Background
Reproductive health and adolescent pregnancy in LMICs
Social determinants associated with pregnancies in Kenyan adolescents
Methods
Epistemology
Characteristics | Focus of the Interview Discussion | |
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Sample 1 (Pregnant Adolescents) N = 12 | Eight participants with moderate to severe depression, two of our participants were HIV positive, two participants with experiences of intimate partner abuse, only three were in school remaining dropped out, two participants with neither parental nor partner support available | Identifying interpersonal (depression, relationships, social support), practical (food insecurity, material support and care, finances), cultural (extended family and community social support) |
Sample 2 (three Caregivers/one partner), N = 4 | Two of three mothers themselves in vulnerable financial conditions, no support from their spouses, two of them had babies during their adolescents themselves, one partner we interviewed depended on his own mother for support. | Identifying understanding of the adolescent’s health and psychological well being, looking at their own reactions and situations (interpersonal and social), appraisal of family, social and financial support |
Domain, underlying dimension and theme | Vignettes from Interviews |
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1. Experience of Pregnancy, acceptance/understanding implications | |
a. Denial of the pregnancy | Tuliendelea kuwa marafiki mpaka wakati nilikosa periods kwa miezi 6, nikajua niko na mimba.Nilimwambia akasema nimekuwa na vijana wengine shuleni. “We continued as friends until I missed my periods for 6 months, I knew I was pregnant. I told him and he said I have been with other boys in our school.”-15 year old,9 months pregnant “Wazazi walinifukuza nyumbani ndiyo nikaanza kuishi na marafiki zangu” “I was sent me away from home that’s why I stay with friends”- 17 year old commercial sex worker,8 months pregnant living with friends Maisha ya ndoa ni ngumu sana, saa zingine akikasirika na mimi, anasema huyu mtoto sio wake, Marriage life is so hard, sometimes when he is annoyed with me; he says that the baby is not his.. 18 years old |
b. Intention to put up the baby for adoption or ask the mother to raise the baby | Daktari akisema mtoto ako sawa, tungependa akizaa, mtoto achukuliwe na childrens’ home au mtu mwenye anamtaka ndio msichana arudi shule kwa vile siwezi kuwalea. “In case the doctor says the child is healthy, we would like to give him/her to a children’s home or somebody who needs a child so my daughter can go back to school because I cannot raise them” - 15 years old, 7 months pregnant Sijui kama kuna watu watanisaidia zaidi ya mama yangu kwa vile huyo kijana hafanyi kazi na anashinda akivuta bangi. Mama naye si mbaya lakini anafanya tu vibarua (Analia).
I don’t know whether others will help me except for my mother because the boy
does not have a job and he takes Marijuana.
My mother is not bad but she does odd jobs. (Crying) -15 years old,9 months pregnant Nimegundua ni mimi ndio rafiki yake pekee na sitaki awe peke yake. Sote tuko sawa kama wazazi na mama in-law ananisupport. Makosa imefanyika. Sisi tutatunza mtoto, arudi shuleni. Mimi ni counselor, nasaidia wazazi wengi wanapitia haya, kwa nini nisisaidie mtoto wangu wa kipekee? I have realized that I am her only friend and I do not want her to be alone. We are all okay with this as parents and my mother-in-law supports me. The mistake has already happened so we are going to take care of the child and she goes back to school. I am a counselor and do this all the time for other parents and why not for my only child?-15 year old’s mother |
c. End of education and need to look for job | Nilikuwa naishi na wazazi uko Kawangware lakini juzi walinifukuza sasa naishi na marafiki zangu tuna tafuta pamoja na kupata chakula. Nilifanya standard 8 lakini sikuenda Form 1 juu ya fees. I am 17 years old, not married. I was staying with my parents in Kawangware but they recently chased me away now I am staying with my friends hustling together and getting food to eat. I did standard 8 examinations but did not go to Form 1 because of school fees- 17 years old Niliacha shule standardi 8 ju sikulipiwa pesa za mtihani. Nimekuwa tu home naboeka bila kufanya chochote, kazi za nyumba tu. Shangazi hatupendi vile na hatusomeshi anashughulikia watoto wake tu. Nili patana na huyu boy last year na tunaishi na madhake hapa Kangemi. Juzi ndio niligundua niko na ball. I dropped out in Standard 8 because the exam fee was not paid. I have been home since, being bored without doing anything but house chores. My aunt does not love us that much because she does not educate us but only her children. I met this boy last year and we are staying with his mother here in Kangemi. Recently, I found out I was pregnant – 18 year old. Niko na 17 years,niliacha shule nikiwa class 6 ju wazazi hawangeweza kulipa fees. Sasa, leo unaenda tu poa na kesho unafukuzwa, nikaamua tu niache shule.
I am 17 years old, I dropped out of school in class 6. My parents could not raise the fees, so today you go to school without incident but tomorrow you are chased away. I decided to drop-out of school.
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d. I tried to abort but that didn’t work out well | Interviewer: Uja uzito huu ni wa nani na anakusaidia?
Who is responsible for your pregnancy and does he support you?
Interviewee: Ni mmoja wa mabeshte zangu. Nikizaa nitajua tu.Wazazi walinifukuza nyumbani ndiyo nikaanza kuishi na marafiki zangu. Nilijaribu kutoa hii ball mara mbili na ilikataa sasa nitazaa tu.
It is one of my friends. When I give birth I will know. My parents chased me away from home, that’s why I stay with friends. I tried to abort twice but it refused now I will just give birth
Interviewer: Ulijaribu na nini? What did you try it with? Interviewee:Juice conk na strong tea vile nilikuwa miezi tatu na nne Concentrated juice and strong tea when it was 3 and 4 months- 17 year old 8 months pregnant |
e. Poverty impact on their pregnancy – absence of nutritious food | Ni katika hali ya kujitafutia ju home hauwezi pata vitu madame wanaitaji na kulala njaa mara mob. Mimi ndiye msoo kwetu kwa hivyo nikileta ata masisters zangu watakuwa poa. Baba anafanya kazi lakini ni mlevi na mama anaoshea wadosi nguo lakini haitoshi.
It was in the course of hustling because at home I could not get what girls need and we were sleeping hungry all the time. I am the eldest and so if I bring even my sisters will be alright. My father works but he is a drunkard and my mother washes clothes for rich people but it’s not enough
Stress kubwa ni kukosa do, inabidi madhake atupe kila kitu na siku hizi naona inaleza kelele sana- 17 years old 8 months pregnant The biggest stress is lack of money. His mother has to provide everything and these days I see it causing a lot of noise- 18 year old married. Babu ndiye kama baba saizi ju baba yetu alituacha. Tuko watoto sita kwa familia. Kwa wakati huu, sijanunua chochote cha mtoto. Sina pesa.
My Grandfather is like our father now because my father left us. We are six siblings. Upto this moment, I have not bought anything for the baby. I don’t have money
- 15 years old 9 months pregnant |
2. Attitude of and support from the boyfriend | |
a. Denial of pregnancy | Mimi na huyu kijana tumekuwa marafiki kwa miaka mmoja na miezi saba. Nilifikiria huyu kijana ndiye rafiki yangu na ananipenda.nikakubali kuwa naye……. Nimepata wakati mgumu sana kwa vile nilikuwa niko class 8 najitayarisha kufanya mtihani. Nilificha kwa miezi tano lakini ikaanza kuonekana. Kijana pia amekataa huyu mtoto.
We have been friends for 1 year and 7 months. I thought the man was my friend and loved me that’s why I accepted to be with him……………I have had a very hard time since I was in class 8 preparing for my exams. I hid it for 5 months but it started to show. The boy has denied the child.- 15 year old
7 months pregnant
Tulikuwa tumezoeana kama majirani. Siku moja nilienda kumtembelea akanishawishi tufanye hiyo maneno na nikakubali. Tuliendelea kuwa marafiki mpaka wakati nilikosa periods kwa miezi 6, nikajua niko na mimba.Nilimwambia akasema nimekuwa na vijana wengine shuleni. We used to get along as neighbours. One day I went to visit him, he convinced me to do that thing and I agreed. We continued as friends until I missed my periods for 6 months, I knew I was pregnant. I told him and he said I have been with other boys in our school- 15 year old, 9 months pregnant |
b. Even the boy’s family denies any responsibility |
I am thinking that when she gives birth, I will take the child to his/her father,
leave him/her in their doorstep. I do not have a job. I am dependent on my husband.
We have 3 children; the last 2 were twins 10 months old. It’s been hard living with her
and this pregnancy. I cannot take care of another child- 15 year old’s mother, 7 months pregnant
I wrote a letter and took to their home, his mother was also shocked,. In the letter
I told them as the mother, I will inform you of her progress, but I would also
like you to talk to your son so we all see the way forward. I wrote the letter
because I didn’t want to talk too much out of anger. So far I have not got any positive feedback. My husband does not want me to call them.-15 year old’s mother, 6 months pregnant |
c. He is very supportive and trying his best | He supports me a lot so I see that I will be fine – 18 year old married
He is a friend of mine since primary school, since I got pregnant, he has not given me stress, he has accepted and even come to speak to my parents- 17 year old
I have known my husband for a while and when I told him that I am pregnant, he said we stay together and be a family – 17 year old
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3. Attitude and support from mothers and significant caregivers | |
a. Mother is quite angry and disappointed | Interviewer: Mara ya kwanza kusikia hii maneno, ulijiskia aje? The first time you heard about it, how did you feel? Interviewee: Imenikera sana. It has annoyed me very much – 15 year olds mother(7 months pregnant) Msichana wangu ni mmoja tu,nimemlea kanisani, hata sijui nini ilifanyika?
My daughter is my only girl, I have brought her up in the church, I just do not know what happened – 15 year old’s mother(6 months pregnant)
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b. Lack of family support | Nilikuwa naishi na nyanya na shangazi zangu kule ushago kwa sababu mama alioewa hapa Nairobi. Walikasirika sana na wakanirudisha kwa mama yangu, I used to live with my grandmother and aunties in rural home because my mother is married here in Nairobi……….My grandmother and aunties were very annoyed with me and told my mother- 15 year old-7 months pregnant Babu alisema anakuja kunichapa kwa vile nimehaibisha familia. Yeye ndiye kama baba saizi ju baba yetu alituacha. Tuko watoto sita kwa familia…… Sijui kama kuna watu watanisaidia zaidi ya mama yangu kwa vile huyo kijana hafanyi kazi na anashinda akivuta bangi. Mama naye si mbaya lakini anafanya tu vibarua My grandfather said he will come to Nairobi and beat me up because I have embarrassed the family. He (grandfather) is like our father now because my father left us. We are six siblings…….. I don’t know whether others will help me except for my mother because the boy does not have a job and he takes Marijuana. My mother is not bad but she does odd jobs. – 15 year old 9 months pregnant.
“I am 17 years old, not married. I was staying with my parents in Kawangware but they chased me away now I am staying with my friends”
Nikituma pesa nyumbani pia anakasirika na mimi. Nikichelewa kutoka kazini anasema niko na vijana wengine huko nje. Mdosi aliniambia nikifanya kazi vizuri, ataniongeza pesa. Nafikiria kukomboa nyumba yangu lakini wazazi nyumbani pia wananitegemea nitume pesa If I send money home, he also gets annoyed with me. If I am late from work, he says I am with other men outside. My boss says if I work well, she will give me a raise. I am thinking of renting a house but my parents at home rely on me to send them money- 18 year old
I understand that my parents are upset but see it as my first big mistake. I have been a good student all through……..so I don’t know why my parents, especially dad is still upset- 17 year old just cleared Form 4
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c. Get support from social and community health workers | Interviewer: Unadhani utaweza kulea mtoto pekee yako?
How do you think you will manage to raise the child on your own?
Interviewee: Mimi ni volunteer social worker Napata huku na kule na niko na savings sio mingi lakini nitamanage.
I volunteer as a social worker and have some savings from a previous job and I think it may not be enough but I can manage on my own
Interviewer: Unajihisi aje juu ya huyu mtoto?
How do you feel about your baby?
Interviewee: Napenda mtoto wangu sana na natamani kumuona. Babake ndio sitaki. I love my child and long to see him/her. It’s the father that I do not want Interviewer: Hiyo ni vizuri, unaishi peke yako kwa sasa?
Are you staying alone now?
Interviewee: Ndiyo naishi peke yangu
Yes I am staying alone
Interviewer: Je, unapata support?
Do you get social support currently?
Interviewee: Ndiyo, napata support kutoka kwa marafiki na social workers wezangu kama Lilian.
“I get support from my friends, social workers here at the hospital like Lilian”-
18 year old |
4. Other challenges impacting depression | |
a. Experiencing domestic violence |
Marriage life is so hard, sometimes when he is annoyed with me; he says that the baby
is not his. When I talk to neighbours, he gets annoyed and beats me.
My husband said I use his name and not my father’s name.
If I send money home, he also gets annoyed with me. If I am late from work, he says I am with other men outside. My boss says if I work well, she will give me a raise. I am thinking of renting a house but my parents at home rely on me to
send them money – 18 year old married,5 months pregnant employed No, he slaps me on the cheeks- 18 year old 9 months pregnant |
(b) Substance use - consuming Miraa (Khat)everyday |
It’s normal where I come from and it doesn’t affect you at all……. Me and my husband
sell it, he gets from home and I can take it anytime I want
Interviewer:- I would just like to advise you that Khat is a stimulant just like other drugs and it can affect the health of the child. Would you consider stopping for the duration of the pregnancy?
I can try but I know it doesn’t affect because people in my area take it every day.
− 16 year old married |
Plans for the future
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a. Will have to plan a life independently |
I volunteer as a social worker and have some savings from a previous job and I think it may not be enough but I can manage on my own…..I don’t see him thinking ahead and preparing for the future life together-18 year old social worker
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b. Parents/partner plan to send me back to school | Makosa imefanyika. Sisi tutatunza mtoto, arudi shuleni The mistake has already happened so we are going to take care of the child and she goes back to school- 15 year old’s mother Mimi pia nataka kupeana mtoto kwa vile siwezi mulea na nataka nirudi shule. I would also like to give up my child because I cannot take care of it and I also want to go back to school- 15 year old Interviewer:“Did you want to continue with school but you were unable to that’s why you went to get married?” Adolescent: “Yes, he had promised to take me to school after delivery” - 16 year old |
c. We live on meagre resources so don’t know how we will look after the baby | “I do not have a job. I am dependent on my husband. We have 3 children; the last 2 were twins 10 months old. It’s been hard living with her and this pregnancy. I cannot take care of another child”– 15 year old’s mother |
Setting
Participants and recruitment process
Data collection
Data analysis
Domain, underlying dimension and theme | Case Vignettes |
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1. Adolescent Pregnancy: Acceptance and Implications | |
(a) Acceptance of the pregnancy |
I have been counseled by the school and I have accepted my daughter’s condition
Interviewer: Na baba yake? What about the father? Mother: Alikasirika wa kwanza lakini nilimwongelesha na ako sawa kwa sasa. He was angry initially but I have talked to him and he is ok now-15 year old’s mother |
(b) Worries about the birth of the baby |
“In case the doctor says the child is healthy, we would like to give him/her to a children’s home or somebody who needs a child so my daughter can go back to school because I cannot raise them” = 15 year olds mother
The mistake has already happened so we are going to take care of the child and she goes back to school-15 year old’s mother “I am thinking that when she gives birth, I will take the child to his/her father, leave him/her in their doorstep”- 15 year old’s mother |
(c) Self-Blaming for the circumstances the daughter is in |
My daughter is my only girl, I have brought her up in the church,
I just do not know what happened. - 15 year old’s mother
She is the one I gave birth to when I dropped out of school.
Her father and grandmother rejected me until I gave birth to her and she
resembled her father so much. I left her with my mother when
I got married here in Nairobi. Perhaps my past is catching up with me.
I mean would my daughter should go through the same experiences
as me if it’s not fate-15 year old’s mother |
2. Attitude of fathers and extended family | |
Possibility of shame, isolation and lack of commitment by fathers within the family | “I do not have a job. I am dependent on my husband. We have 3 children;
the last 2 were twins 10 months old. It’s been hard living with her and this pregnancy.
I cannot take care of another child. My husband is silent on this matter
but I know he is not happy” My mother has returned my burden to me- 15 year old’s mother with reference to the daughter living with her and her step-father as opposed to the grandmother “He was angry initially but I have talked to him and he is ok now”- 15 year old mother |
3. Plans for the future (Responses from Spouse and Mother) | |
(a) Seek economic sustainability(Spouse | Interviewer to spouse:-Umepanga aje?
What are your plans?
Spouse: Nimeanza hii job ya boda boda juzi, ikikua poa, tutakuwa na pesa za kujitegemea si wenyewe
I recently started a boda boda business, if it goes well, we will have
money to rely on ourselves- 23 year old spouse |
(b) Seek financial assistance (Mother) | Mama alisema ataomba dada yangu mkubwa mwenye anafanya kazi ya nyumba uko Mombasa kutusaidia
My mother said she will ask my sister who is a house help in Mombasa to help us.
- 15 year old 9 months pregnant Interviewer: na mwenye anahusika? What about the partner concerned? Mother: Ni mtoto kama yeye. He is also a child like her Interviewer: Na wazazi wake? Munajadiliana? What about the parents, have you had any discussion with them? Mother: Niliandika barua nikapeleka kwao, mama yake alishtuka. Kwa barua, niliwaambia kama mama yake, nitawaeleza vile anaendelea lakini ningependa uongee na kijana yako tuone way forward. Niliandika barua kwa sababu sikutaka kuongea sana juu ya hasira. Mpaka wakati huu, hatujapata feedback. Bwana yangu hataki niwapigie simu. I wrote a letter and took to their home, his mother was also shocked,. In the letter I told them as the mother, I will inform you of her progress, but I would also like you to talk to your son so we all see the way forward. I wrote the letter because I didn’t want to talk too much out of anger. So far I have not got any positive feedback. My husband does not want me to call them. 15 year old’s mother |
Methodological and ethical considerations
Results
Interviewer: Please tell me why you are crying.Adolescent: It’s painfulInterviewer: What kind of pain?Adolescent: That of offending my parents“Adolescent’s Mother (intervenes): Right now, she sleeps a lot and does not eat, she is always indoors”- (15-year old’s mother).
“We have been friends for 1 year and 7 months. I thought the man was my friend and loved me that’s why I accepted to be with him . . . I have had a very hard time since I was in class 8 preparing for my exams. I hid it for 5 months but it has started to show. The boy has denied the child.” – 15-year old, 7 months pregnant
“We continued as friends until I missed my periods for 6 months, I knew I was pregnant. I told him and he said I have been with other boys from our school.” – 15-year old, nearing 9 months.
“I was sent away from home when I got pregnant that’s why I stayed with friends.” – 17-year old commercial sex worker, 8 months pregnant
“I don’t know whether I am depressed the way you describe it but I regret a lot . . . (crying again). I went to a bridge at home and wanted to throw myself because my grandfather is very harsh and upset with me and an aunt told me it is a sin.” – 15-year old, 9 months pregnant.
“I am thinking that when she gives birth, I will take the child to his/her father, leave him/her in their doorstep. I do not have a job. I am dependent on my husband. We have 3 children; the last two are twins 10 months old. It’s been hard living with her and this pregnancy. I cannot take care of another child.” – 15-year old’s mother (adolescent daughter herself is 7 months pregnant).
“In case the doctor says the child is healthy, we would like to give him/her to a children’s home or somebody who needs a child so my daughter can go back to school because I cannot raise them.” – 15-year old, 7 months pregnant
“I got pregnant in the course of hustling because at home I could not get what girls need and we were sleeping hungry all the time. I am the eldest and so if I bring even my sisters will be alright. My father works but he is a drunkard and my mother washes clothes for more affluent people but it’s not enough…” – 17-year old, 8 months pregnant.
“My grandfather is like our father now because my father left us. We are six siblings. Up to this moment, I have not bought anything for the baby. I don’t have money… I don’t know whether others will help me except for my mother because the boy does not have a job and he takes Marijuana. My mother is not bad but she only does odd jobs.” – 15-year old, 9 months pregnant
However, one mother recounted the following in a reconciliatory and heartening tone:“I was staying with my parents in Kawangware but they recently chased me away now I am staying with my friends hustling together and getting food to eat. I did standard 8 examinations but did not go to Form 1 because of lack of school fees.” – 17-year old, 8 months pregnant
This optimistic stance of a caregiver was not shared across the board. For most of our participants pregnancy denoted an end of education and along with that came the pressure to contribute to resources including money to look after the additional member of the family.“I have realized that I am her only friend and I do not want her to be alone. We are all okay with this as parents and my mother-in-law supports me. The mistake has already happened so we are going to take care of the child and she goes back to school. I am a counselor and do this all the time for other parents and why not for my only child?” – 15-year old’s mother
“I do not have hope. I have many thoughts because we do not have money and I do not like insults and noise from his mother. I do not sleep well, eating is tough sometimes but he is trying.” – 17-year old married, 4 months pregnant and living with her mother-in-law.
The most potent theme interspersed along this experience of dejection, sadness and physical adversity (in the form of pregnancy) was of poverty and continuous financial and food insecurity. A vignette from one of the participants underscores the churning and torment adolescents go through in a resource-constrained household, sharing burdens, and forced to become adults early in their lives.“I dropped out of school in class 6. My parents could not raise the fees, so today you go to school without incident but tomorrow you are chased away. I decided to drop-out of school.” – 17-year old, 7 months pregnant
“I wrote a letter and took to their home, his mother was also shocked. In the letter I told them as the mother, I will inform you of her progress, but I would also like you to talk to your son so we all see the way forward. I wrote the letter because I didn’t want to talk too much out of anger. So far I have not got any positive feedback. My husband does not want me to call them.” – 15-year old’s mother, 6 months pregnant
Our participants made us understand that the support of the family particularly the parents and mother especially is critical for the long-term future of the adolescent. We also learnt that this support cannot be taken for granted and comes in stages of negotiation and balancing anger, stigma and hurt with feelings of care, and sympathy for the adolescent. Feelings of dejection and sadness overwhelmed the mothers we interviewed as they felt that they had failed as a parent. Often times it is the mother who is blamed for the fate of the adolescent. One of the mothers we interviewed recounted in a distressed tone:“He is a friend of mine since primary school, since I got pregnant, he has not given me stress, and he has accepted and even come to speak to my parents.” – 17-year old
The sadness often had tones of anger and worry for the adolescent. However, despite this outburst our adolescent participants found their mothers to be the most receptive of the caregivers and there was some hope that she would be angry but support the daughter. The mother and daughter often had to team up to bear the burden of the pregnancy for the family and social ostracization that ensued. A vignette from one of our participants is very telling in this regard.“My daughter is my only girl, I have brought her up in the church, I just do not know what happened.” – 15-year old’s mother (daughter was 6 months pregnant)
The experiences of being thrown out of the house by angry parents and an example of an adolescent participant being threatened by her grandfather that he would come from rural home and beat her. This severely worried her as the father had left and the grandfather took charge of the family. The family’s future was also threatened by the pregnancy and the young girl was aware of that.“I used to live with my grandmother and aunties in rural home because my mother is married here in Nairobi … My grandmother and aunties were very annoyed with me and told my mother.” – 15-year old, 7 months pregnant
“She is the one I gave birth to when I dropped out of school. Her father (mother’s partner) and grandmother initially rejected me until I gave birth to her and she resembled her father so much. I left her with my mother when I got married here in Nairobi. Perhaps my past is catching up with me.” – mother of a 15-year old adolescent