Self-harm and suicidal behaviours among pregnant adolescent girls and young women could be doubly compounded in sub-Saharan Africa: A call for further research

The recent systematic review by Mutahi and colleagues published in eClinicalMedicine¹ sought to synthesise available evidence on the mental health problems and service gaps experienced by pregnant adolescent girls and young women (aged 12–24 years) in sub-Saharan Africa. Among other findings, depression was the most frequently reported mental health problem, while mental health care for pregnant adolescent girls and young women (PAGYW) were characterised by poor health-care worker attitudes, lack of confidentiality, and lack of tailored services.

We provide a complementary perspective that continues the conversation about the mental health of PAGYW in sub-Saharan Africa. Notably, while evidence from the 18 eligible studies provided less than enough basis to address satisfactorily the key aims of the review,¹ it is even more concerning that only three (qualitative) studies have reported evidence on suicidal behaviours among PAGYW in sub-Saharan Africa between 2007 and 2020.¹ The dearth of studies on self-harm and suicidal behaviours among PAGYW in sub-Saharan Africa is troubling and as such warrants both initial and further research attention for at least four reasons:

• 1The rates of (unwanted) pregnancy among adolescent girls (aged 10–19 years) are higher in sub-Saharan Africa—nearly 1 in 5 adolescent girls experiences pregnancy and related maternal conditions²;
• 2About 1·5 million adolescents live with HIV within sub-Saharan Africa, 6 in 7 new HIV infections in adolescents aged 15–19 years are among girls, and adolescent girls living with HIV in the subregion who have a pregnancy are at elevated risk of engaging in suicidal behaviours^3,4;
• 3Emerging evidence suggests (unwanted) teenage pregnancy as a contributor to suicidal and non-suicidal self-harm in adolescent girls and young women in sub-Saharan Africa⁵; and
• 4Globally, suicide is the third leading cause of death in girls aged 15–19 years, after maternal conditions, while Africa records the highest rate of suicide (11·2 per 100 000 people).⁶

Beyond these cardinal reasons, we suspect that self-harm and suicidal behaviours could be a critical public health issue among PAGYW in sub-Saharan Africa due to the sociocultural value placed on children and young people. Generally, across Africa, parents are expected to raise their children and young people ‘well’, as children are considered social insurance for the family-where aged parents become dependent on their adult children in the future.⁷ A possible unhelpful implication of this cultural value is that parents are likely to misconstrue their unmarried adolescent's pregnancy as failed parenting, which could lead to maltreatment of the pregnant adolescent and, in some cases, social ostracism by the family. A pregnant adolescent girl in this circumstance is likely to be depressed, lonely, and experience thwarted belonginess and meaninglessness. School-going adolescent girls who become pregnant are likely to experience shame, stigma, bullying victimisation, and drop out, while those who receive some form of family support are likely to also experience increased perceived burdensomeness (the belief that one is a burden on others or society) and a deep-seated sense of having disappointed their parents and family. These unfavourable circumstances could trigger self-harm and suicidal thoughts and behaviours among PAGYW. Additionally, the prevailing strict gender norms, child marriage, exploitation, intimate partner abuse, and unfavourable patriarchal power dynamics against girls and women in the subregion could be even more pronounced among (unmarried) adolescent girls who have experienced unwanted pregnancy.⁸ These situations could also provoke self-harming behaviours and suicidal tendencies in PAGYW.

We underscore as critical the review's evidence that depression is the most frequently reported mental health problem in PAGYW in sub-Saharan Africa.¹ This evidence could be pointing to a need for future studies to examine self-harm and suicidal behaviours among PAGYW in the subregion, as depression underlies more than half of all deaths by suicide.⁹ While we reaffirm the authors’ recommendation that future quantitative studies seeking to contribute valid estimates should consider applying validated psychological scales,¹ we also wish to add that future studies should consider carefully where they approach PAGYW to participate in research. Most published studies have accessed participants in clinics or hospitals. However, for representative sampling and generalisable findings, researchers should also consider including the sampling of PAGYW within community (household) contexts. There is evidence to suggest that most PAGYW in sub-Saharan Africa do not attend antenatal clinics and many pregnant adolescent girls experiencing major mental health problems tend not to seek professional help.¹⁰

Self-harm and suicidal behaviours among PAGYW could be doubly compounded in sub-Saharan Africa—a critical but unexamined, overlooked public health issue in the subregion. Urgent initial studies and routine research are needed to improve our understanding and inform both universal and targeted intervention and prevention programmes to promote positive mental health outcomes among PAGYW in the subregion.

Contributors

All authors reviewed the manuscript and are in agreement with regard to the contents.

Declaration of interests

We declare no competing interests.