Research design

This study used a focused ethnographic design to explore how adolescent mothers in Matiari, Sindh, Pakistan, experience the transition to motherhood and the mental health challenges associated with that transition. Focused ethnography is particularly suited to examining a specific issue within a clearly defined group and context, especially when the aim is to understand meanings, practices, and experiences related to a particular phenomenon rather than to describe an entire culture [15,16]. In the present study, the bounded phenomenon was adolescent motherhood in a rural Pakistani setting.

The study was informed by an Meleis’ Transition Theory and intersectional lens [17,18]. Transition theory was relevant because adolescent motherhood involves developmental, relational, social, and health-related transitions, including pregnancy, childbirth, caregiving, and maternal identity formation [18]. It was used to inform the broad areas of inquiry in the semi-structured interview guide. The intersectional lens guided attention to how participants’ experiences were shaped by the intersection of multiple social and structural forces. Analysis remained inductive and grounded in participants’ accounts; themes were developed through close reading, coding, and comparison of interview, observation, field note, and artifact data. Intersectionality was then used to interpret how overlapping identities and contexts shaped participants’ transition to motherhood. This study was conducted and reported with attention to the Consolidated Criteria for Reporting Qualitative Research (COREQ) checklist [19].

Study setting

The study was conducted in Matiari, predominantly a rural district in Sindh Province with a population of approximately 0.77 million [20]. Matiari is an agrarian area characterized by dispersed village settlements, limited transportation infrastructure, constrained access to formal health services, and gendered sociocultural norms that shape adolescent girls’ educational, marital, and reproductive trajectories.

The district includes three administrative sub-divisions (talukas): Hala, Matiari, and Saeedabad. Female literacy remains low at 30%, and early marriage is common, with approximately 24% of adolescent girls aged 15–19 reported as married [21]. The public health infrastructure in Matiari includes 7 Basic Health Units (BHUs), 3 Rural Health Centers (RHCs), 3 Mother and Child Health Centers (MCHCs), and one District Headquarter Hospital. RHCs and BHUs are mainly in rural areas, while hospitals and MCHCs are in urban centers. However, access to these services is constrained by limited transportation, gender norms restricting women’s mobility, and lack of adolescent-friendly care [22]. About 42% of births occur at home, with a significant proportion attended by Traditional Birth Attendants (TBAs) without formal medical training [23].

Participants and sampling

Twenty-five adolescent mothers were recruited through purposive and snowball sampling with the support of Lady Health Workers (LHWs), who provide maternal and child health services in rural communities and maintain pregnancy-related records at the community level. Participants were identified based on predefined criteria: women aged 15–19 at the time of pregnancy, currently residing in Matiari, married at the time of pregnancy (pregnancy outside marriage is highly stigmatized in this context and is rarely disclosed), and able to speak Urdu or Sindhi. Participants ages at the time of interview ranged from 18–25 years. There was no maximum age criterion at the time of interview because the study focused on experiences of adolescent transition to motherhood. Purposive sampling was used to recruit participants with direct experience of the phenomenon under study, while snowball sampling enabled the identification of additional eligible mothers through community networks. A member of the research team (Z.M), who worked in the community, introduced the lead researcher (A.H) to the local LHWs. The lead researcher then held multiple meetings with LHWs to discuss the research aims, objectives, recruitment procedures. LHWs were then invited to identify potentially eligible participants and served as the first point of contact. They introduced the study to eligible participants, and shared participants’ details with the lead researcher only after participants agreed. The lead researcher then confirmed eligibility and obtained informed consent directly from participants. To protect confidentiality and reduce perceived influence, LHWs were not present during interviews and did not have access to study data. Participants were recruited between October 2024 and May 2025.

Data collection

Data were collected through semi-structured in-depth interviews, observations, and artifact elicitation. The interview guide consisted of open-ended questions and follow-up prompts designed to elicit adolescents’ accounts of pregnancy, childbirth, early caregiving, family relationships, access to health care, emotional experiences, and changes in self-perception following motherhood. Lead questions were used consistently across interviews, while probes were adapted iteratively to explore issues raised by participants in greater depth and to clarify emerging patterns in the data. The interview guide was informed by focused ethnographic principles and sensitized by Meleis’ Transition Theory (refer to the supplementary file A). It included open-ended questions about participants’ experiences of change during pregnancy, childbirth, and motherhood; preparation for motherhood; changes in identity and relationships; sources of support; barriers to care; emotional responses; and strategies used to manage maternal responsibilities. The guide was developed in English, translated into Sindhi (local language), reviewed by the research team members familiar with local cultural context for relevance and clarity, and used flexibly, with probes adapted to participants’ responses. The guide was pilot tested with three adolescent mother, and minor revisions were made to improve wording, flow, and for cultural clarity. Pilot data were included in the final analysis.

The use of observations and artifact elicitation provided additional contextual and material insight into the everyday lived experience of motherhood and supported triangulation of findings across data sources. Observations were conducted in everyday community settings, including village streets, local bazaars, agricultural fields, and surrounding public spaces. Observations focused on caregiving practices, social interactions, mobility, fieldwork responsibilities, and the broader social and material conditions shaping everyday motherhood.. Artifacts, including baby clothing, feeding items, religious objects, and household materials, were treated as meaningful elements of maternal life and helped illuminate participants’ experiences of pregnancy, caregiving, emotional attachment, and motherhood.

Interviews (40–60 minutes) were conducted in person (n = 13) or via Zoom (n = 12), by the first author, a female doctoral researcher with training in qualitative methods and prior experience in maternal and community health research. Participants had no prior relationship with the interviewer before recruitment. Interviews were conducted in local language (Sindhi), audio-recorded, and transcribed in the original language. Transcripts were then translated into English. Translation was led by the primary researcher (A.H), who had linguistic and cultural familiarity with Sindhi and English. Back-translation and comparison with original-language transcripts were used to support accuracy and preserve participants’ intended meanings. Field notes and observational notes were maintained during and after data collection to capture contextual details and non-verbal observations where possible, and emerging analytical insights. Data collection and preliminary analysis occurred iteratively and continued until data saturation was reached, with no substantially new patterns emerging in later interviews.

Data analysis

Data analysis was conducted alongside data collection and followed reflexive thematic analysis, informed by Braun and Clarke’s approach [24]. Analysis proceeded through repeated reading of transcripts, initial coding, development of candidate themes, review and refinement of themes, and definition and naming of the final themes. NVivo 12 software was used to organize the data and support systematic coding and retrieval. Coding was primarily inductive in that themes were developed from participants’ accounts; however, interpretation was also informed by the study’s intersectional lens.

Several strategies were used to strengthen trustworthiness, drawing on Lincoln and Guba’s criteria [25]. Credibility was supported through triangulation across interviews, observations, field notes, and artifacts; iterative engagement with the data; and regular analytic discussions among the research team. Reflexivity was maintained through memo-writing and documentation of the researcher’s positionality, assumptions, and evolving interpretations throughout data collection and analysis, which also supported confirmability. Contextual richness and transferability were supported through detailed description of the study setting, participants, and analytic process. Dependability was strengthened by maintaining an audit trail of coding decisions, theme development, and revisions across stages of analysis.

Ethical considerations

Ethical approval for the study was obtained from the University of Alberta’s Research Ethics Board (Pro00142593) and National Bioethics Committee, Pakistan (NBC-1128/23/377). After the study was explained, participants were given adequate time to consider participation and ask questions before deciding whether to participate. Written informed consent was obtained from all participants prior to data collection. Consent forms were provided in local language (Sindhi). For participants with limited literacy, the researcher explained the study purpose, procedures, risks and benefits, confidentiality, voluntary participation, and the right to withdraw in simple language. Participants were given time to ask questions and confirm understanding before documenting consent by signature or thumbprint. With participants’ permission, verbal confirmation of consent was also audio-recorded where appropriate. Participation was voluntary, and confidentiality was maintained by removing identifying information and securely storing all data.

Interrupted education and redirected aspirations

Participants consistently described the interruption of formal education as one of the earliest and most consequential disruptions in their transition to adolescence and motherhood. School represented routine, friendship, enjoyment, aspiration, and a sense of self.

Several participants described leaving school at the onset of menstruation, often because of stigma and lack of support made continued attendance difficult. One participant recalled, “When I got my first period, my parents discontinued my schooling because, in our society, girls are not allowed to continue education after they start menstruating.” —P-02. Menarche appeared to operate as a physical marker that shifted girls toward expected futures of marriage, domestic responsibility, and motherhood. Participants’ sorrow about leaving school reflected the loss of education as well as the narrowing of future possibilities once bodily maturity became linked to adult gendered roles.

For some participants, the consequences of limited education continued into pregnancy and motherhood, affecting confidence and their ability to engage with health information. One mother explained, “Because I never studied, I couldn’t understand health information during pregnancy. When doctors told me things, I didn’t always understand their language. Even now, when my child grows, I feel bad that I cannot read, write, or guide him in school later. This lack of education makes me feel less confident compared to others” — P-15. In this way, educational loss remained present in participants’ everyday lives, shaping how they understood themselves as mothers and limiting their sense of competence and authority.

Despite these interruptions, many participants expressed a lasting emotional connection to education. Learning was remembered not only as enjoyable but also as a source of identity and aspiration. The loss of schooling was frequently described as a source of regret, especially when reflecting on missed opportunities for personal growth and future independence. As one mother stated, “Sometimes I sit and think, ‘If I had studied, maybe my life would be different.’ That regret stays with me.” —P-08. This regret reflected an ongoing psychological burden linked to unrealized goals, reduced autonomy, and the feeling that an important part of the self had been prematurely closed off.

Following these early disruptions, many adolescent mothers described a shift in how they understood aspiration. Their hopes moved from themselves to their children. Education, dignity, and independence were imagined for the next generation rather than for their own lives. One mother explained this shift directly: “Now my biggest goal is to educate my child so he can have a better future. Even if my own dreams ended, I want to see my child’s dreams fulfilled.” — P-16

In this way, interrupted education remained psychologically active in participants’ lives, shaping regret, self-perception, and the meanings they attached to motherhood, care, and their children’s futures.

Burden of continuous caregiving and uneven support

Adolescent mothers described a sudden shift into full responsibility for infants, husbands, and household work, with little time for rest or personal care. Daily routines were shaped by continuous tasks that began early in the morning and extended late into the night. Many recalled managing childcare and domestic labor at the same time, often while still recovering from childbirth or navigating late pregnancy. One participant captured this shift in identity and responsibility: “I felt that I was now becoming a mother and needed to think about everything carefully. Before, I was carefree, but now I have to take care of the baby as well as myself.” — P 01. This workload intensified when infants cried, became ill, or needed constant attention, leaving mothers with little space to meet their own needs. As one mother described, “From morning till night, I’m cooking, cleaning, taking care of my baby and husband. I barely sit down.” — P 02. These unbroken routines created physical strain and emotional pressure, especially when mothers felt they had no opportunity to pause or recover. Field observations also showed how caregiving continued throughout mothers’ daily routines. Some mothers watched children while working in agricultural fields, showing how childcare was often managed alongside other domestic and fieldwork responsibilities.

Participants described support as central to how they managed caregiving, household work, and emotional strain, yet they emphasized that it was uneven and often unpredictable. Some received meaningful help from husbands, relatives, or neighbors while others described caring alone despite living in large households. One participant explained how her husband’s involvement eased her burden: “When I’m busy feeding the child, he takes care of his clothes, gets his own food, or does other tasks by himself.” — P‑21. Another shared, “He used to take me to the doctor and bought whatever I needed. During the delivery, he was right beside me” — P-06. In contrast, others described absent or minimal spousal support: “I am raising my child without any support. My husband never supported me, not even once” — P-20. Lack of support also affected care-seeking: “My daughter got very sick, and my husband said I don’t take care of her properly, so he refused to buy medicines. I went to the public hospital myself, got her checked, and brought medicines for her” — P-14. This pattern of mothers carrying care-seeking responsibilities alone was also visible outside a small government clinic in Matiari, where young mothers waited with babies or small children in their laps while managing prescriptions, medicine bags, breastfeeding, and crying children without visible male or family support.

Support from family also shaped motherhood experiences. Some participants described shared household work: “If I’m busy with my child, one of them might cook or sweep the floor… It’s like teamwork” — P-01. In contrast, others described moments when support was absent. As one mother shared, “Even when I cried, they said I was being dramatic. I wanted someone to just sit with me and listen.”— P-21. These accounts suggest that support functioned as practical assistance as well as an emotional buffer; when absent, caregiving was experienced as both relentless labor and psychological isolation.

Barriers to healthcare access

Participants described multiple barriers to accessing maternal healthcare, including long travel distances, lack of transportation, financial constraints, and disrespectful treatment within healthcare facilities. These financial, geographic, and systemic barriers often left mothers feeling abandoned and devalued by the very systems meant to protect them.

Long travel distances and transport costs were particularly burdensome. One participant described: “It takes us almost 3 hours to get there… We booked a car for 2,000 rupees, which was a lot for us.” — P-23. Field observations similarly showed how care-seeking was shaped by distance and waiting; in one instance, two pregnant women waited for a long time for transport to reach the hospital. Such accounts and observations illustrate how geographic and economic constraints could delay or complicate care-seeking, especially for adolescent mothers with limited mobility and few independent resources.

Even when participants did reach facilities, their experiences of care were often undermined by neglect, poor communication, or disrespect. One mother stated: “Doctors never explained procedures… They shouted if we asked too many questions. I felt very small, like I had no right to care because I was poor.” — P-15. Another participant similarly emphasized the lack of guidance within healthcare settings: “Mostly we had to wait too long at the hospital. The doctors wouldn’t give us proper time. If we didn’t know someone there, we had to wait for hours… Sometimes I needed emotional guidance or just someone to explain things in simple words, but no one did that… There’s no one to guide young mothers like us” — P-06. These encounters had emotional consequences beyond the immediate clinical interaction. Participants described feeling humiliated, frightened, and devalued, suggesting that mistreatment within health services contributed to emotional withdrawal and made care feel less supportive.

Emotional distress and psychological strain

Across participants’ accounts, adolescent mothers described substantial emotional strain during pregnancy, childbirth, and the postpartum period. Although they did not use clinical terms, their narratives showed persistent fear, anxiety, cognitive overload, irritability, and moments of despair. These experiences were rarely acknowledged by families or health providers, leaving many to manage distress alone.

Fear was a constant presence, shaped by stories of medical complications, past losses, and the unpredictability of childbirth. One participant described this early fear clearly: “I used to hear stories… This made me worry that I might also have to go through a C section. I feared something might happen to me or my baby.” — P 06. Economic hardship further intensified emotional burden. As one mother stated: “Many times we had no money for food. Some nights, I only drank water and put my children to sleep without meals… It is very painful for a mother when she cannot feed her children.” — P-14. Cognitive strain was also common. Mothers described forgetfulness, confusion, and difficulty concentrating, especially when caring for newborns and managing household tasks. These lapses disrupted daily routines and created frustration and shame. One participant shared, “I would forget simple things or get confused, especially if there were too many tasks to do at once.” — P 17

For some participants, emotional overload escalated into thoughts of self‑harm during moments of exhaustion and hopelessness. These thoughts were described as brief but frightening, often countered by a sense of responsibility toward their children. As one mother stated, “Sometimes I felt so exhausted and hopeless that I even thought about ending my life… But whenever those thoughts came, I reminded myself that I have to live for my children.” — P-15. These accounts indicate that emotional distress formed a central dimension of how many participants experienced the transition to motherhood.

Identity transformation during adolescent motherhood

Participants described adolescent motherhood as reshaping how they saw themselves, their bodies, and their place in the world. This transformation involved both loss and growth. Many mothers mourned the abrupt ending of girlhood and the disappearance of a more carefree sense of self, while others described emerging strength, purpose, and voice through caregiving and endurance. Across these accounts, identity transformation was experienced as a gradual and emotionally complex process rather than a simple shift into adulthood.

Implications for practice and policy

These findings have several implications for maternal and adolescent health practice and policy, particularly in strengthening health systems to better recognize and respond to adolescent mothers’ mental health needs. First, maternal care providers, including Lady Health Workers and community midwives, should be better equipped to recognize and respond to the physical and emotional needs of adolescent mothers, particularly when signs of distress may otherwise go unnoticed or be minimized. Training for frontline maternal health providers should include adolescent-responsive communication, basic mental health awareness, and strategies for identifying distress in contexts where emotional suffering may be expressed indirectly through physical complaints, silence, or withdrawal.

Second, routine perinatal mental health screening and referral pathways should be integrated into antenatal and postnatal, and child health services in ways that are feasible, developmentally appropriate, and accessible for adolescents. Brief screening approaches could include locally adapted versions of the Edinburgh Postnatal Depression Scale, the Patient Health Questionnaire, or short distress-screening checklists administered by trained LHWs, community midwives, or primary care providers. Screening should be accompanied by supportive conversation, privacy, follow-up, and clear referral pathways for adolescents who disclose severe distress, self-harm thoughts immediate safety concerns, or psychosocial needs.

Third, because educational disruption emerged as a major source of emotional loss and reduced future opportunity, community- and policy-level efforts are needed to support continued education after marriage or childbirth. Community-based initiatives could include mother–adolescent support groups, safe spaces for married and parenting girls, home-based or flexible learning programs, links with local schools or non-formal education providers, literacy support, and community dialogues with parents, husbands, mothers-in-law, religious leaders, teachers, and health workers. These initiatives should address the belief that menstruation, marriage, or motherhood marks the end of girls’ educational possibilities. The findings also suggest a need for stronger health outreach strategies, including transportation-sensitive maternal care planning, mobile or community-based service delivery, and safe, nonjudgmental spaces where adolescent mothers can receive emotional support, share experiences, and build practical life and parenting skills. Peer-support models, home-visiting approaches, and locally embedded maternal support initiatives may be particularly useful in settings where adolescent mothers face mobility restrictions or limited autonomy in seeking care. Future research may also examine pregnancy intention and contraceptive use to better understand the reproductive circumstances surrounding adolescent mothers’ transition to motherhood.

Finally, adolescent mothers should be included more meaningfully in the design of reproductive, maternal, and social support services so that interventions are informed by the realities of their lived experiences rather than assumptions about their needs.