Adolescent Pregnancy and Challenges in Kenyan Context: Perspectives from Multiple Community Stakeholders

Exclusive breastfeeding in first-time mothers in rural Kenya: a longitudinal observational study of feeding patterns in the first six months of life

BACKGROUND

Exclusive breastfeeding up to 6 months of age is recommended by the World Health Organization as the optimal mode of infant feeding, providing adequate nutrition for the baby and protection against infectious diseases. Breastfeeding can be adversely affected by individual, cultural and socio-economic factors. The study aimed to explore barriers of exclusive breastfeeding in the first 6 months of life among first-time mothers in rural Kenya.

METHODS

An observational longitudinal design aimed to provide rich data on breastfeeding behaviour. Twenty pregnant first-time mothers were recruited through antenatal clinics and snowballing. Mothers were visited nine times at home from late pregnancy, at 1 week and 2 weeks post-delivery, then monthly until the baby was aged 6 months. Visits were conducted between November 2016 and April 2018. At the first visit, participants were asked about breastfeeding intentions and infant feeding education received. At each postnatal visit, direct observation of breastfeeding, a recorded semi-structured interview on feeding, mother's and baby's health was performed. Interviews were transcribed, checked, content was grouped into categories and analyzed using a qualitative descriptive approach.

RESULTS

Most participants were adolescent (75%) and unmarried (65%). All 20 mothers intended to and did breastfeed, however additional fluids and semi-solids were commonly given. Only two mothers exclusively breastfed from birth up to 6 months of age. Prelacteal feeds, home remedies and traditional medicine were given by over a third of mothers in the first week of life. Concern over babies' bowel habits and persistent crying perceived as abdominal colic led to several mothers receiving advice to give gripe water and traditional remedies. Early introduction of maize porridge from 3 months of age because of perceived hunger of the child was recommended by other family members. Breastfeeding observation showed persistent problems with positioning and attachment of infants.

CONCLUSIONS

Exclusive breastfeeding from birth to 6 months was uncommon. Prioritization of capacity to detect mothers with breastfeeding problems and provide breastfeeding education and support is necessary, particularly during the antenatal and early postnatal period. It is important to engage with other women resident in the household who may offer conflicting feeding advice.

Mechanisms associated with maternal adverse childhood experiences on offspring's mental health in Nairobi informal settlements: a mediational model testing approach

BACKGROUND

Adverse childhood experiences (ACEs) is a significant public health and social welfare problem in low-and middle income countries (LMICs). However, most ACEs research is based on developed countries, and little is known about mechanisms of early ACEs on adulthood health and offspring's wellbeing for populations in LMICs. This area is needed to guide social welfare policy and intervention service planning. This study addresses these research gaps by examining patterns of ACEs and understanding the role of ACEs on adulthood health (i.e., physical, mental health, experience of underage pregnancy) and offspring's mental health in Kenya. The study was guided by an Integrated Family Stress and Adverse Childhood Experiences Mediation Framework.

METHODS

Three hundred ninety four mothers from two informal communities in Kariobangi and Kangemi in Nairobi were included in this study. The Adverse Childhood Experiences International Questionnaire (ACE-IQ), the Kessler Psychological Distress Scale (K10), Overall Health and Quality of Life items, and Child Behavior Checklist were used to study research questions. Data was gathered through a one-time interview with mothers. Structural Equational Modeling (SEM) was applied for mediational mechanism testing.

RESULTS

Among 13 ACE areas, most mothers experienced multiple adversity during their childhood (Mean (SD) = 4.93 (2.52)), with household member treated violently (75%) as the most common ACE. SEM results showedthat all domains of ACEs were associated with some aspects of maternal health, and all three domains of maternal health (maternal mental health, physical health, and adolescent pregnancy) were significantly associated with development of offspring's mental health problems.

CONCLUSION

ACEs are highly prevalent in Kenyan informal settlements. Consistent with cross cultural literature on family stress model, maternal ACEs are robust predictors for poor child mental health. Preventive interventions for child mental health need to address maternal adverse childhood traumatic experiences as well as their current health in order to effectively promote child mental health.

Adversities and mental health needs of pregnant adolescents in Kenya: identifying interpersonal, practical, and cultural barriers to care

BACKGROUND

Adolescent pregnancies present a great public health burden in Kenya and Sub-Saharan Africa (UNFPA, Motherhood in Childhood: Facing the challenge of Adolescent Pregnancy, 2013). The disenfranchisement from public institutions and services is further compounded by cultural stigma and gender inequality creating emotional, psychosocial, health, and educational problems in the lives of vulnerable pregnant adolescents (Int J Adolesc Med Health 15(4):321-9, 2003; BMC Public Health 8:83, 2008). In this paper we have applied an engagement interview framework to examine interpersonal, practical, and cultural challenges faced by pregnant adolescents.

METHODS

Using a qualitative study design, 12 pregnant adolescents (ages 15-19) visiting a health facility's antenatal services in Nairobi were interviewed. All recruited adolescents were pregnant for the first time and screened positive on the nine-item Patient Health Questionnaire (PHQ-9) with 16% of 176 participants interviewed in a descriptive survey in the same Kangemi primary health facility found to be severely depressed (Osok et al., Depression and its psychosocial risk factors in pregnant Kenyan adolescents: a cross-sectional study in a community health Centre of Nairobi, BMC Psychiatry, 2018 18:136 https://doi.org/10.1186/s12888-018-1706-y). An engagement interview approach (Social Work 52(4):295-308, 2007) was applied to elicit various practical, psychological, interpersonal, and cultural barriers to life adjustment, service access, obtaining resources, and psychosocial support related to pregnancy. Grounded theory method was applied for qualitative data sifting and analysis (Strauss and Corbin, Basics of qualitative research, 1990).

RESULTS

Findings revealed that pregnant adolescents face four major areas of challenges, including depression, anxiety and stress around the pregnancy, denial of the pregnancy, lack of basic needs provisions and care, and restricted educational or livelihood opportunities for personal development post pregnancy. These challenges were related both to existing social and cultural values/norms on gender and traditional family structure, as well as to service structural barriers (including prenatal care, mental health care, newborn care, parenting support services). More importantly, dealing with these challenges has led to negative mental health consequences in adolescent pregnant girls, including feeling insecure about the future, feeling very defeated and sad to be pregnant, and feeling unsupported and disempowered in providing care for the baby.

CONCLUSIONS

Findings have implications for service planning, including developing more integrated mental health services for pregnant adolescents. Additionally, we felt a need for developing reproductive education and information dissemination strategies to improve community members' knowledge of pregnant adolescent mental health issues.

Depression and its psychosocial risk factors in pregnant Kenyan adolescents: a cross-sectional study in a community health Centre of Nairobi

BACKGROUND

Adolescent pregnancies within urban resource-deprived settlements predispose young girls to adverse mental health and psychosocial adversities, notably depression. Depression in sub-Saharan Africa is a leading contributor to years lived with disability (YLD). The study's objective was to determine the prevalence of depression and related psychosocial risks among pregnant adolescents reporting at a maternal and child health clinic in Nairobi, Kenya.

METHODS

A convenient sample of 176 pregnant adolescents attending antenatal clinic in Kangemi primary healthcare health facility participated in the study. We used PHQ-9 to assess prevalence of depression. Hierarchical multivariate linear regression was performed to determine the independent predictors of depression from the psychosocial factors that were significantly associated with depression at the univariate analyses.

RESULTS

Of the 176 pregnant adolescents between ages 15-18 years sampled in the study, 32.9% (n = 58) tested positive for a depression diagnosis using PHQ-9 using a cut-off score of 15+. However on multivariate linear regression, after various iterations, when individual predictors using standardized beta scores were examined, having experienced a stressful life event (B = 3.27, P = 0.001, β =0.25) explained the most variance in the care giver burden, followed by absence of social support for pregnant adolescents (B = - 2.76, P = 0.008, β = - 0.19), being diagnosed with HIV/AIDS (B = 3.81, P = 0.004, β =0.17) and being young (B = 2.46, P = 0.038, β =0.14).

CONCLUSION

Depression is common among pregnant adolescents in urban resource-deprived areas of Kenya and is correlated with well-documented risk factors such as being of a younger age and being HIV positive. Interventions aimed at reducing or preventing depression in this population should target these groups and provide support to those experiencing greatest stress.

A cross-sectional study of depression with comorbid substance use dependency in pregnant adolescents from an informal settlement of Nairobi: drawing implications for treatment and prevention work

INTRODUCTION

Adolescent pregnancy is a highly prevalent and significant public health problem in Kenya, and mental health needs of pregnant adolescent girls have been overlooked. Nearly, 50% of the world's population comprises children and adolescents and 85% live in lower and middle-income countries.

OBJECTIVE

Pregnant adolescents were interviewed to ascertain certain social determinants of mental health such as social support, partner or parent support, and demographic profile and assessed for depression using EPDS and for severity of depression using BDI, and their alcohol abuse assessed using AUDIT.

METHODS

A cross-sectional descriptive study using a purposive sample of 212 pregnant adolescents visiting Kangemi Health Centre in Nairobi was conducted.

RESULTS

We found that 60.4% had depressive symptoms scores of 8 and above on EPDS, 51.9% were found to have severe depression score on BDI. About 26.9% were currently consuming alcohol. The more severely depressed participants were demonstrating greater alcohol use. Of the 110 pregnant adolescents who were severely depressed, 39 were currently consuming alcohol. We identified several alcohol use disorder factors associated with depression such as living with an alcoholic, ever and current use of alcohol, alcohol-related harm being experienced, being pressured to take alcohol. On our final multivariate logistic regression, we found that being a student (AOR 5.12, 95% CI 1.19-22.0, P = 0.028); low family income (between 5000 and 10,000 shillings) (AOR 0.22, 95% CI 0.09-0.56, P = 0.02); unplanned pregnancy (AOR 3.41, 95% CI 1.19-9.80, P = 0.023); both negative and ambivalent attitudes of the unborn baby's father, respectively (AOR 8.72 95% CI 2.88-26.37 P < 0.001; AOR 4.26 95% CI 1.35-13.45, P = 0.013); early age at sexual debut (AOR 0.70, 95% CI 0.55-0.89, P = 0.003); and ever used any psychoactive substances (AOR 3.21, 95% CI 1.31-7.88, P = 0.011).

CONCLUSION AND RECOMMENDATIONS

Alcohol abuse during pregnancy presents a significant public health burden and the associated health risks for the adolescent mother and her baby are enormous. We need to bolster screening for the comorbid disorders such as depression and substance use disorders, particularly alcohol in order to address mental health and psychosocial functioning of adolescents. The underlying adversities and sociocultural challenges need to be better understood and mechanisms that lead to comorbidities require further research. Depression interventions for Kenyan adolescents would need to embed screening, treatment and management of substance abuse.