Adolescent Pregnancy by Akili Dada

ADOLESCENT PREGNANCY A CONTEXTUAL ASSESSMENT OF TEN COUNTIES IN KENYA.

PREFACE Akili Dada is an international award-winning leadership incubator whose main aim is to nurture transformative leadership in girls and young women from underserved backgrounds to meet the urgent need for more African women in leadership. Akili Dada’s main work revolves around 1) Investing financially in girls and young women by providing financial support to girls and young women from under-served populations over the long term 2) Developing leadership for young women through building their capabilities to make decisions, take up leadership roles and influence change 3) Feminist movement building and advocacy- strengthening girls and young women voices in their communities by igniting their passion and creating spaces for them to champion their issues 4) Mentorship – facilitating space and opportunities for girls and young women to build support systems for the long term. WE Trust is an independent charity foundation that focuses on building bridges between grantees, local communities and other stakeholders. Prioritizing the importance of human connection, they are committed to investing in people, with a focus on advancing women’s rights and children’s rights, supporting safe migration, and building strong communities. Akili Dada acknowledges that adolescent pregnancy is a major issue that involves high health risks and human rights violations of young women and impedes socioeconomic development. Through its many advocacy, evidence generation, tool development and capacity building programs, Akili Dada has been in the forefront of efforts to prevent adolescent pregnancy in Kenya. Through the support of We Trust, Akili Dada seeks to strengthen its role in sexual reproductive health and rights movement by undertaking an assessment to understand the contextual factors attributed to adolescent pregnancy, consequences of adolescent pregnancy and strategies that can be employed to reduce adolescent pregnancy in ten selected counties with moderate to high teenage pregnancy rates in Kenya. This report draws on literature about adolescent pregnancy in Kenya, details the assessment methodology used, presents the main results and provides general recommendations for policy and practice on adolescent pregnancy in Kenya. The findings and recommendations can be used by different stakeholders working on sexual and reproductive health and rights of young people.

This report and the results presented herein were conducted by QuadExcel Research, Training and Consulting Limited and reviewed by Akili Dada.

TABLE OF CONTENTS ccess

Table of Contents ACKNOWLEDGMENTS ............................................................................................................................ 5 EXECUTIVE SUMMARY .......................................................................................................................... 7 1.0 BACKGROUND AND PURPOSE ........................................................................................................ 1 1.1 Introduction ............................................................................................................................................. 1 1.2 Contributing Factors ............................................................................................................................... 2 1.3 Consequences of Adolescent Pregnancy................................................................................................. 2 1.4 Health Consequences .............................................................................................................................. 2 1.5 Socio-economic Consequences ............................................................................................................... 3 1.6 The Adolescent Pregnancy context in Kenya ......................................................................................... 3 2.0 METHODOLOGY ................................................................................................................................. 6 2.1 Participants and Procedure ...................................................................................................................... 6 2.2 Data Collection Methods ........................................................................................................................ 6 2.3 Study Limitations and Challenges .......................................................................................................... 8 2.4 Data Analysis ........................................................................................... Error! Bookmark not defined. 2.5 Ethical Considerations .......................................................................................................................... 10 3.0 ASSESSMENT FINDINGS ................................................................................................................. 11 3.1 Characteristics of Respondents and Households................................................................................... 11 3.1.1 Participants’ Education ...................................................................................................................... 12 3.1.2 Parental Education ............................................................................................................................. 12 3.1.3 Parental Employment ......................................................................................................................... 13 3.1.4 Ownership of Goods .......................................................................................................................... 14 3.2 Sexual Behavior, Contraceptive and Childbearing ............................................................................... 14 3.2.1 Sexual Debut ......................................................................................... Error! Bookmark not defined. 3.2.2 Early Marriage and Childbearing ....................................................................................................... 15 3.2.3 Contraceptive Use .............................................................................................................................. 15 3.3 Contextual Causes and Consequences of Adolescent Pregnancy ......................................................... 17 3.3.1 Lack of Comprehensive Sexual Education ........................................................................................ 18 3.3.2 Lack of Parental Guidance and Counselling ...................................................................................... 19 3.3.3 Cultural Practices ............................................................................................................................... 19

3.3.4 Poverty and Lack of Economic Influence .......................................................................................... 21 3.3.5 Sexual Violence ................................................................................................................................. 21 3.3.6 Drug and Substance abus ................................................................................................................... 21 3.3.7 Peer Influence .................................................................................................................................... 21 3.4 Risks and Consequences of adolescent Pregnancy ............................................................................... 23 3.5 Strategies to reduce Teenage Pregnancy ............................................................................................... 24 3.5.1 Adolescent perception on averting teenage pregnancy ...................................................................... 24 3.6 NGOs Intervention in reducing adolescent pregnancies ....................................................................... 25 3.7 Knowledge on Sexuality and Sex Education ........................................... Error! Bookmark not defined. 4.0 Conclusion and Recommendations ....................................................................................................... 26 4.1 Discussion ............................................................................................................................................. 26 4.2 Conclusion and recommendation ............................................................. Error! Bookmark not defined.

quality education and learning opportunities * Access other funding sources and opportunities * Successfully navigate transitions between education and posteducation * Gain a competitive edge in job markets and leadership position

ACKNOWLEDGMENTS Our gratitude goes to all the adolescent girls and key respondents who took part in this study and greatly enriched our understanding of the factors contributing to teenage pregnancy, consequences and contextual strategies that can be employed to reduce teenage pregnancies in Kenya. We thank the leaders of the ten counties: Bomet, Bungoma, Busia, Homa- Bay, Kisii, Kisumu, Kwale, Meru, Narok and Siaya who accepted to take part in this assessment. Special gratitude is extended to all the key stakeholders from the National government, CSO Reference Group, County governments, NGOs and CBOs at county level and the local communities, among others who assisted to make the assessment a success. Information gathered from these groups forms the basis for our analysis of findings, conclusions and recommendations. Our sincere thanks go to Instream Consulting Group Limited who spearheaded the study design and provided overall management and oversight of the data collection activities and to Instream’s dedicated team of field supervisors and interviewers who collected all the data presented in this report despite field challenges. We acknowledge and recognize their determination and professionalism during the entire process. We acknowledge QuadExcel Consulting limited for dedicating their time to conduct data cleaning, data analysis and for putting together this report. We recognize the financial support from WE Trust that has enabled effective execution of this assessment commissioned by Akili dada.

LIST OF TABLES AND FIGURES

List of Figures Figure 1: Counties with the highest rate of teenage pregnancy and motherhood (Above National average of 18%)- Source: KDHS 2014 Figure 2: Counties with moderate rates of teenage pregnancy and motherhood (Between 11-17%)- - Source: KDHS 2014 Figure 3: Maternal Education Attainment Figure 4: Parental educational attainment

List of Tables Table 1. Number of In-Depth Interviews (IDIs) and Focus Group Discussions (FGDs) Conducted by Site and Respondent Type Table 2. Assessment Indicators Table 3: Distribution percentage of girls aged 13–19, by selected background characteristics Table 4: Distribution percentage of girls aged 13–19, by selected background characteristics Table 5: Percentage of adolescents who have initiated sex, by socio-demographic characteristics Table 6: Sex education in schools Table 7: Causes of teenage pregnancy Table 8: Risks and consequences of teenage pregnancies Table 9: Adolescents perception to avert adolescent pregnancies

EXECUTIVE SUMMARY Adolescent pregnancy remains a major issue around the world that causes many irreversible health and socio-economic consequences that alter the course of young women’s entire life. These may include childbirth complications, death, unsafe abortions, school dropout, low educational attainment, household poverty, lack of economic independence, limited income-earning opportunities, illiteracy, violence, and social isolation. In Kenya, Adolescent childbearing varies widely by county, from a low of 6% in Murang’a to a high of 40% in Narok. Young women with no education are much more likely to have begun childbearing (33%) compared to those with secondary or higher education (12%). The median age of first intercourse is 18 for women and 17 for men. 15% of women and 21% of men had their first sexual encounter by age 15. Age at marriage varies widely by county of residence with women marrying the earliest in Migori, Tana River and Homa Bay at just over 17 years. The factors driving adolescent pregnancy in Kenya are complex, varied and manifest from deeply rooted gender inequalities, social norms and poverty. Additionally, inadequate access to comprehensive sexual education, adolescent sexual and reproductive health services and limited economic perspectives contribute to high adolescent pregnancy rates. Reduction of adolescent pregnancy therefore requires multifaceted interventions. Since 2019, Akili Dada has been working to develop a toolkit that will package relevant comprehensive Adolescent Sexual Reproductive Health and Rights information and apply a mix of context-specific intervention strategies to reduce adolescent pregnancies in Kenya. This assessment therefore set out to generate quantitative and qualitative data to understand the factors that contribute to adolescent pregnancy, consequences of teenage pregnancy, what state and non-state actors are doing to address adolescent pregnancy in the hotspot counties and identify context specific strategies that can be employed to reduce adolescent pregnancies in Kenya. Objectives The assessment objectives included: 1. Identify the factors associated with adolescent pregnancy in 10 counties with high adolescent pregnancy rates in Kenya 2. To explore the contextual factors contributing to adolescent pregnancy and consequences of adolescent pregnancy in the targeted counties 3. To contribute to the evidence on effective and context-specific intervention strategies to reduce adolescent pregnancy Methodology The assessment was conducted in ten purposively selected counties with high adolescent pregnancy rates in Kenya: 1) Bomet 2) Bungoma 3) Busia 4) Homa- Bay 5) Kisii 6) Kisumu 7)

Kwale 8) Meru 9) Narok 10) Siaya. A mixed methods approach was undertaken. A total of 394 adolescent girls aged 13-19 years were sampled from the ten targeted counties. Of these 377 were interviewed successfully (96%). The main reason for non-response was parent/guardian refusal. Information on key demographic indicators, sexual behavior, asset ownership, contraceptive use, causes and consequences of adolescent pregnancy, community practices that encourage adolescent pregnancy, knowledge, attitudes and perceptions of adolescent pregnancy and strategies that can be employed to reduce adolescent pregnancy was collected using a standard survey tool. Qualitative data was collected to provide a more in-depth understanding of the causes and consequences of adolescent pregnancy and strategies to reduce teenage pregnancy. About 2-5 Focused Group Discussions (FGDs) were conducted with adolescent girls aged 13-19 years in each of the targeted counties. A total of 38 FGDs were conducted. Each FGD had between 8-12 adolescent girls participating. A total of 97 Key Informant Interviews were conducted with gender, education and birth registration officers, school heads, sub-county administrators and chiefs/village heads at the county level. Quantitative data analysis was conducted on key Adolescent Sexual Reproductive Health indicators and custom indicators informed by the local operating context in Kenya were developed to inform the analysis. Qualitative interviews were transcribed and coded for emerging themes using Nvivo software. Output of relevant codes were used for analysis and write up of the report.

Key findings Demographic and Household characteristics A total of 377 adolescent girls aged 13-19 year were interviewed. 45% of the participants were between 13-15, 31% were 16-17 and 24% were 18-19 years old. Majority of participants (46%) were residing in urban areas. About 60% were living with both parents while 24% were living with one parent. Those who did not live with their parent(s) lived with another adult relative (9%), other adult non-relative (3%) or partner (4%). Capturing parental presence in the lives of adolescents is important, as living with a parent affects young people’s behavior such as initiation of sexual intercourse, and the antecedent consequences, such as unintended pregnancy. Education Based on the assessment, about 89% of the adolescents reported that they were still attending school. 51% of the respondents had at least attained some secondary school education. About 2% had no education. Several of the respondents’ parents (fathers 22%, mothers 13%) have not attained formal education. Parental educational attainment is critical in determining children’s educational attainment, especially years of schooling.

Sexual Behavior, Contraceptive Use and Childbearing Sexual activity pre-disposes teenagers to risks such as unintended pregnancy and sexually transmitted infections. About 34% of adolescents were sexually experienced. Older adolescents were more likely to have engaged in sexual intercourse than younger adolescents (13-15 years). The Findings also showed that adolescents who were still in school were less likely to have engaged in sex than their counterparts who were not in school. 15% of the respondents have never used contraceptives. Condoms (34%), oral contraceptives (22%) and injectable (20%) were the most used contraceptives by the adolescents. A significant relationship exists between contraceptive use, age, sibling teenage pregnancy, ever given birth, who the adolescent lives with and if they have a boyfriend. Marriage and childbearing rates were low. About 6% (21) of the respondents reported ever being married and 10% (39) had ever given birth. The rate of adolescent pregnancy was slightly higher in Kisii with 2% of the respondents reporting ever giving birth. Early marriage was slightly higher in Siaya with 2% of girls having ever been married.

Factors contributing to teenage Pregnancy Among the main factors contributing to adolescent pregnancy was lack of sexual education. 45% of the adolescents reported that the sex education received at school is not adequate. The findings also demonstrated that 41% of the respondents believe that cultural taboos inhibit discussion on sexuality and sex education. Almost (42%) of the adolescents interviewed cited parents were to blame for adolescent pregnancy. About 45% of the respondents acknowledge that community practices encourage adolescent pregnancies. Some of the cultural practices cited include the practice of Female Genital Mutilation, Early Marriage, and ‘Moranism’ including cultural ceremonies like “Disco Matanga”. More than half of the respondents (67%) stated that lack of alternative sources of livelihoods contribute to adolescent pregnancy while (20%) of the adolescents attributed poverty to be a leading contributor to adolescent pregnancy. Other factors mentioned included peer pressure, drug abuse and sexual violence.

Risks and consequences of teenage Pregnancy Some of the main risks and consequences of teenage pregnancy as highlighted by the respondents included school dropout, poverty, early marriage, HIV/AIDS and STIs, abortion, death and related childbirth complications.

Strategies of reducing teenage Pregnancy

More than half (54%) of the adolescents cited awareness creation and provision of comprehensive sexual education as a key intervention to avert adolescent pregnancies in their respective counties. Other aspects mentioned regarding teenage aversion included sensitizing the community on existing laws against certain practices such as FGM and other relevant policies, enforce implementation of the school re-entry policy and encourage that girls are maintained in schools even after giving birth, encourage use of contraceptives, abolish cultural practices that promote teenage pregnancies including night vigils like “disco matangas”, create measures or a toll-free line to report those who make impregnant teenagers; prosecute those impregnate teenage girls, avail job opportunities for teenagers to avoid idleness, ban some programs on TV that might influence promiscuous teenager behavior, collaborate with NGOs to assist teenagers by providing free education, and creating unskilled job opportunities, come up with scholarship and empowerment programs for teenage girls and provide sanitary pads and other necessities so that they remain in school. The findings demonstrate the need to have a standardized sex education toolkit to enhance the capacities of adolescents on sexual reproductive health towards reduction of adolescent pregnancy since sex education does not happen at home as stated by the adolescents because of cultural barriers according to the study findings. The goal of this toolkit is to package relevant and comprehensive Adolescent SRHR information that will enable facilitation and access to SRHR information and equip adolescent girls with the necessary skills that will positively change their life course.

1.0 BACKGROUND AND PURPOSE 1.1 Introduction Adolescent pregnancy is a major public health issue occurring in high, middle, and lowincome countries. 1Around the world, however, adolescent pregnancies are more likely to occur in marginalized communities, commonly driven by poverty and lack of education and employment opportunities. Globally, adolescent birth rate has declined from 65 births per 1000 women in 1990 to 47 births per 1000 women in 2015 but despite this overall progress, the global population of adolescents continues to grow, projections indicate the number of adolescent pregnancies will increase globally by 2030, with the greatest proportional increases in West and Central Africa and Eastern and Southern Africa. In 2018, the estimated adolescent birth rate globally was 44 births per 1,000 girls aged 15 to 19.2 Every year, an estimated 21 million girls aged 15–19 years in developing regions become pregnant and approximately 12 million of them give birth. Literature shows that the prevalence of adolescent pregnancy varies across regions of the world. Sub-Saharan Africa however records one of the highest prevalence of UNICEF. Ending child marriage: Progress and prospects. New York: UNICEF, 2013 (2) Darroch J, Woog V, Bankole A, Ashford LS. Adding it up: Costs and 2 benefits of meeting the contraceptive needs of adolescents. New York: Guttmacher Institute; 2016. 1

adolescent pregnancy with some countries recording more than 30% of women aged 20 to 24 giving birth before age 18. 3However, disparities of adolescent pregnancies exist in the region; Central Africa displaying the highest levels and southern Africa displaying the lowest. In West and Central Africa, this figure stood at 115 births, the highest regional rate in the world. Countries such as Central African Republic, Niger, Chad, Angola and Mali top the list of countries with highest adolescent birth rate above 178. 4These disparities across the sub-continent indicate that factors beyond individual levels may influence adolescent pregnancy. In sub-Saharan Africa a high proportion of pregnancies among adolescent girls aged 15-19 years are unintended, ranging from 39% in Tanzania to 59% in Kenya. In Kenya, adolescent pregnancy and childbearing are common. The Kenya Demographic and Health Survey (KDHS 2014) indicates that the adolescent pregnancy rate is at 18% for adolescents aged 15-19 years. It also indicates rates increase rapidly with age: from 3% among girls at 15 yrs. old, to 40% among girls at 19 yrs. 5The situation varies across counties; with some counties seeing higher rates than others. Prevalence of adolescent pregnancy is highest in Narok county at 40% compared to the Edilberto Loaiza Mengjia Liang ADOLESCENT PREGNANCY: A Review of the Evidence UNFPA New York, 2013 4 UNICEF Monitoring the situation of children and women. Early Child Bearing, 2019 5 Kenya Demographic Health Survey 2014 3

national prevalence of 18%. The prevalence rates are lowest in Central Kenya 10% and North Eastern region 12.2%.

economic consequences that alter the course of young women’s entire life. 1.4 Health Consequences

1.2 Contributing Factors Adolescent pregnancy affects all racial, cultural and socioeconomic groups around the world. Some factors among them include early marriage, lack of education including education on sexual and reproductive health, poverty, place of residence, early sexual initiation, sexual abuse/violence and barriers to access sexual and reproductive health services make some adolescents to be more prone to getting pregnant than others. 6In many societies, girls are under pressure to marry and bear children early with at least 39% of girls marrying before they are 18 years of age and 12% before the age of 15 in developing countries 7. Many developing countries have restrictive laws and policies that act as barriers to adolescents’ access to contraceptives. Sexual violence also contributes to adolescent pregnancy in many contexts. 1.3 Consequences of Adolescent Pregnancy Adolescent pregnancy and early motherhood present serious irreversible health and socio-

Clifton D, Hervish A. the world's youth 2013 data sheet: Adolescent Pregnancy and Childbearing. Washington, DC: Population Reference Bureau; 2013 7 World Bank. Economic impacts of child marriage: Global synthesis report. Washington, DC: World Bank; 2017. 6

There are major immediate and long-term health related consequences of adolescent pregnancy that affect both mothers and their babies. According to UNFPA, around 70,000 adolescents die each year of causes related to unsafe abortions or complications during pregnancy and childbirth. High rates of maternal deaths among 15-19-year-old girls in developing countries are attributed to pregnancy and childbirth complications. Adolescent mothers aged 10–19 years face higher risks of eclampsia, puerperal endometritis and systemic infections than women aged 20–24 years. 8Babies born to young mothers’ experience greater risks of low birth weight, preterm delivery and severe neonatal conditions. Stillbirths and deaths in the first week of life are 50% higher among babies born to adolescent mothers than among babies born to mothers in their twenties 9. Other negative maternal outcomes of adolescent pregnancy include Preterm labor, anemia, Hypertensive Disorders of Pregnancy (HDP), Urinary Tract Infection, abortion, Sexually Transmitted Diseases, HumanImmunodeficiency Virus, malaria, obstetric ¿VWXODV puerperal sepsis, mental illness and high rate of Cesarean Sections for WHO. Global health estimates 2015: deaths by cause, age, sex, by country and by region, 2000–2015. Geneva: WHO; 2016. 9 State of the World Population Report- Motherhood in Childhood: Facing the Challenge of Adolescent Pregnancy, released by the UN Population Fund (UNFPA) 8

cephalopelvic disproportion and fetal distress. Adverse fetal outcomes include premature births, low birth weight infants, Still Births, birth asphyxia, Respiratory Distress Syndrome and birth trauma or injury. 10 1.5 Socio-economic Consequences There are many economic and social consequences of adolescent pregnancy that affect the adolescents themselves, their children, families and communities and reverberate throughout their lives and for generations after. Numerous studies have indicated that pregnant adolescents and young mothers face stigma or rejection by parents, peers and community at large and are more likely to experience violence within marriage or a partnership. Isolation, stigma and discrimination can then lead to stress and depression and other related problems at home and in school. Pregnant and parenting adolescents face stigma, lack of emotional support, poor health access and stresses around new life adjustments. 11According to (Black et al), Adolescent girls who become pregnant are significantly poorer than their peers, with poorer nutrition and general health. This in turn increases the likelihood of fetal, perinatal and maternal death and disability by as much as 50 per cent. 12About 5% to 33% of girls’ ages 15 to 24 years drop out of school in some countries as a result of early pregnancy or marriage. This

WHO. Global health estimates 2015: deaths by cause, age, sex, by country and by region, 2000–2015. Geneva: WHO; 2016. 11 Kumar, M., Huang, K., Othieno, C. et al. Adolescent Pregnancy and Challenges in Kenyan Context: Perspectives from Multiple Community Stakeholders. Glob Soc Welf 5, 11–27 (2018). 10

jeopardizes their future education employment opportunities. 13

and

1.6 The Adolescent Pregnancy context in Kenya Kenya has a relatively youthful population where about 78% of the population is under 34 years of age. Adolescents constitute about 36% of the total population yet they experience some of the worst reproductive health outcomes such as: adolescent pregnancies, abortions, high unmet need for contraceptives. Mortality rate is also high in women aged between 15 and 19 years compared to other segments of the population. 14 KDHS (2014) indicates that 18% of young women age 15-19 have begun childbearing: 15% have already had a live birth and an additional 3% are pregnant with their first child. Adolescent childbearing varies widely by county, from a low of 6% in Murang’a to a high of 40% in Narok. Young women with no education are much more likely to have begun childbearing (33%) compared to those with secondary or higher education (12%). The median age of first intercourse is 18 for women and 17 for men. 15% of women and 21% of men had their first sexual encounter by age 15. Age at marriage varies widely by county of residence with women marrying the earliest in Migori, Tana River and Homa Bay at just over 17 years. Women living in Nyeri marry the latest, at a median age of 21.8 years. Overall, more than one-quarter of women are married by Adolescent Pregnancy - Its Impact on Maternal and Fetal Outcome .Gazala Yasmin1, Aruna Kumar2, Bharti Parihar3. InternatiŽŶĂů :ŽƵƌŶĂů ŽĨ ^ĐŝĞŶƚŝ Į Đ ^ƚƵĚǇ ͮ DĂƌĐŚ ϮϬϭϰ ͮ sŽů ϭ ͮ /ƐƐƵĞ ϲ 13 Economic Impacts of Child Marriage: Global Synthesis BrieF world bank 2017 14 KNBS 2009 census 12

age 18, while 8% are married by age 15. Most Adolescent pregnancies are unplanned and more likely to occur among poor and uneducated communities. The Total Fertility Rate is 3.14 while adolescent pregnancy (15-19 years) is 15%. Maternal Mortality Rate/100,000 =362 deaths/100,000 and unsafe abortion is one of the key drivers of maternal mortality. In Kenya, early and unintended pregnancy presents many cross-cutting challenges to education and sexual reproductive health of adolescents. 98% of girls who have ever been pregnant are out of school. 59% of pregnancies among girls aged 15-19 years are unintended and 45% of severe abortion complications are among adolescent girls. Though the Kenyan Constitution which was enacted on 10 August 2010 has been described as both ‘transformative Constitution’ and ‘ceasefire document’ clearly revealing the tension within the document itself and the abortion, which has led to many adolescents opting for unsafe abortion which is one of the leading causes of maternal mortality. In response to the rate of adolescent pregnancies, Kenya has initiated various interventions to address the surging reproductive health challenges faced by adolescents. Among these interventions is the formulation of the National Adolescent Sexual Reproductive Health Policy (ASRH) in 2015. The policy aims to enhance the sexual and reproductive health of adolescents in Kenya to contribute to realizing adolescents’ full potential, as well as to contribute to national development. The policy elaborates key actions to reduce the 15

Kenya 2010 Constitution

various stakeholders involved in its implementation. Adolescent pregnancy and stigmatization have often led to adolescent girls opting to terminate the pregnancy through abortion. Article 26(4) provides that abortion is not permitted unless, in the opinion of a trained health professional, there is need for emergency treatment, or the life and health of the mother is in danger.’ Similarly, Article 43(1)(a) of the Constitution as well as the international and regional human rights and women’s rights instruments including the Maputo Protocol also guarantees the right to sexual and reproductive health rights including safe abortion. Article 43(1)(a) of the Constitution 15provides that ‘[e]very person has the right to the highest attainable standard of health which includes the right to health care services, including reproductive health care. Notwithstanding the above, the Kenyan Penal Code still criminalizes the procurement of adolescent pregnancy rates that remained high at in the last decade.

have

To realize the SDGs in Kenya, it is important to reduce the number of teen pregnancies in the country. When adolescent girls grow up healthy, and can go to school, they are more likely to escape poverty, and they facilitate the upward social and economic mobility of their families and society. Despite the significant effort towards addressing teen pregnancy, county specific policy dissemination in Kenya has not been fully realized. The coverage of most interventions is also quite low. Akili Dada recognizes that the teenage pregnancy situation in Kenya cannot be tackled using a “one size fits all approach” but rather

interventions geared towards reducing teenage pregnancy have to be cognizant of the diverse contextual similarities and differences in socio-economic, cultural and political aspects in the different counties across Kenya. In this regard, Akili Dada set out to conduct an assessment to determine the contextual

situation of adolescent pregnancy. This report presents an analysis of the current adolescent pregnancy situation in selected counties with high adolescent pregnancy rates in Kenya. It discusses the factors attributed with adolescent pregnancy, perceptions and strategies to reduce adolescent pregnancy in these selected counties.

Figure 1: Counties with the highest burden of teenage pregnancy and motherhood (Above National average of 18%)- Source: KDHS 2014

Figure 2: Counties with moderate rates of teenage pregnancy and motherhood (Between 11-17%)- Source: KDHS 2014

2.0 METHODOLOGY A mixed methods approach was undertaken for this assessment. Qualitative and quantitative methods were used. This section describes in detail the methodology which was used to collect the data. 2.1 Participants and Procedure This assessment was conducted in ten counties in Kenya: 1) Bomet 2) Bungoma 3) Busia 4) Homa- Bay 5) Kisii 6) Kisumu 7) Kwale 8) Meru 9) Narok 10) Siaya. The study was confined to selected geographic locations with high adolescent pregnancy rates in Kenya based on the Kenya Demographic and Health Survey (KDHS) 2014. The primary target population is girls 13-19 years old who were residing within selected study sites at the time of the assessment. 2.2 Data Collection Methods Quantitative Methods

The assessment explores contextual factors associated with adolescent pregnancy in some of the counties with high adolescent pregnancy rates in Kenya. Data collection was conducted by trained and qualified enumerators. A two-day enumerator training was conducted. The training aspects included; research ethics, administering informed consent, rapport building, tool review for both the quantitative and qualitative pieces, quantitative and qualitative interviewing techniques, participant identification process and handling difficult participants. The enumerators employed a set of screening questions to ascertain whether there was an eligible participant residing within the household. A consent process was then administered to both parent/guardian and adolescent girl. Interviews were mainly conducted at home, at school or in other

locations that were deemed to offer privacy and confidentiality of the interview process.

Quantitative data was collected on key sociodemographic indicators, as well as sexual behavior, asset ownership, contraceptive use, causes of adolescent pregnancy, community practices that encourage adolescent pregnancy, Knowledge, attitudes and perceptions of adolescent pregnancy and strategies that can be employed to reduce adolescent pregnancy using a structured paper questionnaire.

Data collection was conducted using paperbased questionnaires. Data validation checks and skip logics that decreased human error in data entry were incorporated. Secondly, survey supervisors conducted spot check verifications of the enumerators’ data collection. The Data Analyst checked for duplicate entries in the data entered as well as outliers. Field supervisors were responsible for quality assurance measures, data management and frequent coordination with Akili dada project staff during fieldwork.

This report will analyze data from 377 girls from the ten targeted counties and carry out bivariate and multivariate analysis to understand the association between various background factors and adolescent pregnancy. interviews with adolescent girls, informed consent was obtained from their parents/guardians and from assent obtained from the girls.

Qualitative Methods

Qualitative data was collected with purposively selected key stakeholders to provide a more in-depth understanding of the causes, consequences, knowledge, attitudes, perceptions of adolescent pregnancy and contextual strategies of reducing adolescent pregnancy. Interview guides were developed and touched on a set of cross-cutting domains. Following the identification of participants, the trained enumerators obtained informed consent and conducted the KIIs and FGDs in the household or other public spaces that still allowed for adequate visual and auditory privacy, such as community halls, churches, and schools. For

Focus group discussions (FGDs) were conducted with adolescent girls aged 13-19 years. Each FGD consisted of 8-12 participants. Key informant interviews were conducted targeting gender officers, education officers, school heads, sub county and ward administrators and chiefs. Table 1 provides thematic domains of the interviews including the number of participants interviewed.

Table 1. Number of In-Depth Interviews (IDIs) and Focus Group Discussions (FGDs) Conducted by Site and Respondent Type Respondent Type Gender Officers

KIIs Bomet

Bungoma

Busia

Homa Bay

Kisii

Kisumu

Kwale

Meru

Narok

Siaya

Education Officers School Heads (HM/DH) Sub-County Administrators Ward administrators Chiefs/Village Heads Births Registrations Officers Total Number of Respondents

1 3 0 0 2 1

1 6 1 0 3 1

0 5 0 0 2 1

1 7 1 0 2 1

1 4 0 0 1 0

0 7 1 0 3 1

1 3 0 0 1 0

0 3 0 0 2 0

0 3 0 0 5 1

1 6 1 0 2 1

Adolescent Girls

FGDs

2.3 Assessment Limitations A summary of the assessment limitations is presented in the table below:

Response Rates A total of 394 adolescent girls were sampled from the ten targeted counties. This included a 5% non-response rate. Of these 377 adolescent girls aged 13-19 years were successfully interviewed (96%). The major reason given for non- response was refusal by parent/guardian. Sample Size The target population for this assessment consists of adolescent girls aged 13-19 years residing in the ten targeted counties. This assessment was designed to get point estimates for the key indicators listed in Table 2 with 95% confidence interval and 5% margin error. Based on the sample size calculation the recommended minimum sample size of 384 was required for this participant-based assessment

1. Ethical Review: This assessment was considered an internal preliminary activity to enable the conduct of larger, more definitive studies and will provide information that is valuable in local contexts. Ethical approval from the Review Board was therefore not sought. Albeit informed consent was administered prior to participation and ethical considerations were applied to ensure the risks were minimized and participants were protected from any harm. The assessment findings may therefore not be published in peer reviewed journals. 2. Random Selection of participantsPurposive sampling was conducted. Assessment findings are aligned only to objectives of the assignment and not generalized to represent similar context in Kenya 3.Sample size Power- Small sample size used. Assessment findings aligned only to

objectives of the assignment and not generalized to represent similar context in Kenya.

2.4 Data Analysis Quantitative Analysis The quantitative data was analyzed using Stata version 14. Demographical and behavioral data were described. Key

Adolescent Sexual Reproductive Health indicators on adolescent pregnancy and custom indicators informed by the local operating context in Kenya were developed to inform the analysis. For categorical variables, significance tests comparing younger girls and older girls were estimated using Pearson’s Chi Square. For continuous variables, linear regression models were estimated using options for obtaining robust standard errors in the dataset.

Table 2. Assessment Indicators Indicator

Source

Causes of Adolescent Pregnancy Age at First Sexual Intercourse: Percent of adolescents who have had sexual intercourse Sex Education: Percentage of adolescents who acknowledge there is enough sex education offered in schools/ Percentage of adolescents acknowledging lack of sex education contributes to adolescent pregnancy Socioeconomic characteristics: Level of education for the adolescents /Level of Paternal Education/Level of Maternal Education/Employment Status of Mother/Employment Status of Father/Asset ownership Relationship Status: Percentage of adolescents in a relationship with a boyfriend Community Practice that encourage to Adolescent pregnancies: Percentage of community practices that encourages adolescent pregnancy Effects of Adolescent Pregnancy Stigma:

Questions on age of first sexual encounter deused to calculate percentages of adolescents who had ever had sex and age of first sex presented. Questions on Sex education used to calculate percentages on number acknowledging there is enough/lack of sex education in school Questions on socioeconomic characteristics used to answer related socioeconomic characteristics

Questions on Relationship status used Questions on community practices encouraging adolescent pregnancy

Questions on “Do pregnant adolescents suffer stigma and isolation?” used

Percentage of pregnant adolescent suffer stigma and isolation Effects of adolescent pregnancy Strategies to Reduce Adolescent Pregnancy Government: Government measures taken to address adolescent pregnancies

The Akili dada internal assessment used the answers to the questions on “Government measures taken to address adolescent pregnancy?”

NGOs: NGOs measures taken to address adolescent pregnancies

The Akili dada internal assessment used the answers to the questions on “NGOs measures taken to address adolescent pregnancy?”

Adolescents Perception: Adolescent Perception on measures to be taken to address adolescent pregnancies

The Akili dada internal assessment used the answers to the questions on “What should be done to address adolescent pregnancy?”

Qualitative Analysis The KIIs and FGD interviews were audiorecorded with participant permission and transcribed by two research assistants trained in qualitative research methods. All transcripts were coded for emerging themes by a trained research assistant using NVIVO software. These preliminary themes were then reviewed by the second research assistant. The team then triangulated collated interview themes from the transcripts, and these were then categorized into core themes. After all transcripts had been coded, output for all relevant codes were generated and used for analysis and the write-up of the report. Word-for-word quotations are presented to illustrate the key issues and themes that emerged. For all relevant codes were generated and used for analysis and the write-up of the report. Word-for-word quotations are presented to illustrate the key issues and themes that emerged.

2.5 Ethical Considerations The training of the enumerators was arranged but the protocol was not reviewed by ethics review board. The assessment team ensured that all evaluation activities were conducted in the best interest of the beneficiaries involved and the do-no-harm principles and ensure that they are safeguarded in all the assessment activities, including data collection, data analysis, report writing and dissemination. During the data collection process, the assessment team upheld the integrity of the process including fidelity to the tools, rights of the beneficiaries to participate including voluntary participation, informed consent from the respondents, confidentiality of the respondents; anonymity will be a high priority and all materials in the evaluation process will solely remain the property of the project.

3.0 ASSESSMENT FINDINGS This chapter presents empirical data and an analysis of the responses derived from a cross-sectional assessment conducted to determine factors contributing to teenage pregnancy in selected ten counties in Kenya with high adolescent pregnancy rates and includes a presentation of the qualitative findings obtained from different stakeholders including adolescent girls. The analysis describes characteristics of adolescents aged 13-19 based on a sample of 377 respondents in the ten targeted counties for this assessment. The results section begins with a description of the sociodemographic characteristics of respondents and their households, followed by results on sexual behavior, child marriage and contraceptive use, the contextual factors contributing to adolescent pregnancy, existing interventions and strategies to prevent teenage pregnancy and program and policy recommendations regarding reduction of adolescent pregnancy in Kenya.

3.1 Characteristics of Respondents and Households A total of 377 adolescent girls aged 13-19 year were interviewed. 45% of the participants were between 13-15, 31% were 16-17 and 24% were 18-19 years old. Majority of participants (46%) were residing in urban areas. About 60% were living with both parents while 24% were living with one parent. Those who did not live with their parent(s) lived with another adult relative (9%), other adult non-relative (3%) or partner (4%). Capturing parental presence in the lives of adolescents is important, as living with a parent affects young people’s behavior such as initiation of sexual intercourse, and the antecedent consequences, such as unintended pregnancy. Table 3: Percent distribution of girls aged 13–19, by selected background characteristics County Bomet Bungoma

(N)

(%)

32 46

8.49 12.20

Age 13-15 16-17

(N)

(%)

170 118

45.09 31.30

Busia Homa -Bay Kisii Kisumu Kwale Meru Narok Siaya Total Residence Urban Rural Peri Urban No Response Total

39 42 39 43 22 41 41 32 377

10.34 11.14 10.34 11.41 5.84 10.88 10.88 8.49 100.00

175 88 108 6 377

46.42 23.34 28.65 1.59 100.00

3.1.1 Participants’ Education

Table 4: Percent distribution of girls aged 13– 19, by selected background characteristics In school

(N)

(%)

Yes

334

88. 59

Total

377

No education Primary grade 1-5 Primary grade 6-8 secondary Form 1-2 Secondary form 3-4 Technical/Vocational college Total

6 27 124 108 85 27 377

89 377

23.61 100.00

Lives With Parent(one) Both Parents Adult relative Adult non-relative Partner Total

92 227 33 10 15 377

24.40 60.21 8.75 2.65 3.98 100.00

3.1.2 Parental Education

Based on the assessment, about 89% of the adolescents reported that they were still attending school. 51% of the respondents had at least attained some secondary school education. About 2% had no education.

Level of Education

18-19 Total

11. 41 100

1.59 7.16 32.89 28.65 22.55 7.16 100

Findings showed that 22% of fathers had no education, 33% had attained some secondary school education and about 28% had attained some college/university level education. Mothers tended to report slightly higher educational attainment compared with fathers.13% of mothers had no education, 37% had attained some secondary school education and about 23% had attained some college/university level education.

Figure 3: Maternal Education Attainment

Figure 4: Parental educational attainment

Parental educational attainment is critical in determining children’s educational attainment, especially years of schooling. Similarly, parental socioeconomic status (SES) may not only impact the health of the parent themselves but also the health outcomes of their children. This association is partly explained by the fact that educated parents tend to have better health knowledge and are more likely to practice better health behaviors. Studies in Kenya have established that 33% of the girls aged 15-19 years that get pregnant have no education,19% with incomplete primary education while 36% have incomplete secondary education. This implies that with limited access to education, the burden of adolescent pregnancy in Kenya might not reduce as expected. Kenya has created an enabling environment in education through ratifying most international treaties that protect the right to education, which form part of the country’s laws. The Constitution of Kenya, in Article 53 (1) (b) state that every child has a right to free and compulsory basic education and Article 55 (a) the State shall take measures, including affirmative action

programs, to ensure that the youth access relevant education and training. To give effect to the Constitution, the Basic Education Act (No 14 of 2013) has been passed into law to regulate the provision of basic education and adult education in the country. The Children’s Act also acknowledges and protects every child’s right to education. This set measures have enabled over the past few decades an increase in school enrollment, transition to secondary school and improved school completion rates. Yet, with all these policies in place, enforcement of the laws and policies is still wanting. Kenya has also ratified guidelines for reentry policy in case of teenage pregnancy which provides clear guidelines to be followed to ensure teenagers access to education in case of pregnancy. 3.1.3 Parental Employment Several studies have indicated that the Socioeconomic status (SES) of parents impacts the health outcomes of their children. This association is partly explained by the fact that educated parents tend to have better health knowledge and are more likely to practice better health behaviors. The findings indicate that about 17% of the mothers were employed and 48% were selfemployed. About 22% of the fathers were unemployed while 59% of them were either selfemployed or employed. Majority of both fathers and mothers who reported being selfemployed were mainly businessmen/women and farmers.

3.1.4 Ownership of Goods Approximately 62% of the households had a television while 32% of the respondents owned a mobile phone. 27% reported that they have access to the internet either through a phone or computer and 74% watch television at least once or twice per week. Ownership of these items and access to media through internet or television is higher in urban areas than in rural areas.

3.2 Sexual Behavior, Contraceptive and Childbearing 3.2.1 Sexual Debut Sexual activity pre-disposes teenagers to risks such as unintended pregnancy and sexually transmitted infections. About 34% of adolescents were sexually experienced. Older adolescents were more likely to have engaged in sexual intercourse than younger adolescents (13-15 years). The percentage of adolescents who had engaged in sexual intercourse was higher among those with secondary education than those with primary or a lower level of education, though this might be in part a UHÀHFWLRQ RI WKH IDFW WKDW the youngest age group mainly had a primary level of education. The findings also showed that adolescents who were still in school were less likely to have engaged in sex than their counterparts who were not in school.

Table 5: Percentage of adolescents who have ever had sex, by socio-demographic characteristics %

In school

Age group 13-15 16-17 18-19 Total Education Level

18.7 35.2 46.1 100

24 45 59 128

No Education Primary grade 1-5

0.8 7.8

1 10

No Yes Total

N 25.8 74.2 100

33 95 128

17.2 55.5

22 71

Lives With One Parent Both Parents

Primary grade 6-8

22.6

secondary Form 1-2 Secondary form 3-4 Technical/Vocational Total Marital Status

25 29 14.8 100

32 37 19 128

Married Single Divorced Total

10.2 86.8 3 100

13 111 4 128

3.2.2 Early Marriage and Childbearing Marriage and childbearing rates were low. About 6% (21) of the respondents reported ever being married and 10% (39) had ever given birth. The rate of adolescent pregnancy was slightly higher in Kisii with 2% of the respondents reporting ever giving birth. Early marriage was slightly higher in Siaya with 2% of girls having ever been married. Majority of the respondents who have given birth are between ages 18-19. The findings further demonstrated a relationship between age at first sexual encounter debut and ever giving birth which aligns to the proximate determinants of fertility studies that have age at sexual debut as one of the determinants of early pregnancy 16. The assessment findings established there is a relationship between adolescents giving birth and living with parents. Further, the findings showed there was a relationship (1) UNICEF. Ending child marriage: Progress and prospects. New York: UNICEF, 2013

Adult Relative Adult Nonrelative Partner Total

between adolescents education status.

10.1

6.2 11 100

8 14 128

giving

birth

and

3.2.3 Contraceptive Use The assessment findings demonstrate that 15% of the respondents have ever used contraceptives. Condoms (34%), oral contraceptives (22%) and injectable (20%) were the most used contraceptives by the adolescents. A significant relationship exists between contraceptive use, age, sibling teenage pregnancy, ever given birth, who the adolescent lives with and if they have a boyfriend. Unmet need and demand for family planning among young women is one of the leading contributors for adolescent and young women pregnancy which validates the proximate factors of fertility in Kenya. Adolescents find themselves with unwanted pregnancy and some opt to seek for abortion

services from untrained healthcare workers which is prohibited according to Article 26(4) which provides that ‘abortion is not permitted unless, in the opinion of a trained health professional, there is need for emergency treatment, or the life and health of the mother is in danger.(put constitution ref here) Unsafe abortion is one of the key contributors of Adolescent (10-19 years) Maternal Deaths in Kenya.

Health data has demonstrated there is increase in uptake of Post Abortion Care services amongst adolescents yet there is unmet need of family planning services. Moreover, one of the main drivers of adolescent mortality is unsafe abortion as a result of unwanted pregnancy hence the state and non-state actors should review policies and programs in the country and in the targeted counties to address the teenage pregnancy burden.

Table 6: Percent distribution of young people age 13-19 years by contraceptive use and other characteristics (N)

Ever used contraceptives? No 319 Yes 58 Total

377

Contraceptive Methods Used Condom 20 Emergency Contraceptive 5 Implants 4 Injectables 12 Oral Contraceptives 13 No response 4 Total

(%) 84.62 15.38 100 34.48 8.62 6.9 20.69 22.41 6.9 100

(N) (%) Contraceptive use by age 13-15 4 6.90 16-17 21 36.21 18-19 33 56.90 Total 58 100 Contraceptive use by education level No education 2 3.45 2 3.45 Primary grade 1-5 Primary grade 6-8 6 10.34 secondary Form 1-2 22 37.93 Secondary form 3-4 16 27.59 Technical/Vocational 10 17.24 Total

Table 7: Multilevel analysis of the association between contraceptive use and other factors contraceptives age Education level

0.056 (2.08)* 0.019

100

Residence Sibling teenage pregnancy Ever given birth Has a boyfriend Lives with _cons R2 N *significant at p<0.05 **significant at p<0.01

(1.04) 0.000 (0.01) 0.095 (2.20)* 0.207 (3.64)** 0.202 (5.75)** 0.095 (5.20)** -0.324 (4.82)** 0.33 377

3.3 Contextual Causes and Consequences of Adolescent Pregnancy 3.3.1 Lack of Comprehensive Sexual Education Comprehensive sexual education is key in ensuring that adolescents have healthy sexual and reproductive lives. Despite the signed declaration to promote scaling up of comprehensive rights-based sexuality education beginning in primary schools by the Kenyan government in 2013 17and the existence of various advocacy and lobby measures on sex education in schools, the findings demonstrate that 45% of the adolescents reported that the sex education received at school is not adequate. Further, 46% of adolescents who cited sex education received at school is not adequate would like more teachers to teach adolescents about sex and provide comprehensive sexual education.

No Yes Total

Do Cultural taboos inhibit discussion on sexuality and sex education

No Yes Total

The findings also demonstrated that 41% of the respondents believe that cultural taboos inhibit discussion on sexuality and sex education. This perhaps could be a key factor to consider in the design of sexual education programs. As indicated from the qualitative interviews: “there is need to open conversation at home and in school, between parents, guardians and teachers to fill the void that exist in sexual education among

Table 6: Sex education in schools

Is sex education, for teenagers received at school sufficient

risks of substance misuse and to combat all forms of discrimination and rights violations including child marriage. They have also been shown to improve knowledge and selfconfidence and self-esteem and increase contraceptive use among sexually active adolescents.

teenagers.” (School Teacher, Busia)

(N)

(%)

172 205 377

45.62 54.38 100.00

223 154 377

59.15 40.85 100.00

“It is a taboo for parents to engage with adolescents in sexual related advice and talks. This therefore makes it difficult to learn and get advice that could be useful in navigating the challenging and pressured environment of teenage pregnancies” (Adolescent girl, Narok)

Comprehensive sexual education programs encourage effective strategies to educate and protect all children, adolescents and young people, including those living with disabilities, from early and unintended pregnancy, unsafe abortion, sexually transmitted infections (STIs) including HIV,

Sex education should ideally start at home but because of barriers created by different cultures including cultural taboos that prohibit matters of sex from being discussed with

Ministerial Commitment on comprehensive sexuality education and sexual and reproductive

health services for adolescents and young people in Eastern and Southern Africa,

parents, this subject is rarely discussed at home. When adolescents’ bodies start to experience changes at puberty, they require quality teaching and education about sex and sexuality to help them navigate relationships and manage their health. Comprehensive sex education can contribute to reduction in adolescent pregnancy and STIs, this is one of the core reasons why Akili Dada is working towards developing a comprehensive sexual education toolkit to strengthen the capacities of various CSOs and community led organizations in the targeted counties to contribute towards reduction of adolescent pregnancy. Though the toolkit will be developed, and institutions capacities strengthened, more community awareness and sensitization has to be deliberately made to create an enabling environment for formal and informal institutions both in communities and at schools to be able to effectively use the towards preventing adolescent pregnancy. 3.3.2 Lack of Parental Guidance and Counselling Almost (42%) of the adolescents interviewed cited parents were to blame for adolescent pregnancy. Source of information on sexual reproductive health is one of the key interventions used to address adolescent. The FGDs conducted amongst adolescent girls was able to contextualize the parenting issues that contributed to adolescent pregnancy as shown below: “Most parents do not teach and advice their children on issues to do with sexual and reproductive health. They let this role outsiders who might not teach the children the correct information” (FGD, Busia)

“There is lack of parental guidance and care since most of time we see our parents doing prostitution business with truck drivers to go and look for money, therefore, I would not take any advice from her” (FGD, Busia)

The Family provides an environment where adolescents learn norms and values that allow them to fit within the society. Where there is a deviation from any of these, they are corrected by their parents who also serve as role models that the adolescents would want to emulate. Within the family, adolescents are supported with the resources they need as they grow. Absence of parents and family dysfunctions and situations in which these roles are not well performed have a direct bearing on adolescent sexuality. 3.3.3 Cultural Practices The assessment looked at whether there were any social and cultural beliefs, attitudes and practices that escalates teenage pregnancies in the counties. In some counties, there were no major notable cultural practices that were cited to be directly linked to the teenage pregnancies. The quantitative results however indicate that about 45% of the respondents acknowledge that community practices encourage adolescent pregnancies. Some of the cultural practices cited include the practice of Female Genital Mutilation, Early Marriage, and ‘Moranism’.

Female Genital Mutilation “The practice of FGM which occurs to girls between age 10 and 14 among the communities in Bomet and Narok County, it is believed that once a girl has been initiated through FGM “chondoni”, then they are adults hence free to get married as well as have children. It is further believed that it is not a taboo for circumcised girl to get pregnant” (FGD, Bomet)

Early Marriage “Our parents marry us off at a tender age in exchange for wealth and even encourage us to get married because they cannot afford to educate us as they view girl child education as waste of resources and of no material value” (Adolescent Girl, Bomet)

“Moranism” “Moranism is where groups of the same age (around 14-19 years of age) are initiated (circumcised) into adult life during an open-initiation period. During this life stage they live in isolation in the bush, learning tribal customs. They roam around the whole Masai land and are allowed to get into homesteads, and they cause havoc as they do this. They are known to rape girls that they meet during these escapades” (Child protection officer, Narok)

Other associated community and cultural practices that were mentioned in most sites for contributing to teenage pregnancies include “disco matangas” which basically means funeral dancing night parties and other kinds of night parties. In Kwale County, it was revealed that “disco matangas” and wedding dances were a big thing for the teenagers and is a high contributor to teenagers having unprotected sex”. (FGD, Kwale) One of the Chiefs in Bomet county indicated that the directive from the National Government to ban “disco matanga” in the villages has not borne fruit as “they are done illegally and are well attended by teenagers where all evil things happen”. Similarly, in Kisumu, Homabay, Busia and Siaya, it was evident that “disco matanga” was well rated among the teenagers as an environment where promiscuous behavior like unprotected sex happens among teenagers and hence teenage pregnancies. Church ‘Kesha’ is also a main source of teenage pregnancies in Narok County. “Most teens go for the night prayers and unfortunately, a big number of them engage in other activities that would later lead to teen age pregnancies. Most community leaders have therefore banned these night church prayers as they were being misused by the teenagers. Morans also take advantage of these church keshas to attack the girls and defile them”. (FGD, Narok)

Harmful cultural practices are key drivers for adolescent pregnancy in the hotspot counties. The State, Non-state actors and key influencers in communities need to sensitize the communities against these practices. Parents and guardians need to shun these harmful community practices and ensure adolescents access the health-related human rights including sexual reproductive health.

3.3.4 Poverty and Lack of Economic Influence Poverty among families and communities was cited to be a grave factor in contributing to teenage pregnancies in all the counties. More than half of the respondents (67%) stated that lack of alternative sources of livelihoods contribute to adolescent pregnancy while (20%) of the adolescents attributed poverty to be a leading contributor to adolescent pregnancy. From the qualitative findings, it was noted that poverty level has major impact in teenage pregnancies as the families struggle to put food on the table. “Poverty has played a big role in teenage pregnancies in Bomet County. When the parents are poor and unable to pay school fees for their children, especially girls, they stay out of school doing nothing and eventually go get married” (Children’s officer, Bomet) “There is a lot of poverty in Kisii County. This poverty causes desperation on many teenage girls pushing them to having sexual relations in order to provide for their needs”. (FGD, Kisii)

3.3.5 Sexual Violence The qualitative findings revealed that rape has contributed to adolescent pregnancies. Specifically, in Kisumu and Homabay Counties, it was indicated that rape cases were rampant along sugar belts in Muhoroni and Rodi Kopany respectively which aids teenagers to be raped since they are vast with sugarcane plantation and are lonely. In Busia county, there exists a considerably high number of defilement cases that also contribute to adolescent pregnancies. FGD discussions reliably revealed that the perpetrators are most of the time well known by the community members but they either pay the victims’ family or threaten them, so that the cases somehow end without them being apprehended. 3.3.6 Drug and Substance abuse The findings showed that drug abuse among the adolescents led them to make irrational decisions which contribute to adolescent pregnancies. The health risk behaviors of substance use and adolescent pregnancy and childbearing appear to be linked; hence awareness creation should be deliberately targeted to teenagers to avert risk of teenage pregnancy. 3.3.7 Peer Influence The findings showed that 22% of the adolescents cited peer pressure as a cause of adolescent pregnancy. One of the many challenges of being a teenager aside from significant physical changes is peer influence.

Peer influence was cited as one of the major causes of teenage pregnancies. In most FGDs, teenagers indicated that they were adequately influenced by their peers in terms of how well they live and get support from their boyfriends. The teenagers indicated that they are driven further to have multiple partners to outdo one another and have greater influence in economic resources from men. “The desire to live well in the society has also accelerated the teenagers to get lured and get unwanted pregnancies. Influence from the older girls who have boyfriends making it look fashionable or ‘Cool’ to have a boyfriend. This is highly likely to end up in teenage pregnancies”. (Adolescent Girl, Siaya)

Peer pressure also results from the young girls who get married after getting pregnant. Many of the teenage girls reported that girls who get pregnant are most of the time married off and start their families so at that point, it looks fashionable and some of the young schoolgirls see them as achievers. It is important to make adolescents aware of the importance of choosing the right person to be with. Peer pressure is one of the main reasons of teenage pregnancy, and parents, guardians and community, should provide them with comprehensive sexuality education so that they are skilled to navigate through adolescence.

Table 7: Causes of teenage pregnancy What do you think are the causes of teenage pregnancy in this county? Cultural Practices Drug and Substance Abuse Early Marriage Early Sexual Debut Female Genital Mutilation Gender Discrimination HIV/AIDS and STIs Idleness Lack of Guidance and Counselling Lack of comprehensive sexuality education Lack of self-control and self esteem

(N) 18 31 10 7 4 1 1 2 17 50 3

(%) 4.77 8.22 2.65 1.86 1.06 0.27 0.27 0.53 4.51 13.26 0.8

Non contraceptive use Other Parental Neglect Peer Pressure Poverty School Drop Out Sexual Violence Social media Influence Stress and Depression No Response Don’t Know Total

(N) 4 2 3 85 77 15 10 4 1 7 25 377

(%) 1.06 0.53 0.8 22.55 20.42 3.98 2.65 1.06 0.27 1.86 6.63 100

3.4 Risks and Consequences of adolescent Pregnancy Some of the main risks and consequences of teenage pregnancy as highlighted by the respondents included school dropout, poverty, early marriage, HIV/AIDS and STIs, abortion, death and related childbirth complications. Table 8: Risks and consequences of teenage pregnancies What are some of the risks/consequences of Teenage Pregnancy (N) (%)

Abortion Can lead to poor childcare Causes Low self esteem Childbirth Complications Death Drug and Substance Abuse Early Marriage Early Pregnancy HIV/AIDS and STIs Negative Health Consequences

20 4 1 10 61 1 13 4 32 4

6.71 1.34 0.34 3.36 20.47 0.34 4.36 1.34 10.74 1.34

Parental Neglect Peer Pressure Poverty School Drop Out Stigma and Discrimination Stress and Depression No response Other Total

(N)

4 1 15 82 6 3 2 35

298

(%)

1.34 0.34 5.03 27.52 2.01 1.01 0.67 11.74 100

Most of the risks and consequences identified in the quantitative data were also echoed through the qualitative interviews. Discussions from the qualitative interviews for example suggested that girl’s education is not highly regarded in most of the assessment areas. Therefore this translates into school dropouts especially for pregnant adolescents. From the quantitative data many of the respondents (63%) reported that pregnant teenagers and adolescent mothers face stigma and discrimination. They are rejected by both their family and community and are viewed as immoral and regarded as bad influence on their peers. The excerpts below indicate some of the risks and consequences of teenage pregnancy that were highlighted from the qualitative discussions. “In some parts of Bomet particularly areas around Chepalungu, there is high dropout rate of girls from school to get married”. (FGD, Bomet) “Most of the parents would marry off their adolescent girls at early age since they believe that educating girls has no material value”. (FGD, Narok) “The society has a different view of teenagers who have gotten pregnant making them feel ashamed and stigmatized. After giving birth, it is very shameful and late to get back to school after pregnancy, therefore, we would opt for early marriage and abandon school altogether”. (Adolescent Girl, Siaya) “Young poor and vulnerable girls are lured into sex by the fishermen and they do not have a choice but to give in. this is unfortunately giving rise to teenage pregnancies as well as fueling the HIV and STD cases in the County”(FGD, HomaBay)

3.5 Strategies to reduce Teenage Pregnancy 3.5.1 Adolescent perception on averting teenage pregnancy More than half (54%) of the adolescents cited awareness creation and provision of comprehensive sexual education as a key intervention to avert adolescent pregnancies in their respective counties. Other aspects mentioned regarding teenage aversion are highlighted in the table below. Table 9: Adolescents perception to avert adolescent pregnancies What do you think can be done to avert teenage pregnancies in this county? (N) (%) Abolish harmful Cultural practices 3 0.8 Create Guidance and Counselling programs 43 11.41 Create awareness and provide comprehensive sexual education 203 53.85 Don't Know/No response 59 15.65 Employ more Counselors, teachers and peer educators 2 0.53 Enforce implementation of existing relevant policies 8 2.12 Enhance accessibility, acceptability and availability of contraceptives 15 3.98 Ensure there is access to justice 7 1.86 Fight drug and substance abuse 1 0.27 Girl child empowerment 1 0.27 Other 4 1.06 Promote girl child education 21 5.57 Provide financial support to girls 8 2.12 Provide sanitary towels 2 0.53 Total

377

100

From the FGDs, the adolescents emphasized that the Government should take leadership in creating awareness and offering comprehensive sexuality education through schools beginning from grade 5 in primary school. They should also sensitize the community on existing laws against certain practices such as FGM and other relevant policies, enforce implementation of the school re-entry policy and encourage make sure that girls are maintained in schools even after giving birth, encourage use of contraceptives, abolish cultural practices that promote teenage pregnancies including night vigils like “disco matangas”, create measures or a toll-free line to report those who impregnate teenagers; prosecute those who make teenage girls pregnant, avail job opportunities for teenagers to avoid idleness, ban some programs on TV that might influence teenager’s promiscuous behavior, collaborate with NGOs to assist teenagers by providing free education, and creating unskilled job opportunities, come up with scholarship and empowerment programs for teenage girls and provide sanitary pads and other necessities so that they remain in school.

3.5.2 State and Non-State actors’ interventions targeted at reducing adolescent pregnancies About 16% of the adolescents mentioned that Non-Governmental Organizations (NGOs) are creating awareness and provide sexual education towards reducing adolescent pregnancies. During the FGDs and KIIs it was noted that there is distribution of sanitary towels by well-wishers, community aid organizations and schools. There are also girl child education programs, sensitization and trainings geared towards abstinence, safe sex and use of family planning. Some communities work towards eradication of poverty through creation of economic empowerment programs like saving and starting businesses. Guidance and counselling for teenage girls is carried out in some counties. There is involvement and corporation with other non-governmental entities to provide support. Most communities are also working closely with the police, children officers and judicial officers in ensuring that all cases of teenage pregnancies resulting from rape, defilement or child marriage are reported adequately and handled appropriately. Despite the many interventions happening on the ground geared towards reducing teenage pregnancies, several existing gaps were identified from the assessment. These included lack of adequate financial resources to effectively implement comprehensive sexuality education programs, loose

implementation of policies including arresting perpetrators of sexual violence, school re-entry for pregnant adolescents, shortage of peer educators and other personnel who can create awareness, lack of goodwill from parents to support abolishment of harmful traditional practices, corruption at the county level where government officials including child officers, the police, parents conspire to subvert justice for teenage girls, embezzlement of funds allocated for sexual and reproductive health programs, lack of clear strategy and communication between channels of addressing injustices to teenage girls due to lack of education, training and sensitization about teenage pregnancies and related causes in the society. There is also a total neglect for boy child would still be the ultimate cause of teenage pregnancies. Other factors emanating from the qualitative discussions included the lack of safe spaces for teenage girls to seek advice and information as well as guidance and counselling. Both the teachers and the parents are not approachable and the teachers who are approachable do not maintain confidentiality so the girls do not have anyone or anywhere to turn to should they have questions or issues to discuss. Community interventions fail to sensitize community members on existing law criminalizing cultural practices that enable teenage pregnancies as well as laws criminalizing sexual abuse.

Table 10 gives a summary of agencies engaged in reducing teenage pregnancies in the ten counties County Homabay

Kisumu

Intervening Agency in Teenage Pregnancy a. Plan International b.

CRS

World Vision

CARITAS

ICS

b. Catholic Relief Services (CRS) c. T-safe

County Siaya

Meru Bomet

Intervening Agency in Teenage Pregnancy a. Impact

County Kwale

Intervening Agency in Teenage Pregnancy a. Haki yetu

Dream girl

Kesho Kenya

Plan International

Child Society

Plan International

World Vision

Ripples

Impact

SoS

World vision

ACT childrens Home

Jerusha Mwiraria

Narok

World vision

Bungoma

Plan International

Pamoja

Arrow Children

Plan International

IAHA

Dream Girls

e. KCCB-Kenya Catholic Bishop Conference

Kisii

4.0 Key Findings and Recommendations This chapter synthesizes the empirical data and analysis presented in the previous chapter with findings made by other researchers on similar studies as covered in the literature review chapter. Based on the discussions of the findings, the chapter attempts to make a general evaluation of the assessment followed by a conclusion on the key factors contributing to teenage pregnancy in the ten targeted counties. Further recommendations on what needs to be done in addressing adolescent pregnancy are also presented in this chapter. 4.1 Discussion This study explored the contextual factors contributing to teenage pregnancies in ten counties with high adolescent pregnancy rates, the consequences of teenage pregnancy and strategies of reducing teenage pregnancy in these counties. The assessment findings indicate that about 34% of adolescents were sexually experienced. Older adolescents (16-19) were more likely to have engaged in sexual intercourse than younger adolescents (13-15 years). Early sexual encounters was also

identified in the assessment as one of the factors that contribute to early teenage pregnancy. Similar studies have found that early sexual encounter is a significant predictor of adolescent pregnancy, contraceptive nonuse and HIV infection 21-22. The percentage of adolescents who had engaged in sexual intercourse was higher among those with secondary education than those with primary or a lower level of education, though this might be in part a UHÀHFWLRQ RI WKH IDFW WKDW WKH \RXQJHVW DJH group mainly had a primary level of education. The Findings also showed that adolescents who were still in school were less

likely to have engaged in sex than their counterparts who were not in school. This is consistent with findings of previous studies from developing and developed countries that have shown higher education is a protective factor against early and unintended pregnancies 23-25 The study has further shown that contraception utilization increases with age. The findings are in harmony with the KDHS 2014 results that contraception increases with age for any method. Contraceptive access for teenagers however remains a challenge. Although the government has trained Community Health Workers and provided Family Planning commodities like pills and condoms, teenagers have been left out and are not well targeted. Perhaps this could be a form of restriction like the one found in other countries where providers were most likely to set minimum age restrictions for certain contraceptives (Sidze, 2014). Various risk factors have been distinguished in the assessment that exposes teenagers to vulnerability that predispose them to early pregnancy. No significant differences between the different counties were observed for most of the indicators. Some contextual factors contributing to adolescent pregnancy were however realized in some of the counties. These included factors the practice of early marriage, Moranism and FGM in some communities like Narok and Bomet, Community practices like “Disco Matanga” in Kwale and Bungoma counties. The qualitative component enabled gaining a better understanding of these factors.

Many of the respondents indicated that peer pressure is a key factor that influences teenage pregnancy. Drug and substance abuse were also mentioned as a contributing factor to teenage pregnancy. These echoes other findings in the country and world. For instance, in investigating patterns and determinants of entry into motherhood in two informal settlements in Kenya, having negative models in peers were associated with early childbearing among females’ teenagers (ibid). Similar findings have been made in America where a friend ‘s childbearing increases an individual ‘s risk of becoming a parent (Balbo, 2014). 4.2 Conclusion and Recommendation More effective and contextualized interventions need to be implemented in order to reduce adolescent pregnancy or early motherhood in these ten counties. Intervention programs should focus on. Accelerated implementation of programs that create awareness on comprehensive sexuality education, promote enforcement of existing SRHR policies and take into consideration contextual community level factors that contribute to high adolescent pregnancies and early motherhood rates are required in order to provide positive impacts on adolescents sexual reproductive health. These findings provide a good platform for Akili dada to develop a clear toolkit for sexual reproductive health targeting teenagers. There is a need for further research into the extent to the kind of role that sexual and gender-based violence played in contributing to teenage fertility.

Adolescent Pregnancy

Articles inside

3.6 NGOs Intervention in reducing adolescent pregnancies

ACKNOWLEDGMENTS

3.1.3 Parental Employment

EXECUTIVE SUMMARY

2.3 Study Limitations and Challenges

3.3 Contextual Causes and Consequences of Adolescent Pregnancy

3.4 Risks and Consequences of adolescent Pregnancy

2.5 Ethical Considerations

3.3.1 Lack of Comprehensive Sexual Education