Introduction

Every year, approximately 21 million adolescents become pregnant in Low and Middle Income Countries (LMICs) [1]. In Sub-Saharan Africa (SSA), most adolescent pregnancies occur within the context of marriage driven by traditional practices, cultural norms and poverty or occur out of wedlock, and are often unintended [2]. A study conducted in Brazil revealed that suicidal behaviour is common in teenage pregnancies, with a prevalence rate of 13.3% and is associated with psychiatric disorders like anxiety and major depressive disorder [3]. Adolescent motherhood alone has far reaching negative effects to the progeny including elevated suicidal behaviour when the children reach early adulthood [4].

The transition from a ‘school girl’ to pregnancy state is not often a smooth process and may affect a woman’s mental wellbeing resulting in suicidal behaviour (considered the most common cause of death among female adolescents) [5]. The maternal mortality risk in adolescents has been rated at 28% higher than older women [5] with suicidal attempts risk as high as 20% [6]. Socio-economic and environmental factors occurring just before a suicide attempt influences an individual’s decision to end one’s life and a better understanding of these factors may protect against suicide or provide insights on prevention strategies during this period [7]. In the attempt to standardize and improve accuracy reporting of maternal deaths, the World Health Organization (WHO) recommended the description of all critical information prior to death and identification of suicide as a direct cause of maternal death (‘under other category’) in the WHO application of International Classification of Diseases (ICD-10) to deaths during pregnancy, childbirth and puerperium [8]. This data is critical in establishing the magnitude of the problem. To effectively address suicidal behavior in pregnant adolescent mothers, it is imperative to understand the risk and develop mitigation plans especially at the family and community level.

To our knowledge, there is no study in Kenya that has qualitatively explored the suicidal behavior risks for adolescent pregnant mothers (using multiple stakeholders’ views including adolescent pregnant mothers and both formal (health care workers) and informal health providers (traditional birth attendants). We aimed to investigate the suicidal behaviour risks of adolescent pregnant mothers. We believe that such a study would inform the development of suicidal risk reduction strategies with a focus on early detection at the community level. Additionally, implementation of the strategies would attenuate maternal and child health complications post birth. Most interventions designed for use in LMICs have addressed the need to reduce access to the means of suicide as a way of preventing future attempts. However, identifying the principal causes of suicidal behaviour or persistent distress could provide an opportunity for prevention of suicide among at-risk adolescent mothers. Kapungu and colleagues have also affirmed that the general scarcity of research among pregnant and out of school adolescents require immediate attention [9].

Methods

Theoretical approach (Fig 1)

This study was contextualized using the Social Ecological Model (SEM) [10] which perceives that human interaction with different social and ecological factors at different levels has influence on individuals experience and behavior. These levels include individual, interpersonal, community and societal interactions. Examples of the individual suicide risk factors include minority identity, socio demographic (e.g. gender), psychological issues like high impulsivity, agitation low self-esteem and hopelessness which should be a basis for suicidality risk assessment[11]. Feeling of being left out and sense of being a burden contributes to the suicidal tendencies [12] and thus interpersonal high risk factors include family violence or conflicts, social isolation and dysfunctional relationships. In a community where adolescent pregnancy is considered an aberrant behavior, this is detrimental to the mental wellbeing and could lead to suicidal behavior. Therefore, some identified risk factors at this level include community perceptions and tolerance of violence against adolescent mothers and barriers to access of community integrated health care, while societal risk factors include policy issues with negative implications, economic depression, poverty and stigma [13].

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Fig 1. An illustration of socio-ecological model highlighting suicide behaviour risks in adolescent mothers.

https://doi.org/10.1371/journal.pone.0236269.g001

Results

Out of the 21 adolescent mothers (age ranged from 15–19 years) interviewed during the discussions, none was employed, 60% were single, majority (60%) had attained primary school level education as the highest level of achievement while only four had completed secondary school education. More than 90% of care givers who turned up to participate in the study were mothers-in-law of the perinatal mothers. All the caregivers were unemployed and 88% had primary school as the highest level of education. For ethical reasons, it is important to note that there was no adolescent pregnancy resulting from rape.

After qualitative analysis, five main themes relating to suicidal behavior risks among adolescent mothers emerged as described by use of SEM framework. These were identified as chronic physical illnesses, intimate partner violence (IPV), family rejection, social isolation and stigma from the community and poverty. Respondents stated that exposure to extreme stressors such as IPV or rejection by the husband, mother-in-law or relatives, dropping out of school with resulting extreme financial needs increases the risk of suicidal behavior in adolescent mothers. Depressive symptoms related to the pregnancy journey and HIV diagnosis was also associated with suicidal ideation.

Discussion

This study explored the factors associated with suicidal behavior among adolescents in a low resource and rural setting. The greatest contributor to suicidal behaviour as explained by the study participants was IPV and lack of family support. Violence during pregnancy (estimated to be 38% among low-income adolescent mothers) has been associated with a heightened risk for suicidal behavior (resulting to about 55% pregnancy-related suicides) [16], mental illnesses, miscarriage, missed antenatal visits, still birth, fetal injury, premature labour and birth and low birth weight [17]. Furthermore, women who are abused have limited ability to make decisions hence lacking control over their reproductive and sexual health [18]. They are also likely to experience repeated unwanted pregnancies due to fear resulting to an increased rate of maternal mortality, adverse health outcomes during the postnatal period and intergenerational cycles of ill-health [19]. In SSA, violence may still persist even after the pregnancy period because of gender inequality and social acceptance of violence related to religious beliefs and patriarchal society. Since extant research has found this to be a precursor to suicidal ideas [17, 20–22], similar to the current findings, evaluating the effectiveness of interventions addressing norms and beliefs inherent in SSA may transform behaviour that support violence. A workshop that was held by the National Academy of Sciences, Engineering and Medicine [23] concluded that community-level norm change has a potential to minimize IPV in low-resource settings since these norms mediate violence and contribute to gender inequality.

Similarly, family conflict, rejection and lack of support has been considered as a trigger for suicidal behavior [24]. In this study, lack of family support was a common factor implicated in suicidal ideation and attempts among pregnant adolescent mothers. A combination of social and emotional development for adolescents, unplanned pregnancy and family rejection especially when their partners force them to get abortions or reject the child or mother-in-law’s lack of support for the adolescent during pregnancy or criticisms from peers results in social isolation, feelings of guilt and hopelessness. The end-result if these triggers are not addressed is suicidal ideas, attempts and untimely deaths associated with completed suicide during pregnancy. These findings corroborate evidence from other low income settings [25] and highlights a need for parent-adolescent communication interventions [26] in order to engender family and social support. This lack of social support is further heightened by poverty which was an integral theme in this study. It is therefore not surprising that all the adolescent mothers in this study were unemployed and dependent on their families or spouse for both social and economic support. Previous studies support the causal relationship between poverty and incidence of mental illness [27].

Often times, adolescent pregnancy is unplanned and affects students from impoverished backgrounds and there may be limited opportunities for employment after dropping out of school. This predisposes the adolescent mothers to a high risk of economic insecurity and thoughts of suicide emerge. In congruence with earlier research, low-socio-economic status, unemployment and poverty [28] have been linked to suicidal behaviors.

The presence of mental disorders particularly depression was also mentioned as a risk factor for suicidal behavior in pregnant adolescents. Other physical illnesses that were major contributors included HIV, complicated by poor health-care transition [29]. Earlier evidence has demonstrated that the presence of comorbid disorders during pregnancy is often intertwined with reproductive events [30] and this increases the risk among the adolescents. Due to limited resources for mental health services in low-income settings, access to timely appropriate evidence-based care is a challenge. However, demonstrating the effectiveness of integrated mental health care or using evidence-informed models for lay workers has been shown to produce significant results [31, 32] but still requires more research to fully scale-up interventions to where they are most needed.

Findings from this study have important implications for understanding the risks for suicide attributed adolescent maternal deaths, an area that has been given little attention. Suicide is a global public health issue among adolescents and the risks during pregnancy should be addressed to save the life of the mother, the unborn child and future generation. Furthermore, prevention strategies including monitoring for suicidal behavior risks during pregnancy in health care settings and using lay workers through dialogue discussions could duly reduce the risk of pregnancy-related suicide mortality in SSA.

Conclusion

We aimed to qualitatively investigate the suicidal behaviour risks of adolescents during the period of heightened vulnerability (pregnancy). Suicide is a rapidly growing public health concern for adolescents and the risk is higher among adolescent pregnant mothers. Therefore, our findings add to the current understanding of prevention and management of suicidal behavior among at-risk adolescent mothers in order to attenuate maternal and child health complications in Low and Middle-Income Countries (LMICs).

Our study identified that intimate partner violence, lack of family and community support, poverty and chronic physical illness increase the risk of suicidal behaviour in adolescent mothers. Therefore, the community should explore ways of addressing IPV, economic empowerment and access to youth friendly health care for chronic physical conditions in adolescent mothers. The intervention should target all the key players including parents and the male spouse. The issue of substance use disorder as a contributing factor to IPV should be addressed at the family and community level by use of integrated approaches which are inclusive. The strategies should include monitoring for substance use disorder by the male partner and signs of suicidal behavior risks by the pregnant adolescent. This should be implemented at the primary health care facilities and also by lay workers in the community.

Supporting information