Table 2.

Multi-stakeholder views on adolescent pregnancy and depression

Sample 1: Interviews with 8 depressed mothers and 2 non-depressed adolescents.
Given high prevalence of depression among pregnant adolescents (80%), our 1st goal was to understand these depressed pregnant adolescents’ experience and needs
Study samples and key interview objectives	Core themes		Corresponding vignettes from interviews
1. Adolescents’ experience with pregnancy Personal experiences (positive or negative) Challenges (economic, social, medical) Psychological well-being (experience with depression particularly) Coping mechanisms Coping mechanisms and positive thinking demonstrated 2. Reactions from boyfriend and other related members (friend, relative, neighbors)	Overall, none of the adolescents felt it was a positive experience. It was overwhelmingly difficult experience only the number of adversities varied from person to person. Negative experiences were as follows: (a) Lack of emotional/relationship support: Majority of depressed pregnant adolescents did not receive needed support from boyfriend or family members. The most painful thing was that the boyfriend/partner vanished from the sight once a girl was pregnant. Two girls were working as sex workers and in a disconnected and distant voice mentioned that this was the fate of their lot. (b) Social stigma The main challenge was stigma, unacceptability by the family starting from the male figurehead. For most girls. it was a negative experience filled with shame. For two adolescents, the partners were neighbors who rejected them when they learnt about the pregnancy. Even for the individual with family support (n = 1; caregivers help bring up the baby and send her to school), the pregnant adolescent still felt ashamed and demotivated. (c) Life adjustment stress Food and financial insecurity, and end of education and a struggle to deal with pregnancy and baby while thinking of finding a job. The immediate implication is that the girl has not been focusing on her studies/work but the pregnancy is a punishment for her transgressions. (d) Health care access Apathy but it cannot be avoided as the girls or their families cannot afford healthcare. At times. CHWs help map the communication gap between the nurses and girls/patients Adolescents also displayed positive thinking and useful coping mechanisms and strategies aiming to reduce their stress (e) Useful coping strategies Soliciting maternal support so that the baby can be looked after and the adolescent can find work. Problem solving and staying positive by focusing on the baby was a potential support and a loving being (in Kenyan cultural imagination the baby is highly valued). (a) Partner/boyfriends reactions: this is mostly negative. However, we had one partner who was very supportive and aware of his role (b) Support is often mainly from the mother Among 8 interviewed depressed adolescents, 3 were accompanied by their mothers during prenatal visit, and 1 was accompanied by partner. Most girls said that the boyfriends denied that the baby was theirs even when the adolescent’s parents pursued the boy in owning up responsibility. The mother/other maternal figures are a little tolerant but the father and his family use this opportunity to caste a dark shadow on the irresponsibility of the adolescent’s mother in parenting her. (c) Occasional family rallying support to look after the baby Among those with family support, one mentioned that her parents had accepted to help, bring up the baby and send her to school; Two were living with the grandparents in the rural homes where they got pregnant and were relocated to Nairobi to be looked after by their mothers		“I feel embarrassed all the time and also feel that I have let them (family) down.”-15 years old “Thoughts and anxieties are many and I am not as happy at home but I am fine at work.”-18 years old, married, domestic violence and lack of spousal support) “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 an aunt told me it is a sin.”-15 years old—full term—almost 9 months pregnant “We used to get along as neighbors. One day I went to visit him, he convinced me to do that thing and I agreed and see the consequences and now I am stigmatized for life.”-15 years old “I do not have hope. I have many dark thoughts because we do not have money and I do not like insults and noise from his (partners’) mother. I do not sleep well, eating is tough sometimes but he is trying and I am trying.”-17 years old, married “I am the only one who reached class 8, the rest of us have not been to school. He (the father) had promised to take me to school. Earlier on, I was staying with my sister but food was always a problem for her and her children and me were struggling. She advised me to remove the pregnancy that’s why I decided to go to back to my home. I have been chewing miraa (khat) that eases the pain.”-16-year-old pregnant adolescent’ high scores on EPDS for depression) “I have no one to look after me and girls like me have to find their own way. I will talk to the social worker and find some help to start a business or some food support from them. I can’t do the same thing now (sex work) and if I can’t manage I will give up the baby to an adoption home.”-17-year-old pregnant adolescent “Once you make a girl pregnant, you have to support her. Both of us are responsible for this. I know men leave girls/women alone. I am there to support my partner”-boyfriend of an 18-year-old pregnant adolescent “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 years old “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 years old. “I am thinking that when she gives birth, I will take the baby to the father, leave the baby on 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 mother
Sample 2: The 2nd goal was to understand pregnant adolescents’ needs from their caregivers’ perspective. Interview data for this aim was collected from a few caregivers who accompanied adolescents during their prenatal visits.
1. Caregivers’ experience/view on their girls pregnancy Personal experiences (positive or negative reaction) Views on challenges posed by their daughter’s pregnancy (economic, social, medical)		Following themes emerged from adolescents’ mothers who accompany child during health visit were (a) their empathetic reactions for their daughters’ pregnancy; even as they cope with disappointment and sadness The most poignant descriptions by the mothers were that they had babies when they were adolescents themselves and tried all their best for these circumstances to not repeat in their children’s lives. Mothers did think of this to be acts of transgressions but were more tolerant. They also lamented the choice of boys such that the same abandonment should repeat itself. The caregivers refer to their own experience of feeling let down by the adolescent, own memories of early pregnancy and feeling very let down by the family, the adolescent as well as the boyfriend. They also remember they had no friend accompanied and neither did any neighbor (b) Concerns for new life/adjustment and life stressors for their adolescent daughters Their main concern was for the daughter’s disconnect from education, employment or a decent future. Alluding to the price girls have to pay for something that involves men and women together The caregivers are less explicit or interested in addressing depression but more worried about provisioning for the growing needs of the adolescent, her baby. Acceptance that the situation is depressing and challenging for the young person (c) Need for exploring solutions and preparation during current state especially those who were married and lived in parents-in-law. Some talk about discussing psychosocial issues with CHWs to find solutions, i.e., finding extra work, medical assistance, food banks. (d) Adolescents developing child care clashes with her own mother’s expanding family If the adolescents mother is relatively younger and remarried her say in the family decisions is limited. One or two mothers mentioned that they had families with young kids and the adolescent daughter’s baby needs would clash/competing with her new family. No friend accompanied and neither did any neighbor Grandmothers came and once a maternal aunt came— same concerns but also worries about their own burden increasing	“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 mother “My daughter is my only girl, I have brought her up with the Christian value system, I just do not know what happened.”-17-year-old mother “I have realized that I am her only friend and I do not want her to be alone.”-17-year-old mother “It is so hard to get money or to meet my basic needs, I am married but we both do not work, we scrape from here and there doing odd jobs.”-17-year-old married. “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 mother “The biggest stress is lack of money. His mother has to provide everything and these days I see it causing a lot of noise.”-17-years-old adolescent “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 mother “In case the doctor says the child is healthy, we would like to give him/her to a children’s home or some-body who needs a child so my daughter can go back to school because I cannot raise this one.”-16--year-old mother
Sample 3: The 3rd aim was to understand adolescents’ experience change overtime (before and after gave birth). Qualitative data were collected from adolescent mothers (who may or may not have prenatal depression). Different from aims 1 and 2, which used individual interview format, data collection for this aim was based on first focused group and a few new mothers not interviewed earlier.
Experience change overtime (before to after gave birth) Feeling change overtime (when discovering pregnant and over the course pregnancy) Feeling towards baby (feeling change over the course of pregnancy and after gave birth) Experience with medical care (behaviors/attitudes towards medical staff, and experience changes overtime)		Focused group results indicated challenges described during prenatal period maintain after giving birth (as results described in aims 1 and 2). In addition, new parenting challenges arise after giving birth. Psychological burden—Feeling very burdened and demoralized from the relationship side Life adjustment stress—Coming to terms with the reality of the baby and the need to refocus on life’s priorities based on the arrival of the baby Health service access challenges—Overall negative to neutral experience at the health facility but one that cannot be avoided. New parenting challenges Worries around breastfeeding and mother’s own nutritional care. Not receiving enough money or material support from parents/partner. Feeling very low, drained out, and demotivated due to high pressure, lack of support, and material provision to care for the baby No parenting program or information readily available in the community or health center Experience as a parent Roles: Balance parenting with other responsibilities) Sources of support (for parenting related questions, for psychological support (for stress, sadness, depression), type of services needed) Challenges (general challenges, sources of stress, food security, relationship with partners, change roles as a parent) Parenting program experience The focused group also generated a few suggested strategies that may help reduce adolescent mothers’ burden and stress Finding means of livelihood to sustain this unit (sense of being a dyad) The FGDs focused on the need for the MCH staff to be more empathic and helpful. Particularly providing guidance on the kinds of changes taking place in the body, nutritional support and emotional support, and parenting support	“Problems with feeding our own selves as the food is limited in the house, some days we have to go hungry and we are told by the nurses to still keep feeding the baby as the body can still make milk.” (three 16-, 17-, and 15-year-old adolescent girls share same experience during the FGD) “We feel that the nurses/clinic look down upon us. with no food to eat, pressure to work and this new baby – no sleep, sickness of the baby and a husband/partner not supporting us….life is hard.” (two 16-year-old adolescents during FGD) “Some days I just sit and cry, I ask my mother for money to go to see a doctor she doesn’t have, I asked my partner and he chases me away. It was hard to come today to the health centre. I had to walk a lot.”-16-year-old adolescent mother. “I would wish that there should be maternity near here instead of going far …. we have to go to Pumwani or sometimes in private and I wish follow ups with the baby could be done at my convenience at my home or near to me.”-20-year-old new mother of three “Over partner coerces us for sex, my body is still sore, I don’t have the urge to be sexually active but he says I am being disrespectful.”-18-year-old new mother) “Alcoholism is my biggest pain … my partner come home he sleeps, he doesn’t get concerned about the child …. he doesn’t get concerned about me; he doesn’t to know that you’re supposed to eat such like things, yah ….”-19-year-old new mother of two “To understand how to care … care … care for baby I went at Child Fund, this time we learnt how to … how to take care of children, we were taught how to take care of those children by card, you show what is this to two months old or year old child, or below 4 years, we should know how to take care of him/her. Another thing I noticed was that the moment when the mother separates from the father, children get problems.”-18-year-old adolescent “Getting money also becomes a problem, food in the house …. sometimes like me I stay there the whole day and get may be only supper …. so if it’s the weekend they stay at home you see they have to skip lunch …. so you get stressed because the children are used to eating in school so one gets stressed.”-adolescent mother says about her family and her younger sibling, 17 years old ‘You see if a service emerges where mothers meet and then they …. a person is brought to talk to them about bringing up the baby, teaches them business, teaches them how to get money, at least you will get mothers without much stress, don’t you think that would be so much better.’-new mother, 18 years old
Sample 4: Interviews with HW, CHWs, and MCH center nurses and program officers
Health needs of parents and children. These interviews were FDGs and KII and aimed to identify the needed service and gaps (have enough resources to provide the needed service)
Parental service provided in community health centers (psychological and health services provide for parents and quality and challenges) Child services provided in community health centers (physical and mental health services provided for child and quality and challenges)		One key theme emerged was adolescent mothers have multiple needs, but there is a lack of holistic service approach Adolescent mothers’ needs include social support from partners (who tend to absent from the process); care for mother’s mental health; resources to obtain food for their child; parenting/child related services These girls know nothing about caregiving and are in such a difficult role as mothers Physically weak and emotionally disturbed girls and how would they attend to the needs of a new born The domestic environment generates more shame and stigma; there is also role conflict between adolescents parents about their girls’ plight. Gaps There are big gaps in thinking holistically about health needs of young parents and their children There is another gap in engaging with male partners who seem absent from the system No programmatic focus on mental health or training of CHWs on mental health, focus on adolescents Absence of networking with iNGOs to provide real resources to women and children such as food, supplements, and information. In relation to quality of maternal and child service, several gaps were mentioned This (maternal depression) is the most needed service but there’s no expertise or even training program available Both health professionals and CHWs agree that no services directed towards psychosocial support of parents or parenting challenges, or towards new/adolescent parents are in place. The adolescent friendly services are not there at all. The infant and child care services are minimal and do not provide relief for everyday stressful events, there are not resources or support networks available such as a breastfeeding support group Health workers say no child MH or parenting training has ever been provided to them Resource and cost: Sometimes the health facility is so pressed with time and resources that not all patients are attended to. for patients the transport costs matters so if not seen then unlikely to return again and again	“We are approachable and can link them back to the health facility.”-male CHW in Kariobangi “We offer a shoulder to cry and link these girls and women to the right places.”-two female CHWs in Kariobangi and Kangemi “What do they know about their own body or caring for a baby? They need support!”-MCH nurse in charge, Kariobangi and Kangemi “Peer pressure also determines these early pregnancies.”-CHW, Kariobangi “I would like to be able to start a support group for these mothers. I would like to find a supporter (funder) who could provide resources for these girls to meet, discuss what they need for their future, their babies and for themselves. When women got money for transport or a plate of food on their returning appointment, relaxing and talking to one another became easy ….”-nurse in charge, Kariobangi health center “Let’s take the case of HIV for example, may be the young lady/adolescent has come alone in the antenatal clinic tested and found positive …. so to take that message home it is a problem. Once the partner hears or understand or gets to know that the lady is reactive or positive; that is the end of that marriage ‘hiyo ni yako’ (that is yours) ‘you know where you got it from,’ and the man disappears. So especially in the issue of HIV, it is a problem … it is a problem. The others are financial problems, the domestic task; but in the issue of HIV it is a problem, most of the ladies are alone after realizing they are positive. Because even I talk to them when I’m immunizing their baby I am asking now you are taking treatment what about your partner, ‘he just went; he left me pregnant, he left me when I gave birth to the baby’ …. and it is all like that; it is a problem I have very many single adolescent mothers after the test.”-deputy nurse in charge, Kangemi health center “We are volunteers most of the time the money we get from are from participating in trainings and delivering to the community—these aren’t always ongoing—we rely on programs that people bring to the facility. Once we finish the clinic work we don’t stay here the whole day. In all these trainings we have done so far none has been on mental health or dealing with parenting. We use our own wisdom and knowledge in counselling women who come to us. sometimes we go to find other ways to get money— like driving taxi, doing casual work, running second hand clothes business.”-3 community health workers in a FGD, two women and one male CHW