic. Adolescents reported being at high risk of experiencing intra-household violence and, in the case of Lebanon and, to some extent, Côte d’Ivoire, girls reported being at a heightened risk for community-level violence [14]. In addition, married Syrian girls also reported increased tensions with their husbands, in-laws, and neighbors, along with reports of intimate partner violence [14]. Married girls in Ethiopia also became victims of intimate partner violence due to financial hardships and lockdown situations [14]. The lockdown caused male partners to easily become frustrated and violent, as reported in an Ethiopian study. In this study, a female partner reported that her husband became easily irritated when she asked for help in taking care of their children while she took care of other household chores and hit her with a stick on her head [14]. On the contrary, in another study conducted in urban and rural regions in Kenya, the majority (45%) of adolescent girls reported less violence at the beginning of the COVID-19, as compared to only 6% of adolescents who reported more violence, including physical, emotional, and sexual violence, and other forms of violence [18].

2.4. Disruption in Maternity Care

In Afar, a town in Ethiopia, married girls were concerned about infection transmission and remained fearful of seeking antenatal care, due to which they opted for home-based births, resulting in several maternal deaths [14]. Muhaidat et al. [17] conducted a study in Jordan that reported an increase in the number of women unable to access antenatal care during the COVID-19 curfew.

2.5. Adolescents’ Involvement in Risky or Exploitative Work

The pandemic caused great financial challenges to families and communities during the lockdown. As a result, youth were compelled to engage in or consider risky or exploitative work [14]. In Ethiopia, adolescent girls in towns and cities were noted to be vulnerable to sexual harassment and abuse while working. This was largely because of the closure of bars, which led people to turn to locally brewed alcohol and traditional alcohol houses. Banati, Jones, and Youssef [14] found that adolescent girls who helped their mothers in making and selling ‘tella’ (a local alcoholic drink) were exposed to unwanted sexual attention and sexual abuse.

2.6. Interventions to Improve Sexual and Reproductive Health Services during COVID-19

Interventions to make SRH service available and accessible to adolescents were proposed during the COVID-19 pandemic lockdown. The UNFPA [22] was one of the international organizations that outlined interventions that could be used by countries to make SRH services accessible and available through local adolescent-friendly mass and digital media platforms. Information regarding comprehensive sexual education, and how this can be delivered outside of schools during the COVID-19 era using media platforms, was highlighted [22].

Another intervention was the involvement of healthcare professionals to ensure that adolescents had access to age-specific, accurate, and up-to-date information on SRH verbally through the media and pamphlets. This information included access to information on contraceptives, comprehensive care, antenatal, intrapartum, and postnatal care, testing and care for HIV and other STIs, and menstrual health available to adolescents during the lockdown [22].

Additionally, telemedicine was encouraged as an intervention to provide services for safe and easy access to medical abortions, counselling, and screening to adolescents [22]. Moreover, adolescent-friendly phone lines that would provide advice on the side effects of contraception, contraceptive self-use, and available contraceptive options could be a beneficial intervention. Furthermore, other suggested the testing of adolescents for HIV and other STIs at home, and sending results through messaging, ensuring privacy and confidentiality [22].

2.7. Policy Development Related to Adolescent Sexual and Reproductive Health

As restrictions were imposed due to COVID-19 in most parts of the world, some countries and international organizations outlined the development of policies on adolescent SRH. Two articles [14,20] and one grey literature article [22] included in this systematic review highlighted the need for policy developments for adolescent SRH. These policies were aimed at supporting the adolescents during the COVID-19 lockdown in some countries. Herran and Palacios [20] mentioned the need for policies that would concentrate on the social and cultural barriers and economic inequalities, with the aim of lessening adolescent pregnancy during the COVID-19 era. This approach by Herran and Palacios [20] was based on previous situations similar to the COVID-19 pandemic, which contributed to an increase in the number of adolescent pregnancies. Similarly, Banati, Jones, and Youssef [14], in their study, mentioned the need for community-based and culturally focused models directed towards serving the population in the locality.

As reported by Herran and Palacios [20], communities with limited access to job opportunities, and with existing social isolation, could negatively explore early parenthood as an approach to heightening their social status. Therefore, the need for career counselling and job creation opportunities for disadvantaged adolescent boys and girls in such communities may address this issue. Additionally, the creation of a virtual platform that would offer the chance for the early delivery of psychosocial services to adolescents was recommended by Banati, Jones, and Youssef [14], and the UNFPA [22] highlighted the need for countries to develop policies that would aid access to SRH services to adolescents during COVID-19. Policy recommendations for countries by the UNFPA [22] included the use of available media platforms to provide information to adolescents on access to (a) sexuality education; (b) contraceptive counselling and services; (c) comprehensive abortion care; (d) antenatal, intrapartum, and postnatal care; (e) prevention of HIV and other STIs; (f) prevention, care, and response to sexual and gender-based violence; g) prevention of cervical cancer through HPV vaccination; and (h) counselling and services for sexual health and well-being that include the provision of menstrual health information and services. Moreover, policies to empower adolescent girls, reduce their reliance on male partners, and enable them to stay away from unprotected sex were needed to reduce adolescent pregnancy during this era [20]. The UNFPA [22] in their document also further encouraged countries to institutionalize the approaches used during the lockdown period to improve access to quality services after the curfews.