This study is associated with some limitations: In particular, its core findings emanated from the narratives of a small, select group of pregnant and parenting girls who requested counseling support when it was offered, and from the accounts of an even smaller group composed of affected girls’ parents. We therefore craft our discussion of the findings with great care, and with the important caveat that our conclusions are not driven by a concern for ‘representativeness’ in the quantitative sense. They are, rather, propelled by the conceptual issues emerging from the data. As Ulin and colleagues  remind us, ‘Our goal [with qualitative inquiry] is to produce data that are conceptually, not statistically, representative of people in a specific context’. It is noteworthy, nonetheless, that the key findings from this study are in concurrence with results from several population-based studies, which are also discussed in this section. Findings from this study provide a portrait of existing psychosocial support challenges and opportunities in the context of teenage pregnancy, based on the lived experiences of some affected girls and parents in Kenya. This portraiture could serve as a useful starting point for developing psychosocial support interventions for pregnant and parenting girls in low- and middle-income countries where such interventions are rare .
Sexual violence, for instance, turned out to be the most prominent theme emerging across the majority of the case notes, with 15 out of the 20 girls in the sample indicating that they had gotten pregnant as a result of rape. The high prevalence of sexual violence among pregnant/parenting girls is reflective of findings from an earlier, population-based study in the same context, which showed that over a third (35%) of ever pregnant 12- to 16-year-olds reported getting pregnant as a result of rape or coercion .
Oftentimes, sexual violence occurred in the context of girls’ ‘boyfriend-girlfriend’ relationships, supporting findings from a population-based study in the same sites which indicated that about 90% of teenage mothers reported getting pregnant by their boyfriends, with a considerable proportion of these boyfriends (37%) being their fellow students at the time . Other perpetrators that emerged from the case notes included relatives, friends, and strangers. Pregnant girls also struggled with disclosing their experience of sexual violence.
The realities of girls in this study who experienced sexual violence mirror those of their peers nationwide: A nationally-representative survey in Kenya  demonstrated that 43% of 13- to 17-year-old girls who experienced an incident of sexual violence in the past 12 months did not tell anyone about their experience. Screening interventions to support sexual violence disclosure have been observed to be feasible and effective in Kenyan settings  and could potentially be embedded into psychosocial response efforts for pregnant and parenting girls. Additionally, perpetrators were often the girls’ schoolmate boyfriends or peers, and pregnant/parenting survivors were reticent about disclosing sexual violence. These findings draw our attention to the need to incorporate boys into the portrait of teenage pregnancy. Related to this is the critical need to embed sexuality and relationships education (which would include sensitization to certain concepts such as gender-based violence, consent, self-management, kindness, and relationship skills , for example) in the discourse and programming around teenage pregnancy. Such education is clearly required early on in the lives of girls and boys within and outside of school contexts. While the Kenyan government has demonstrated support for sexuality education, it has privileged abstinence-only approaches , which, in addition to being incomprehensive, overlook the realities of sexual violence (and other grave, sexuality-related issues) occurring as early as primary school age.
The need for sexuality and relationships education is all the more important, given parents’ recurrent request in the present study for external support in communicating with their children about sex and sexuality. This parent-child communication challenge plausibly stems from cultural prescriptions in some Kenyan sub-cultures, which hold that conversations about sex and sexuality contravene notions of ‘respect’ within parent-child relationships . Consequently, parent-child communication around these subjects is often only prompted by negatively-perceived events, including early pregnancy . Sexuality and relationships education efforts could, therefore, be designed to support parents in this regard, and to complement related endeavors within and outside schools.
The study’s findings demonstrate that mental health concerns are not the preserve of pregnant/parenting girls alone. Parents of girls who had experienced pregnancy sometimes faced psychological trauma of their own – an issue that has received much less attention in the literature. Intersections between adolescent and parental trauma also requires a response and further investigation in the context of teenage pregnancy, given evidence of their co-occurrence in this study. While this intersection could potentially have a cyclical effect, prolonging recovery for both girls and their parents, it also holds potential for whole-family healing, if properly addressed. Although evidence of this intersection emerged only once in the present study (in a case where a pregnant girl and her mother alike were physically abused by her father in response to her teenage pregnancy), intersections between violence against girls and violence against women in the context of teenage pregnancy are also worth exploring further, given the likelihood that this is occurring much more often than this qualitative study was able to capture.
Adolescent mothers face higher risks of adverse birth outcomes than older mothers . As seen in this study, this reality can place extra pressure on girls whose babies face health challenges (or whose babies do not survive), coupled with the stigma of being a young mother of school-going age, and the prevalent experience of rape-related pregnancy. Adverse birth outcomes and their psychosocial effect on teenage mothers are rarely considered, and should become a part of response interventions for this population.
It is also important to highlight existing family support for pregnant and parenting girls as a major theme that emerged in this study. Childcare is a major barrier to parenting girls’ advancement . Nonetheless, as the study findings suggest, parents, grandparents, and other relatives can serve as an important childcare resource to support the future endeavors of pregnant and parenting girls. Grandmothers, in particular, emerged from the case notes analysis as relatives who offered a safe space and ‘guaranteed’ support for pregnant/parenting girls. These family resources should be part and parcel of psychosocial responses in low-resource settings.
Overall, the findings from this study are quite similar to results from research around the psychosocial issues of teenage mothers in non-African contexts. Interpersonal violence, mental health challenges, and economic issues are commonly experienced among pregnant and parenting girls in other settings as well [4, 5, 29], and incorporating the parents and extended family of teenage mothers into support interventions is considered important and effective . Parent-teen communication about sexuality issues is also noted as being challenging in other settings . However, conduct disorders among pregnant/parenting teens did not emerge in the current study, but were highlighted as relevant in the broader literature . Its absence from the present study could be due to the small sample size (which may not have allowed for certain issues to be captured), or could be associated with sociocultural factors in Kenya that might moderate conduct problems (such as oppositional defiant disorder) in households with pregnant/parenting teenage girls. The broader literature also extends the framework of psychosocial support, going beyond pregnant/parenting girls and their parents alone, to include the children of teenage mothers, who are noted to require psychosocial support as well [4, 5]. Future psychosocial studies and interventions that give attention to the children of teenage mothers would be valuable for strengthening needed responses.