The European Journal of Development Research (2021) 33:1274–1302

https://doi.org/10.1057/s41287-021-00438-5

SPECIAL ISSUE ARTICLE

‘If She’s Pregnant, then that Means that Her Dreams Fade
Away’: Exploring Experiences of Adolescent Pregnancy
and Motherhood in Rwanda

Ernestina Coast1 · Marie Merci Mwali2 · Roberte Isimbi2 ·

Ernest Ngabonzima2 · Paola Pereznieto3 · Serafina Buzby4 · Rebecca Dutton5 ·
Sarah Baird5

Accepted: 12 July 2021 / Published online: 4 August 2021

© The Author(s) 2021

Abstract
Adolescent motherhood can alter the future opportunities available to girls and the
challenges they face. This article considers how adolescents’ capabilities are influ-
enced by pregnancy and motherhood, using a mixed-methods case study of Rwanda.
Adolescent motherhood impacts girls’ lives across multiple capabilities including
education, psychosocial well-being, voice and agency, and economic empowerment.
Rarely were adolescent mothers in our sample supported to return to school, for
instance. Their pregnancy and motherhood were stigmatised by their families, peers,
wider community and service providers. The psychosocial consequences of adoles-
cent motherhood are significant, linked to social isolation and multifaceted stress-
ors, including poverty. Despite recent policy and service improvements, adolescent
mothers continue to be left behind.

Keywords Adolescents · Motherhood · Pregnancy · Rwanda · Capabilities · Sexual

and reproductive health and rights

Résumé
Pour les adolescentes, le fait de devenir mère peut changer la donne quant aux oppor-
tunités qui vont s’offrir à elles à l’avenir et quant aux difficultés auxquelles elles sont
confrontées. Cet article se penche sur la façon dont les capacités des adolescentes
sont influencées par la grossesse et la maternité, grâce à une étude de cas au Rwanda
utilisant des méthodes mixtes. Chez les adolescentes, le fait de devenir mère a un
impact sur leur vie dans de multiples domaines, notamment l’éducation, le bien-être
psychosocial, le fait de pouvoir faire entendre sa voix et d’être en capacité d’agir par
et pour soi-même, ainsi que l’autonomisation économique. En guise d’exemple, les
mères adolescentes de notre échantillon ont rarement été soutenues pour retourner à

* Roberte Isimbi
isimbi@fateconsulting.com
Extended author information available on the last page of the article

Vol:.(1234567890)
‘If She’s Pregnant, then that Means that Her Dreams Fade Away’:… 1275

l’école. Leur grossesse et leur maternité ont été stigmatisées par leurs familles, leurs
pairs, la communauté au sens large et les prestataires de services. Les conséquenc-
es psychosociales de la maternité chez les adolescentes sont importantes, liées à
l’isolement social et à des facteurs de stress de toutes sortes, y compris la pauvreté.
Malgré les récentes améliorations apportées aux politiques et aux services, les mères
adolescentes continuent d’être laissées pour compte.

Introduction

Adolescence is a period of opportunities and risks, and individuals’ experiences

and behaviours during adolescence can have lifelong consequences. Many adoles-
cents are sexually active, and while they may want to avoid pregnancy, they often
lack knowledge about or access to contraception or the agency to make decisions
about their sexual and reproductive autonomy. Adolescent motherhood can signifi-
cantly alter the future opportunities available to girls. We need to better understand
the implications of adolescent pregnancy and motherhood, centring the insights and
experiences of adolescents within their individual context (household, community,
society). This paper considers how adolescents’ lives are influenced by adolescent
pregnancy and motherhood, using a capabilities framework for a case study of
Rwanda.
‘Leave no one behind’ underpins the Sustainable Development Goals (SDGs)
and Agenda 2030 of the United Nations’ Every Woman Every Child (EWEC) global
strategy (UNSG 2015). Both approaches emphasise equity. Inequities related to sex-
ual and reproductive health rights (SRHR) force attention to be paid to the diverse
factors operating at multiple levels (individual, community, structural) that affect
adolescents’ abilities to exercise agency in their sexual and reproductive lives. Ado-
lescents globally experience significant inequities in SRHR. A study of coverage
of maternal and reproductive health indicators (2008–2017) in 58 countries shows
that adolescents: have lower coverage of family planning interventions than women
aged 20–49 years; had the slowest rate of improvement in coverage for reproduc-
tive health; and that children of adolescent mothers were significantly disadvantaged
(Amouzou et al. 2020). Approaches to leave no one behind need to ensure equity in
access to SRHR information and services for adolescent girls.
To identify who is being left behind, and how to intervene, there is a need for dis-
aggregated data to illuminate inequities (Boerma et al. 2020). The evidence on ado-
lescent sexuality in Rwanda—including non/ consensual sex—is limited. A qualita-
tive study of rural secondary students in Rwanda identified two stereotypical sexual
interactions: ‘experimental’ sex between adolescents, and transactional sex with
older partners (Michielsen et al. 2014). The authors concluded that young people
have little capacity or agency to manage their vulnerabilities in these relationships.
Evidence from Rwandan secondary school students identified gendered norms relat-
ing to sexual coercion and its acceptance, including but not limited to age-disparate
relationships (Van Decraen et al. 2012).
The Rwandan evidence base on adolescents, contraceptive use and services is
more extensive, reflecting secondary analyses of Demographic and Health Survey
1276 E. Coast et al.

data (Hakizimana et al. 2019; Uwizeye et al. 2020). A regional comparison of young
women’s (15–24 years) contraceptive use shows how Rwanda lags significantly
behind its neighbours, despite increases in contraceptive use over the last twenty
years (Dennis et al. 2017). Even when adolescents are aware of, and knowledge-
able about, effective contraception, its use remains low for reasons that include:
judgemental service providers; inaccessible services; low availability of special-
ist healthcare workers, socio-religious norms, concerns about side effects; stigma
(and the need for privacy/secrecy); and the costs of accessing and using services
(Binagwaho et al. 2012; STPH 2015). A survey of social and healthcare providers
in urban Rwanda concluded that SRH services are “fairly accessible” to adolescents,
but noted that family members and faith leaders may actively discourage use of con-
traception and/or promote abstinence (Ndayishimiye et al. 2020).
Adolescent pregnancy is common in Rwanda; more than a tenth (11.5%) of girls
aged 18 have begun childbearing (NISR 2016) and a non-representative sample sur-
vey of female adolescents found that 18% of those aged 16–19 years had given birth
(Calder and Huda 2013). A study of near-miss maternal mortality found that unin-
tended pregnancy and unmet need for contraception were common. Young women
have low levels of awareness of effective long-acting reversible contraception, and
demonstrate either no use of contraception or reliance on male condoms and/or
counting (Påfs et al. 2016). Over a fifth (22%) of all pregnancies in Rwanda are
estimated to end in induced abortion (Basinga et al. 2012) and a study on maternal
near-misses among women of all ages in the capital, Kigali, showed that abortion
was related to nearly half (45%) of all severe morbidities and over a quarter (28%) of
mortalities (Rulisa et al. 2015). There are no age-disaggregated data or estimates on
adolescent abortion-related care-seeking in Rwanda, but evidence from elsewhere in
Africa suggests that adolescents are more likely to seek less safe abortion methods
than older women (Bankole et al. 2020).
Evidence about adolescent motherhood in Rwanda has two main frames—social
problem and public health—reflecting a pattern identified by Macleod and Feltham-
King (2019). A study of paradoxes of women’s empowerment in Rwanda included
interviews with adolescent mothers in Rwanda and identified the shame of unmar-
ried motherhood. Girls are described as losing agaciro (value) when they become
pregnant, and have to leave school because of the incompatibility with childcare
(Berry 2015). A study of adolescent mothers living in a Rwandan refugee camp
identified the ways in which stigma intersected with girls’ in/ability to remain in
education (Ruzibiza 2020). A non-peer-reviewed qualitative study of the needs of
adolescent mothers reported far-reaching impacts on their lives, many rooted in the
stigma of an adolescent pregnancy, including: being forced to leave the parental
home; being unable to secure justice; mental ill-health; curtailment of education;
and poverty, leading to inability to seek healthcare (for the mother and her child)
(Kvinna 2018). A descriptive observational study of postpartum depression among
adolescent mothers in Rwanda concluded that nearly half (48%) of the conveni-
ence sample had clinically high levels of depressive symptoms (Niyonsenga and
Mutabaruka 2020). A hypothetical ranking exercise about barriers to future aspira-
tions with Rwandan adolescents in a non-peer reviewed study found that ‘without
exception’ education and poverty were identified as critical to girls achieving their
‘If She’s Pregnant, then that Means that Her Dreams Fade Away’:… 1277

life aspirations, with pregnancy and rape ranked third and fourth respectively (Cal-
der and Huda 2013). Notable from this work is the implicit causal pathway between
rape, pregnancy, education and, ultimately, poverty.
However, we still know relatively little about Rwandan adolescent girls’ experi-
ences of pregnancy and motherhood, and the implications for their lives. In order
to examine the multiple implications of adolescent pregnancy and motherhood, we
use a framework that incorporates six capabilities: education and learning; bodily
integrity; physical and reproductive health and nutrition; psychosocial well-being;
voice and agency; and, economic empowerment (GAGE 2019). This socio-ecologi-
cal framework is rooted in a gendered capabilities approach informed by the work of
Nussbaum (2011) and Kabeer (1999) that explicitly incorporates the ways in which
adolescents’ environments shape their lives and trajectories. Next we provide an
overview of structural factors—policies, laws, services—that form part of the envi-
ronment within which adolescents experience pregnancy and motherhood.

Structural Factors Related to Adolescent Pregnancy and Motherhood

The challenges facing adolescent mothers in Rwanda are set against a national
context that is relatively enabling, at the regional level (Coast et al. 2019). Table 1
provides details of national legislation and policy frameworks relating to adoles-
cent SRH in Rwanda. The cross-sectoral National Integrated Child Right Policy
(NICRP) complies with the United Nations Convention on the Rights of the Child
(UNCRC) and is aligned with international agendas such as the SDGs and Agenda
2030’s call to leave no one behind. In 2011, the Ministry of Health (MoH) adopted
the Adolescent Sexual Reproductive Health and Rights Policy, setting out the need
to provide adolescents with greater access to information on contraception and
healthcare. Contraceptive services are available through village community health
workers alongside limited ‘youth-friendly’ SRH services (Tuyisenge et al. 2018).
In the National Strategy for Transformation (NST1), goal 60 is to scale up aware-
ness and use of contraception ‘with a particular focus on the youth’ (Rwanda 2017).
NST1 is framed by enhancing Rwanda’s demographic dividend, linked to its large
young population with 62% of the population aged below 25 years. This framing is
a shift from the country’s Economic Development and Poverty Reduction Strategy
II (2013–2018), which prioritised limiting population growth for economic develop-
ment, in addition to a health or human rights framing (Dennis et al. 2017).
The current Health Sector Strategic Plan (Rwanda 2018a, b) highlights adoles-
cent pregnancy and its health risks and builds on earlier efforts to expand the avail-
ability of contraception from community health workers (Wesson et al. 2011; Den-
nis et al. 2017). Some girls are not covered by health insurance, while those that are
covered may face high out-of-pocket costs. Adolescents are deterred from seeking
contraception and risk being stigmatised if they try to access SRH services, facing
barriers at multiple levels (family, community, healthcare institution) when they try
to do so (2CV 2014; Rwanda 2018a, b). Adolescents’ needs for accurate SRH infor-
mation remain unmet to a large extent (Hub 2011; Abbott et al. 2014). The cur-
rent Health Sector Strategic Plan emphasises the need for affordable and accessible
Table 1  National legislation and policy frameworks relating to adolescent SRH in Rwanda
1278

Issue Framework

Age of consent and statutory rape Legislation The Constitution of Rwanda, Article 1:
A child is any person under 18 unless a specific law specifies that majority is attained earlier
Age of consent is 18
Rwandan penal code, Article 133: ‘Child defilement’
When committed to a child under fourteen (14) years, the penalty is life imprisonment that cannot be
mitigated
When committed on a child of fourteen (14) years of age or older has resulted into an incurable illness or
disability, the penalty is life imprisonment
When followed by cohabitation as husband and wife, the penalty is life imprisonment that cannot be
mitigated
Law N°59/2008 of 10/09/2008 on Prevention and Punishment of Gender-Based Violence
Article 10: Preventing violence and catering for the victims of violence: everyone is assigned to avert
gender-based violence, rescue and call for rescue the victims of this violence
Policies National Integrated Child Rights Policy
Adolescents will be made aware of their rights to be protected against under-age marriage, abuse and
exploitation (p.16)
Access to sexual reproductive health and Legislation Law Relating to Human Reproductive Health, N° 21/2016 of 20/05/2016
rights services Policies National Integrated Child Rights Policy
The government will promote adoption of family planning practices through education and support
services to households, youth, men and women (p.13)
Specific measures will be undertaken for providing sexual and reproductive health education to children
at appropriate ages (p. 15)
Pregnant adolescents will be supported in their pregnancy with adequate care, pre, ante and post-natal
services. Appropriate strategies will be developed for assisting adolescent mothers in taking care of
their children and or in finding alternative care arrangements for their children (p. 16)
Health Sector Policy: Universal quality health services that are accessible and affordable. The policy
highlights the promotion adolescent health—including reproductive health, prevention and treatment of
sexual violence and gender-based violence. The psychosocial health of adolescents is a priority
E. Coast et al.
Table 1  (continued)
Issue Framework

Abortion Legislation Rwandan Penal Code, Article 164 ‘Abortion resulting in death’
Women, including girls below 18 years, have a right to terminate a pregnancy before 22 weeks gestation,
under certain conditions (the pregnant person is a child; rape; incest; foetal impairment; pregnancy as a
result of forced marriage; risk to the health of the pregnant person or foetus)
Age at marriage Legislation Rwandan Persons and Family Law, Article 168 ‘Marriageable age’
Minimum legal age for marriage is 21
Policies National Integrated Child Rights Policy
Government will undertake campaigns to discourage under-age marriage

Source Stavropoulou and Gupta-Archer (2017) and Isimbi et al. (2018)

‘If She’s Pregnant, then that Means that Her Dreams Fade Away’:…
1279
1280 E. Coast et al.

contraception for all ages, together with non-judgemental counselling and services
for adolescents (Rwanda 2018a, b). The Competence-based Curriculum aims to pro-
vide age-appropriate school-based sexuality education (Rwanda 2015).
Rwanda amended its abortion law (Government of Rwanda, 2012) to permit legal
safe abortion under certain circumstances and developed new guidelines to increase
access to post-abortion care, but implementation of services remains limited (Påfs
et al. 2020). The law was updated in 2019, and although the regulations address
access for adolescents, requests for abortion for any female below 18 years must be
made by a guardian or legal representative.
Legal and safe abortion thus remains difficult to obtain in Rwanda, particularly
for adolescents (Umuhoza et al. 2013; Påfs et al. 2016), while post-abortion care is
available but its accessibility and quality varies (Vlassoff et al. 2015).

Research Design, Methods and Analyses

Our mixed-methods evidence includes qualitative interviews with key inform-

ants and young mothers, as well as focus group discussions with young mothers.
Quantitative face-to-face interviews were conducted with adolescent mothers and
non-mothers. All researchers were made aware of their obligations in relation to
confidentiality and had signed formal agreements to maintain confidentiality. For
additional detail on research methodology and instruments see (placeholder for
methodological article in special collection). We refer to individuals who had given
birth or were pregnant before age 18 as ‘adolescent mothers’. We refer to individuals
who had never been pregnant as ‘non-mothers’. A minority of respondents classi-
fied as ‘adolescent mothers’ may not have subsequently become mothers if the preg-
nancy did not result in a live birth.

Study Location

Quantitative survey data was collected from one sector (administrative unit below
the district) each in three provinces (Kigali, Southern, Northern), purposively
selected for exhibiting a range of economic and social vulnerabilities (Table 2).
Selected sectors have similar poverty headcount indexes to the province overall
(NISR 2017) and are in districts (Gasabo, Huye, Gakenke) where at least 5% of
women aged 15–19 have had a live birth (NISR 2016). Qualitative interviews were
conducted in these three sites, plus an additional two sites (Nyabihu district in West-
ern Province and Ngoma district in Eastern Province) using the same criteria.
In each of the five sites, researchers conducted four key informant interviews
(KIIs), one focus group discussion (FGD) with adolescent mothers, and five indi-
vidual in-depth interviews (IDIs) with adolescent mothers (with the exception of
Gasabo, where four IDIs were conducted). The quantitative survey was conducted
with adolescent mothers and non-mothers in three sites.
Table 2  Study site description
Province District Urban/rural Sector Quantitative survey of Site characteristics
female adolescents aged
15–19

Kigali Gasabo Urban Kinyinya N = 21 mothers Urban area in Kigali. Adolescent girls migrate here for domestic work. Developed infrastruc-
tures: schools, hospitals, health centres, busy trading centre and offices
N = 17 non-mothers
Southern Huye Semi-urban Simbi N = 5 mothers Remote with limited business opportunities, no trading centres, limited access to electricity,
primary schools and secondary schools. Reported high levels of adolescent rural–urban
migration for domestic work
N = 33 non-mothers
Northern Gakenke Rural Muzo N = 24 mothers A rural area distant from the main road. Factories, secondary and primary schools, churches
‘If She’s Pregnant, then that Means that Her Dreams Fade Away’:…

and a technical and vocational education and training (TVET) school, which are relatively
accessible
N = 17 non-mothers
Western Nyabihu Rural Jomba – Rural area although close to the main road. Limited infrastructure (e.g. trading facilities),
economic activity and health facilities in the surrounding area
Eastern Ngoma Rural Remera – The site was close to a town with a university. There were factories, schools, trading centres,
petrol station, stadium, brick furnace and markets
1281
1282 E. Coast et al.

Qualitative Sample

Key informant interviews were conducted with 20 individuals, drawn from a range
of government and community organisations, including para-social workers (com-
munity health workers). Individuals were purposively selected for working with
or on adolescents, in education and health. Qualitative IDIs were conducted with
24 female adolescents aged 15–19 years who had given birth before the age of 18
(n = 22) or were currently pregnant before the age of 18 (n = 2).
Adolescent mothers were selected through purposive sampling. In the three sites
where the quantitative survey took place, adolescent mothers were sampled from
the survey respondents. It proved difficult to re-contact surveyed adolescent moth-
ers, reflecting the stigma of adolescent motherhood and the demands on adolescent
mothers’ time. In the two sites where there was no quantitative survey (Jomba and
Remera), the research team purposively sampled adolescent girls who had given
birth before the age of 18, and two interviews were conducted with adolescents who
were pregnant. Participants were identified by local leaders and community health
workers. Five FGDs were conducted with adolescent mothers. Overall, in each of
the five sites, four key informant interviews, one FGD with adolescent mothers and
five individual interviews with adolescent mothers were conducted (with the excep-
tion of Gasabo with four individual interviews with adolescent mothers). FGD with
adolescent mothers were recorded and used community and institution mappings to
stimulate discussion.

Quantitative Sample

Quantitative surveys were conducted with 117 adolescent females aged 15–19 years,
of which 50 had given birth or were pregnant before the age of 18, and 67 were non-
mothers. To identify adolescents aged 15–19 to sample in the three quantitative sites,
village leaders and community health workers prepared lists of all households in
their villages that had adolescent girls aged 15–19 as members. Community health
workers were also requested to list adolescent girls who had given birth or were
pregnant and under 18. Enumerators visited the identified households to confirm eli-
gibility of the adolescent girls and enroll them in the study. Thus, in our quantitative
analyses “adolescent mothers” refer to female adolescents who had given birth or
been pregnant before age 18, and “non-mothers” refer to female adolescents aged
15–19 who never been pregnant. The surveys, which included questions on adoles-
cent sexual and reproductive health (SRH), nutrition, education, paid work, experi-
ences of violence and gendered attitudes, were translated into Kinyarwanda. Sur-
veys were administered verbally by trained female enumerators using tablet-based
software in a private setting away from the home with the adolescent respondent.
Enumerators were trained in ethical procedures to ensure confidentiality. In addi-
tion, a survey was conducted with the primary female caregiver in the adolescent’s
household, which included household-level data (on assets, household composi-
tion, uptake of safety net programmes, etc.). Data were uploaded to BoxSync using
‘If She’s Pregnant, then that Means that Her Dreams Fade Away’:… 1283

secure procedures to ensure security of participant data throughout the data collec-
tion and analysis process.

Qualitative Analyses

The analyses use the Gender and Adolescence: Global Evidence (GAGE) concep-
tual framework (GAGE 2019). GAGE is a 9-year longitudinal research project on
gender and adolescence across multiple low- and middle-income countries (LMICs;
placeholder for GAGE conceptual article in special collection). Adolescents are situ-
ated at the centre of this socio-ecological framework. Our framework encompasses
the deeply gendered processes by which adolescents acquire key capabilities during
this life stage, and how these capabilities are affected by pregnancy and mother-
hood before the age of 18. We developed a thematic code book informed by our
conceptual framework, inviting comments from researchers involved in the field-
work to sense-check codes and add nuance. FGDs and interviews were recorded and
transcribed directly into English by professional transcribers external to the research
team. Coding was done using MAXQDA qualitative data analysis software. A lim-
ited number (n = 2) of coders were given common training and the first transcript by
each coder was checked for reliability, and through spot-checks thereafter.

Quantitative Analyses

The quantitative analysis is primarily focused on supporting the thematic findings

of the qualitative analysis and aims to describe the differences between adolescent
mothers and non-mothers. Significant differences between adolescent mothers and
non-mothers were determined using the following bivariate linear regression:
y = 𝛼 + 𝛽1 Adolmother + 𝜀. (1)
In the regression equation, y is the outcome for an individual and β1 is an indica-
tor for the individual being an adolescent mother. The model in Eq. 1 is then further
expanded to look at outcomes of interest using a multivariate regression model as
follows:
y = 𝛼 + 𝛽1 Adolmother + X + 𝜀, (2)
where X represents a set of control variables determined to be significantly different
between the adolescent mothers and non-mothers and includes respondent age, an
indicator for current enrollment in school, highest grade attended, and location. Note
that school enrollment was also significantly different, but no adolescent mothers
were in school so this is not included in the model. Due to the small number of non-
mothers reporting ever having had sex (n = 6), a comparative analysis was not con-
ducted for indicators related to sexual experience. For ease of presentation, we used
linear probability models for binary outcomes but the effect sizes and associations
are qualitatively the same as findings using logistic regression. Statistical analyses
were conducted using Stata15.1.
1284 E. Coast et al.

Ethics

The quantitative survey received approval (13/9/2019) from the Rwanda National
Ethics Committee (RNEC) (No. 861/RNEC/2019). The qualitative research
received approval (23/9/19) from RNEC (No. 801/RNEC/2019). Researchers
were trained on research ethics, how to interact appropriately with adolescents,
and referral process for identified risks of harm or adverse events. Participants
were provided with, and read out loud, a document describing: the purpose of
research and process of data collection; the risks and possible benefits of partici-
pating; their rights to confidentiality; and their rights to end participation or sub-
sequently withdraw from the study. If participants were under 18 years and living
with a guardian, participants provided their written assent and their guardian pro-
vided consent. If participants were over 18 or living alone or with a partner, they
provided their own written consent.

Results and Analyses

We present our mixed-methods evidence thematically, reflecting the chronologi-

cal themes emerging from the qualitative analyses: relationships, sex and contra-
ception; pregnancy disclosure; and the consequences of adolescent motherhood.
We merge evidence and insights across our evidence sources to give the fullest
picture possible. Table 3 provides some overall characteristics of the quantitative
sample.
Among our quantitative samples, mean ages were 17.6 years for mothers
and 16.6 years for non-mothers. The mean age of respondents in the qualita-
tive research was 17 years. While there were differences in school enrollment
and educational attainment (discussed below), there was not significant differ-
ences between adolescent mothers and non-mothers in the quantitative sample for
household level variables such as household size, an asset index, or literacy of the
household head.

Relationships and Sex

To understand the experiences of adolescent mothers first requires understand-

ing of the circumstances—relationships and non-/consensual sex—that led to
pregnancy. This is because, for example, whether a boyfriend accepts or denies
paternity of a pregnancy can have implications for the support that an adolescent
mother receives. Or, if a pregnancy was the result of rape, the ways in which this
has implications for how an adolescent’s family or community treat her.
Data on age at first sex were collected in the quantitative survey. Among ado-
lescent mothers, the age at which they first had sexual intercourse ranged from 12
‘If She’s Pregnant, then that Means that Her Dreams Fade Away’:… 1285

Table 3  Demographics: quantitative survey (n = 50)

Mean (s.d.) Significance p
Overall Adolescent mothers Non-mothers

Individual level variables

Age 17.026 17.580 16.612 < 0.001***
(1.323) (1.326) (1.167)
Currently attending formal school 0.333 0 0.582 < 0.001***
(0.473) 0 (0.497)
Highest grade attended 7.205 6.400 7.806 < 0.001***
(2.272) (2.176) (2.169)
Household level variables
Household size 6.333 6.600 6.134 n.s
(2.185) (2.399) (02.007)
Household head literate 0.376 0.380 0.373 n.s
(0.486) (0.490) (0.487)
Father alive 0.752 0.680 0.806 n.s
(0.434) (0.471) (0.398)
Mother alive 0.923 0.880 0.955 n.s
(0.268) (0.328) (0.208)
Asset index (0–10) 5.077 5.140 5.029 n.s
(2.907) (3.084) (2.791)
Female headed household 0.265 0.320 0.224 n.s
(0.443) (0.471) (0.420)
Location
Gasabo (urban) 0.325 0.420 0.254 < 0.01*
(0.470) (0.499) (0.438)
Huye (semi-urban) 0.325 0.100 0.493 < 0.001***
(0.470) (0.303) (0.504)
Gakenke (rural) 0.350 0.480 0.254 < 0.05**
(0.470) (0.505) (0.438)
Number of observations 117 50 67

Mean differences statistically different than 0 at 99% (***), 95% (**), and 90% (*) confidence indicate
difference between adolescent mothers and non-mothers

to 18 years (Table 4); a minority of adolescent non-mothers had also had sex—
including at a young age—but due to the small number of non-mothers reporting
ever having had sex (n = 6), we did not conduct an analysis for indicators related
to sexual experience.

Consensual Sex

More than half (15/24) of respondents in the qualitative research described the sex
that led to pregnancy as consensual and part of a ‘love relationship’.
1286 E. Coast et al.

Table 4  Adolescent mother sample characteristics: quantitative survey (n = 50)

Mean (s.d.)

Mean age at first sexual intercourse 15.920 (1.614)

Reported willingness of engaging in first sexual intercourse
Willing 0.180 (0.388)
Somewhat willing 0.080 (0.274)
Not willing at all 0.740 (0.443)
Reported desire of first pregnancy
Wanted the pregnancy 0.100 (0.274)
Wanted to wait until later to become pregnant 0.620 (0.490)
Did not want children 0.280 (0.454)
Ever heard of method to delay pregnancy 0.640 (0.485)
Ever used anything to delay pregnancy 0.420 (0.499)
Currently using anything to delay pregnancy 0.400 (0.495)
Current method(s) of contraception among users (n = 20)
Intra-uterine device (IUD) 0.150 (0.367)
Injectable 0.150 (0.367)
Implant 0.650 (0.489)
Male condom 0.095 (0.294)

We were in love. He told me to go and visit him, and when I went there, that is
when he got me pregnant.
(Adolescent aged 19 years, rural, consensual sex with boyfriend, IDI)
Girls in consensual love relationships presumed or hoped this would lead to formal
(legal) marriage:
Before we slept together, we were in love and he usually was telling me that
he needs to take me to his family, to show them that he has a girl he wants to
marry.
(Adolescent aged 17 years, rural, cohabiting consensual relationship, IDI)
Given the stigma surrounding adolescent sexuality and pregnancy, it was not unu-
sual for girls to frame their sexual activity in terms of being ‘tempted’ into it:
There was a neighbouring boy that used to tempt me with small money like 200
Rwandan francs and make me do things I didn’t know. Because I hadn’t gone
to school I had no idea about how to get pregnant… then he impregnated me.
(Adolescent aged 17 years, rural, sex in exchange for goods, IDI)
This respondent explicitly linked her lack of education to her lack of understanding
about how she might become pregnant. This is reflected in the quantitative data,
where 64% (n = 32) of adolescent mothers had heard of a method to delay preg-
nancy, compared to 84% (n = 56) of non-mothers (Table 4). Key informants framed
some girls’ sexual activity as motivated by poverty, and differentiated between gen-
dered norms for girls’ and boys’ sexual practices:
‘If She’s Pregnant, then that Means that Her Dreams Fade Away’:… 1287

When a girl experiences a life of poverty, it pushes her to get involved in sexual
intercourse. This may result in her adopting some bad behaviours for her to
get what she did not get in her family, while a boy is not easily deceived. Also,
a girl can have an unwanted pregnancy not due to bad behaviour but because
of poverty that made her do what’s unworthy of her.
(Community health worker, Kigali, KII)
The stigma of being sexually active before marriage means that adolescents keep
these relationships secret. Adolescents were clear that the only reason—apart from
pregnancy—for disclosing sex might be if it were non-consensual:
Because he did not do it by force, there was no reason to reveal it to people
(Adolescent aged 18 years, rural, consensual sex with boyfriend, IDI)

Coercive Sex and Sexual Violence

In the quantitative survey, 26% of adolescent mothers reported being forced by a

male who was not their husband or partner attempt to have sexual intercourse with
them. In the bivariate analysis, this is significantly higher than non-mothers, where
10% reported this experience (p < 0.05); what is notable is the levels of reported
forced sex amongst adolescents. More than a fifth (22%) of all adolescents reported
being touched sexually or being forced to touch a male who was not their partner
or boyfriend. There was not a statistically significant difference between adolescent
mothers and non-mothers experiencing unwanted sexual touching in both the bivari-
ate and multivariate analyses (Table 5). In the qualitative data, consensual sex and
rape are both reported by adolescent mothers.
Non-consensual sex is a common feature of adolescent girls’ lives and was
reported in both the qualitative IDIs and in the quantitative survey; nearly three-
quarters (74%) of adolescent mothers reported in the survey that they were ‘not at
all willing’ when they first had sex (Table 4). For adolescents who become pregnant
because of non-consensual sex, there is a triple stigma to contend with: sex, preg-
nancy and non-consent.
I was like an idiot because it was the time I came from countryside. I entered
in his house and then he directly closed the door because there was no one else
around there… So, because there wasn’t any one around, it [rape] was done.
(Adolescent aged 18 years, raped by an acquaintance, IDI)
One respondent was pregnant due to having been raped by her employer; she had
left her rural home to migrate to an urban area:
I was a maid and later I got pregnant. My boss had a wife and when she went
to work, he pretended to go for work, but he came back after his children went
to school and then he closed the doors and then he raped me.
(Adolescent aged 19 years, IDI)
Adolescents reported that stigma—including against girls who have been raped—
would frequently mean their families keeping everything secret, and not pursuing
 1288

Table 5  Experiences of adolescent mothers and non-mothers: quantitative survey (n = 50)

Non-mothers mean Magnitude change (bivari- Magnitude
(s.d.) ate) change (multi-
variate)

Has source of information on puberty 0.881 − 0.281 − 0.193

(0.327) p < 0.001*** p < 0.01*
Experience forced or attempted sexual intercourse (excluding husband/male partners) 0.104 0.156 0.122
(0.308) p < 0.05** n.s
Experienced unwanted sexual touching or was forced to touch sexually any male (excluding 0.224 0.096 0.000
husband/male partners)
(0.420) n.s n.s
Ever talked with other about serious problem affecting the community 0.313 − 0.173 − 0.120
(0.467) p < 0.05** n.s
Talked to female guardian about education, future work, bullying and religion 0.492 − 0.1925 − 0.145
(0.504) p < 0.05** n.s
Talked to male guardian about education, future work, bullying and religion 0.194 − 0.134 − 0.045
(0.398) p < 0.05** n.s
Participated in paid work in the last 12 months 0.582 − 0.122 − 0.164
(0.498) n.s n.s
Has savings 0.358 − 0.238 − 0.236
(0.782) p < 0.05** p < 0.01*
Has money she controls 0.373 − 0.073 − 0.043
(0.487) n.s n.s
Number of observations 67

Mean differences statistically different than 0 at 99% (***), 95% (**), and 90% (*) confidence indicate difference between adolescent mothers and non-mothers. Covariates
included as controls were: respondent age, highest grade attended, and location
E. Coast et al.
‘If She’s Pregnant, then that Means that Her Dreams Fade Away’:… 1289

justice. In some cases, adolescents or their parents decided not to report the rape in
case the father of the child would provide economic support, but this support rarely
materialised. Adolescents were aware that it was possible to seek justice, but identi-
fied structural barriers to doing so:
Sometimes, you go to Rwanda Investigation Bureau (RIB) and they tell you to
go back to local leaders and put your claim there. But the problem is that you
might claim against someone and find that your local leader is their relative,
and the claim just vanishes like that.
(Adolescent mother, FGD, Western Province)
Key informants acknowledged the difficulties that adolescents who have to disclose
a pregnancy due to rape have to contend with, in the seeking of justice:
If it [rape] happens and by chance the adolescent girl gives information, lead-
ers follow the case and punish those who committed the crime. However, the
adolescent girls cannot easily give the information because they think it is
shameful to share information.
(School teacher, Kigali, KII)
The stigma of adolescent pregnancy in general—not only in cases of rape—affects
both adolescents and their families. This is reinforced by normative perspectives that
presume poor or absent parenting as the cause of adolescent pregnancy:
The causes of unwanted pregnancy start from families, when a child grows
without someone who controls and advises her on how to behave as an ado-
lescent.
(Government officer, Eastern Province, KII)

Knowledge, Access to and Use of Contraception

Adolescents in our study had diverse knowledge understanding and experience of

using contraception; reflecting universal patterns that knowledge does not necessar-
ily translate to use. In the multivariate analysis, adolescent mothers in our survey
were significantly (p < 0.05) less likely than their non-mother peers to have had a
source of information about puberty (60% vs. 88%). Non-mothers reported having
spoken to their guardians about puberty more so than adolescent mothers did. Non-
mothers were also significantly more likely to have talked with their own mother
about menstruation than adolescent mothers in the bivariate analysis (p < 0.01,
Table 5). Given that puberty and menstruation have occurred prior to motherhood, it
is possible that girls who are less likely or able to discuss issues relating to physical
maturity might have less knowledge about pregnancy or contraception; however, as
we do not have any data on the content of these intergenerational conversations, this
suggestion is speculative.
In the qualitative interviews, only one adolescent mother reported having ever
used contraception before becoming pregnant. She said she reminded her partner
to use the male condom, but that he had lied to her about using one. By contrast,
1290 E. Coast et al.

adolescents reported that, having become mothers, they received information about
contraception as part of maternity care.
Some girls had limited knowledge about contraception:
Yes, I knew it. I knew that sleeping with a boy makes a girl pregnant. I knew
that sex without protection leads to pregnancy. And we did not use any protec-
tion, and I got pregnant.
(Adolescent aged 17 years, rural, consensual cohabiting relationship, IDI)
For others, knowledge of contraception did not translate to use, possibly reflect-
ing limited agency to insist on contraceptive use with a consensual partner, or low
understanding about the likelihood of pregnancy, or an inability to access contracep-
tive services, or non-consensual sex:
I knew that if you are in family planning, you don’t get pregnant. However, I
did not use family planning as I did not think of giving birth.
(Adolescent aged 19 years, rural, non-consensual sex with an acquaintance,
IDI)
In some cases, adolescents had concerns about side effects of contraceptives:
I heard from people saying that when women use those family planning meth-
ods, they get headache, dizziness, or have eye problem. So, I think those things
can destroy my health.
(Adolescent aged 19 years, non-consensual sex with boyfriend, IDI)
Many healthworkers find the provision of contraception to adolescents challenging,
reflecting community-level norms stigmatizing adolescent sexuality. Key inform-
ants’ views and mis/information informed their contraceptive counselling for adoles-
cents, reflecting a service environment that does not facilitate contraceptive use by
sexually active adolescents:
Telling a girl of 14 or 15 years to put that thing [female condom] is not well
trusted, what if she puts it into [herself] and fail to conceive! I encourage the
under 18 girls to be abstinent.
(Para-social worker, Eastern Province, KII)
Such community-based advice often contrasts with policy statements:
There should not be an obligation of using family planning methods, but they
[healthcare workers] should accept it and give to any child who would ask for
it.
(Government official, Southern Province, KII)

Pregnancy Awareness and Disclosure

To understand girls’ trajectories to adolescent motherhood, it is important to under-

stand how girls learn they are pregnant and subsequently disclose the pregnancy,
to whom, and with what consequences. Understanding pregnancy awareness and
‘If She’s Pregnant, then that Means that Her Dreams Fade Away’:… 1291

disclosure in settings where pre-marital sexuality is highly stigmatized adds ana-

lytic insight to understanding the circumstances of adolescent motherhood. It illu-
minates how secrecy, stigma and shame reflect institutional and community norms
about adolescent sexuality. Pregnancy awareness and timely confirmation also have
critical implications for a girl’s ability to access safe and legal abortion. Pregnancy
disclosure means simultaneous disclosure of sexual activity—whether consensual or
not—and the most common outcome was denial of paternity:
I immediately told him and he told me that they don’t impregnate girls in his
family. I felt like killing him if I was able to.
(Adolescent aged 18 years, urban, consensual sex with her boyfriend, IDI)
Since the moment I told him that I am pregnant, he already told me that the
child is not his, that I should look for his/her father.
(Adolescent aged 18 years, raped by an adult male acquaintance, IDI)
Abortion is one of the potential outcomes considered by girls, sometimes linked to
paternity denial:
Many people told me not to abort the baby, but I had made a decision of abort-
ing it because it is what I wanted and no one was going to change my mind. I
kept thinking about it, and I was confused. I didn’t know what to do about it.
And I could not find money, but if I had, I could have aborted it.
(Adolescent aged 18 years, urban, consensual sex with boyfriend, IDI)
One key informant framed the need for abortion for adolescent girls, explicitly
linked to young age. Acknowledgement of abortion as an option by key informants
we interviewed was rare:
For those who get pregnant while they are still young and don’t accept it, they
can allow them to abort.
(Government official, Southern Province, KII)

Consequences: For Adolescent Mothers

The chain of potential consequences for adolescent mothers—for future aspirations,

education and employment, for example—is captured by the words of a community
health worker:
If she’s pregnant, then that means that her dreams fade away. If she’s pregnant
before she completes her studies, then she goes home to raise the baby. It’s like
her vision has just been erased.
(Community health worker, Kigali, KII)
In the qualitative IDIs none of the adolescent mothers reported wanting to become
a mother at the time they became pregnant. In the quantitative survey, 10% of ado-
lescent mothers reported that they wanted their pregnancy, 28% reported that the
pregnancy was not wanted at that time, or ever and 62% wanted to wait until later
to become pregnant (Table 4). Dissonance between the qualitative and quantitative
1292 E. Coast et al.

data is to be expected; the critical insight is that the majority of adolescent moth-
ers did not want to be pregnant at that point in their lives. Following disclosure of a
pregnancy, adolescent mothers reported being treated differently by their families,
reflecting a swift transition from childhood to adulthood as a result of pregnancy:
My parents? After they hear that everything changes, the way they take you
before is different from how they take you now. You become a woman so they
can’t take you the same way.
(Adolescent aged 15 years, rural, consensual sex with her boyfriend, IDI)

Implications for Education

Adolescent mothers experienced rejection by their peers, and some had to leave
school to care for their child. None of the adolescent mothers surveyed were cur-
rently enrolled in school (compared with 58% of their peers who are not mothers)
(Table 3). Adolescent mothers reported leaving school in anticipation of the atti-
tudes they expected to face:
I dropped out because I didn’t want the teacher to notice that I am pregnant.
I thought that they would announce it in the school and that my classmates
would mock me.
(Adolescent aged 18 years, raped by an adult male living in the same com-
pound, IDI)
This is reflected in adolescent mothers achieving lower levels of school grade than
their peers (6.4 vs 7.8, p < 0.001, Table 3). For a minority of girls interviewed, their
families provided support—for them and their child—and an enabling environment
to return to school:
It was not a problem for my mom to take care of my baby because she is the
one who requested me to go back to school. The baby used to stay at home with
my mother and at school they used to give me permission to go and breastfeed
her at noon time.
(Adolescent aged 19 years, raped by her boyfriend, IDI)

Stigma and Social Exclusion

Reflecting the rapid transition from childhood to adulthood as a result of pregnancy,

many adolescents described the shrinking of their social world and their ability to be
seen outside of the home:
All my friends rejected me when they saw what happened. I was alone and I
could see it, and I started to hate myself. I was worried, and I feared to go in
public and wished to stay at home all the time.
(Adolescent aged 19 years, non-consensual sex with her boyfriend, IDI)
Individual friendships ruptured, reflecting the normative stigma associated with
adolescent pregnancy:
‘If She’s Pregnant, then that Means that Her Dreams Fade Away’:… 1293

A girl, we studied in the same class, she saw what happened to me and she
is no longer my friend because she may say that I can lead her into bad
behaviours and she gets pregnant too because I gave them a bad example.
(Adolescent mother, FGD)
Girls’ relationships with the father of their baby changed over time (Table 6).
Pregnancy and motherhood disrupt girls’ consensual sexual relationships and
reduce their social networks and support. While 82% of girls reported being
engaged, living with or in a relationship with a boyfriend before the pregnancy,
only 54% reported staying in this relationship afterwards.
These relationship changes likely reflect instances of paternity denial and/or
familial responses to stigmatized pregnancy and motherhood:
He does not help me, he does not ask me about our kid, he did not register
the baby.
(Adolescent aged 17 years, rural, consensual sex with her boyfriend, IDI)
Key informants tended to present the girls’ family as the most appropriate or
unproblematic source of support for adolescent mothers. In some cases key
informants reinforced the stigma of adolescent motherhood “No man would
accept her with a child”:
When she gets pregnant, she comes home and lives with her parents and
they raise the child together. You can’t chase her away while she’s your
child. But rather, you keep her home and you both raise the child, pay insur-
ance for him/her. No man would accept her with a child. So what she does
is stay home and help her parents and what parents do in return, they try to
find money to provide her with whatever she needs.
(Village security leader, Western Province, KII)

Table 6  Adolescent mother’s description of relationship with the child’s father before pregnancy and
currently: quantitative survey (n = 50)
Relationship with baby’s father Current relationship status with
before pregnancy child’s father

Married or living together 2 (4%) Married or living together 4 (8%)

Engaged to be married 4 (8%) Engaged to be married 3 (6%)
Regular boyfriend 35 (70%) Regular boyfriend 20 (40%)
Casual sex partner 2 (4%) Casual sex partner 2 (4%)
Raped, father unknown 2 (4%) Raped, father unknown 1 (2%)
Nothing 3 (6%) Nothing 14 (28%)
Friend 1 (2%) Friend 1 (2%)
Guardian/caretaker 1 (2%) Guardian/caretaker 1 (2%)
Only that he is the child’s father 0 (0%) Only that he is the child’s father 4 (8%)

Open-ended responses, categorised for analysis

1294 E. Coast et al.

Normative stigmatizing views about adolescent sexuality, pregnancy and mother-

hood were experienced by adolescents throughout the pregnancy, including during
childbirth:
You tell her/him that s/he is hurting you, s/he tells you that ‘When you were doing
it [having sex], did you think of the outcome of it?’ And you feel offended.
(Adolescent mother, FGD)

Psychosocial Well‑Being

Taking the quantitative data on mental health and ability to talk to someone about their
problems together with the range of worries that adolescent mothers reported, a picture
emerges of adolescent mothers being less able to talk to people about a wide range of
problems and being more likely to experience poorer mental health than their peers
who are not mothers. Compared to their peers, the bivariate analysis indicates that ado-
lescent mothers were significantly less likely to have ever talked with community mem-
bers about a serious problem affecting the community (14% vs. 31%, p < 0.05), though
there is not a statistically significant relationship between mothers and non-mothers in
the multivariate analysis (Table 5). Our quantitative evidence suggests that adolescent
mothers also experience significantly higher likelihood of being moderately or severely
depressed in both the bivariate and multivariate analyses (Table 7). In the bivariate
analysis, adolescent mothers were also more likely to report suicidal ideation in the past
two weeks compared to non-mothers (20% vs. 9%, p < 0.05), while this relationship is
no longer significant with the inclusion of covariates in the model..
Adolescent mothers were significantly less likely to be able to talk to their male or
female guardian about problems compared to their peers who are not mothers. Half of
non-mothers reported being able to talk to a female guardian about marriage, future
work, religion, and bullying compared to only 30% of adolescent mothers (p < 0.05).
19% of non-mothers and 6% of adolescent mothers reported being able to talk to a
male guardian about these topics (p < 0.05). In the multivariate models, while there
were similar trends, the differences were not statistically significant difference between
adolescent mothers and non-mothers speaking with their male or female guardians on
these topics (Table 5). Adolescent mothers reported lots of worries for themselves and
their child, for the present and for the future. For some, denial of paternity added to
these worries:
It really worries me. Because I have heard that when children grow up, they can
make you crazy while asking who is his/her father… oh my God it worries me.
(Adolescent aged 18 years, rape by an adult male acquaintance, IDI)

Economic Insecurity

Adolescent mothers face economic insecurity as a result of motherhood, needing to

provide for themselves and their child, with no or limited support:
Table 7  Distribution and severity of depression symptoms: quantitative survey (n = 50)
Adolescent non-mothers Magnitude change Significance p Magnitude change Significance p
(n = 67) Mean (s.d.) (bivariate) (multivariate)

Not depressed (PHQ ≤ 4) 0.508 (0.504) − 0.227 < 0.05 − 0.072 < 0.05
Mild depression (PHQ 5–9) 0.388 (0.491) − 0.148 − 0.133
Moderately or more depressed (PHQ ≥ 10) 0.090 (0.104) 0.21 0.148
‘If She’s Pregnant, then that Means that Her Dreams Fade Away’:…

Reported suicidal ideation in the past 2 weeks 0.090 (0.288) 0.11 < 0.05 − 0.109 n.s

Covariates included as controls: respondent age, highest grade attended, and location
1295
1296 E. Coast et al.

As I gave birth at earlier age, I am not even able to pay health insurance and I
am not able to feed the baby.
(Adolescent aged 16 years, rural, consensual sex with love partner, IDI)
Just over half (53%) of the adolescents reported being involved in paid work (46%
mothers vs. 58% non-mothers) (Table 5) and adolescent mothers find it harder to
find regular paid work, in part due to the need for childcare:
Now I am not able to cultivate [farming] because of the baby. No one will give
you a job when you are going to spend time caring for the baby…
(Adolescent aged 16 years, rural, consensual sex with love partner, IDI)
These constraints mean that adolescent mothers are typically engaged in petty trad-
ing or working on someone’s plot of land for very limited income:
Do you think that selling avocadoes can give you money?… Before, there was
nothing to worry about… but now, I think about what my baby will eat, will
wear, and so on.
(Adolescent aged 18 years, rural, consensual sex, IDI)
I do it all… I can take a field and when I find someone who is renting I put
in some physical labour and I go with them… to take care of my children… I
carry them with me to the field.
(Adolescent aged 18 years, rural, consensual sex with a love partner, IDI)
In most cases adolescent mothers earn very little, which may explain why they
reported lower savings than non-mothers, with significant differences in both the
bivariate and multivariate analyses (12% vs. 36%, p < 0.05) (Table 5).

Limitations

There are limitations to our evidence and analyses. In our quantitative evidence, we
cannot establish whether adolescents who are mothers were—before they became
mothers—different from adolescents who are not (yet) mothers. We can only com-
pare how adolescent mothers and non-mothers differ at the time of data collection.
The highly stigmatised context of adolescent pregnancy and motherhood meant that
systematic sampling of mothers from the survey for qualitative interviews was not
possible; our evidence is therefore restricted to those surveyed adolescent mothers
who consented to be re-contacted and interviewed in depth. We do not know if the
adolescent mothers who refused re-contact are systematically different from those
who consented to re-contact and interview.

Discussion

Using a socioecological framework that centres an individual’s capabilities reveals

how adolescent motherhood exposed adolescents to experiences of enacted stigma
(from friends, family and community [including healthcare workers]), internalized
‘If She’s Pregnant, then that Means that Her Dreams Fade Away’:… 1297

stigma (feelings of shame and disgrace) and led to behaviours to avoid or reduce
stigma (secrecy, not going to school, contemplating induced abortion). The stigma-
tizing of adolescent pregnancy and motherhood—particularly unmarried adoles-
cents—has been identified in other African contexts (Hall et al. 2018).
The evidence base on the linkages between adolescence, pregnancy and men-
tal health is very limited and dominated by evidence from high income countries
and few low- and middle-income countries (BeLue et al. 2008; Fisher 2011; Dil-
lon 2014; Siegel and Brandon 2014; Field et al. 2020). Our evidence shows that the
impacts of adolescent motherhood for psychosocial capabilities are significant and
negative and reflect the multiple interconnected and cumulative ways in which preg-
nancy and motherhood affect adolescents’ lives—curtailed education; social exclu-
sion; worries about themselves and their child; internalized and enacted stigma; and,
limited economic opportunities. Our evidence supports insights from a descriptive
observational study of postpartum depression among teen mothers aged 15–19 years
in Rwanda that identified that nearly half (48%) of the sample had clinically high
levels of depressive symptoms (Niyonsenga and Mutabaruka 2020).
Adolescents in our study—both mothers and non-mothers—reported challenges
to their bodily integrity from coercive sex and rape; adolescent mothers were sig-
nificantly more likely to have experienced coercive sex or rape than their peers.
Coercive sex was reported for peer and age-disparate relationships, and linked to
gendered norms (Van Decraen et al. 2012; Michielsen et al. 2014). Legal justice
for sexual violence was rarely reported, impacting adolescent voice and agency
capabilities, reflecting both the stigma of having to disclose and structural factors
that reduced trust or confidence in the justice system. Rwanda has made substantial
investments and progress in justice services for sexual violence, however adoles-
cents and key informants in our study identified stigma-related barriers to accessing
and using these services.
Adolescents involved in consensual sexual relationships had limited agency in
their ability to prevent pregnancy for a range of reasons including: partner refusal
or coercion not to use; limited knowledge and understanding about fertility and con-
traception; concerns about side effects; and, healthworker attitudes that stigmatized
adolescent sexuality. Adolescent girls in consensual sexual relationships are poorly
equipped with contraceptive information or access to services that meet their contra-
ceptive needs; they are left behind by a health system that has only recently begun
to prioritise adolescents. However, information and services do not equate to use or
contraceptive autonomy (Senderowicz 2020). Adolescents’ access to contraception
is shaped by a legal framework that criminalises consensual sex between adolescents
who are minors, societal norms that stigmatise adolescent sexuality (Dennis et al.
2017) and gendered norms around coercive sex. Access to justice for sexual vio-
lence is constrained, despite legal provisions, reflecting normative expectations that
these matters can and should be dealt with privately by the girl’s family (Umubyeyi
et al. 2016).
Pregnancy—its disclosure and visibility—reveals hidden adolescent sexual
activity that affect capabilities across domains. For many adolescent mothers, the
desire to avoid or reduce stigma was linked to withdrawal from or rupturing of
education, social networks and friendships. For some adolescent mothers induced
1298 E. Coast et al.

abortion was considered as a way of avoiding the stigma of adolescent mother-

hood; our study does not include pregnant adolescents that aborted. Although the
Rwandan penal code on abortion makes provision for a legal abortion on a range
of grounds, including if the pregnant person is a child or as a result of rape, ado-
lescents in our study did not appear to be aware of these provisions, reflecting low
levels of knowledge and understanding among Rwandan healthcare workers (Påfs
et al. 2020).
Disclosure of a pregnancy marked an instant transition from childhood to adult-
hood for some of our respondents. For the majority of adolescent mothers in our
study, pregnancy signaled the end of their education, reflected in low school grade
achievement compared to their peers. For a minority of adolescent mothers, sup-
portive and enabling families and schools (childcare, returning home to breastfeed)
meant that education could continue. Although Rwandan education policies make
provision for pregnant schoolgirls to remain in education and for adolescent mothers
to return to education (HRW 2018), there are barriers to adolescents being able to
access this provision. For example, adolescent mothers could make use of the Early
Childhood Development (ECD) Centres as a source of childcare. However, ECD
fees are not included in compulsory, universal and free basic education which makes
it difficult for adolescent mothers to afford the fees for their child. In addition, ECD
are only accessible for children aged between 3 and 6 years which means that ado-
lescent mothers have little access to childcare for children under three. Finally, ECD
opening hours (8–11 a.m.) do not align with school hours (7 a.m.–5 p.m.). The need
to provide and care for a child makes it exceptionally difficult for adolescent mothers
to continue in education. National policy also makes no provision for an adolescent
mother and her child if they are rejected both by the child’s father and the girl’s fam-
ily; the implicit assumption is that families will provide.
The social exclusion of adolescent mothers identified in our analyses aligns with
conclusions drawn from research on unmarried motherhood in Rwanda (Debusscher
and Ansoms 2013; Berry 2015). For the majority of adolescent mothers, their eco-
nomic capabilities were impacted by the demands of childcare; the sorts of income
generating opportunities that could be combined with childcare, such as agricultural
labour, were precarious and poorly paid.

Conclusion

Adolescent mothers in Rwanda face significant disadvantages across multiple capa-

bility domains, all connected by stigma of adolescent motherhood. Our mixed-
methods analysis suggests that adolescent motherhood has negative implications for
adolescent girls’ lives and their likelihood of being further left behind. Concerted
and multisectoral efforts—across education, justice and health—are critical to pre-
vent sexual violence and unwanted adolescent pregnancy and to support adolescent
mothers, to reduce the likelihood that adolescent mothers and their children are left
behind and the intergenerational transmission of disadvantage.
‘If She’s Pregnant, then that Means that Her Dreams Fade Away’:… 1299

Author Contributions Conceptualization: EC, RI, MM. Primary research: PP, SB2. Methodology: EC,
PP, SB1, SB2, RI, MM. Analysis: EC, RD, RI, MM, SB1. Writing-original draft: EC, RI, MM. Writing-
review and editing: all authors.

Declarations
Conflict of interest On behalf of all authors, the corresponding author states that there is no conflict of
interest.

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References
Abbott, P., L. Mutesi, C. Tuyishime, and J. Rwirahira. 2014. Reproductive and sexual health in Rwanda:
A review of the literature and the policy framework. Kigali: IPAR.
Amouzou, A., S.S. Jiwani, I.C.M. Da Silva, L. Carvajal-Aguirre, A. Maïga, and L.M. Vaz. 2020. Closing
the inequality gaps in reproductive, maternal, newborn and child health coverage: Slow and fast pro-
gressors. BMJ Global Health. https://​doi.​org/​10.​1136/​bmjgh-​2019-​002230.
Bankole, A., L. Remes, O. Owolabi, J. Philbin, and P. Williams. 2020. From unsafe to safe abortion in
Sub-Saharan Africa: Slow but steady progress. New York: Guttmahcer Institute.
Basinga, P., A.M. Moore, S.D. Singh, E.E. Carlin, F. Birungi, and F. Ngabo. 2012. Abortion incidence
and postabortion care in Rwanda. Studies in Family Planning 43: 11–20.
BeLue, R., A.S. Schreiner, K. Taylor-Richardson, L.E. Murray-Kolb, and J.L. Beard. 2008. What mat-
ters most: An investigation of predictors of perceived stress among young mothers in Khayelitsha.
Health Care for Women International 29 (6): 638–648.
Berry, M.E. 2015. When “bright futures” fade: Paradoxes of women’s empowerment in Rwanda. Signs:
Journal of Women in Culture and Society 41 (1): 1–27.
Binagwaho, A., A. Fuller, V. Kerry, S. Dougherty, M. Agbonyitor, C. Wagner, R. Nzayizera, and P.
Farmer. 2012. Adolescents and the right to health: Eliminating age-related barriers to HIV/AIDS
services in Rwanda. AIDS Care: Psychological and Socio-medical Aspects of AIDS/HIV 24:
936–942.
Boerma, T., C.G. Victora, M.L. Sabin, and P.J. Simpson. 2020. Reaching all women, children, and ado-
lescents with essential health interventions by 2030. BMJ Global Health. https://​doi.​org/​10.​1136/​
bmj.​l6986.
Calder, R., and K. Huda. 2013. Adolescent girls economic opportunities study, Rwanda. Kigali: Nike
Foundation and Girl Hub Rwanda.
Coast, E., N. Jones, U.M. Francoise, W. Yadete, R. Isimbi, K. Gezahegne, and L. Lunin. 2019. Adoles-
cent sexual and reproductive health in Ethiopia and Rwanda: A qualitative exploration of the role of
social norms. SAGE Open 9: 215824401983358.
2CV. 2014. Girl Hub Rwanda: Influence and advocacy research, landscape analysis. London: 2CV and
Girl Hun.
Debusscher, P., and A. Ansoms. 2013. Gender equality policies in Rwanda: Public relations or real trans-
formations? Development and Change 44 (5): 1111–1134.
Dennis, M.L., E. Radovich, K.L.M. Wong, O. Owolabi, F.L. Cavallaro, M.T. Mbizvo, A. Binagwaho, P.
Waiswa, C.A. Lynch, and L. Benova. 2017. Pathways to increased coverage: An analysis of time
trends in contraceptive need and use among adolescents and young women in Kenya, Rwanda, Tan-
zania, and Uganda. Reproductive Health 14: 130.
1300 E. Coast et al.

Dillon, M.E. 2014. Adolescent pregnancy and mental health. In: International handbook of adolescent
pregnancy, 79–102, New York: Springer.
Field, S., S. Honikman, and Z. Abrahams. 2020. Adolescent mothers: A qualitative study on barriers and
facilitators to mental health in a low-resource setting in Cape Town, South Africa. African Journal
of Primary Health Care and Family Medicine 12 (1): 1–9.
Fisher, J. 2011. Mental health aspects of sexual and reproductive health in adolescents. International
Journal of Social Psychiatry 57 (1_Suppl): 86–97.
GAGE. 2019. Gender and Adolescence: Why understanding adolescent capabilities, change strategies
and contexts matters GAGE conceptual framework. London: Gender and Adolescence: Global
Evidence.
Girl Hub. 2011. Girl Hub: State of girls in Rwanda. Kigali: Girl Hub Rwanda.
Hakizimana, D., J. Logan, and R. Wong. 2019. Risk factors for pregnancies among females age 15
to 19 in Rwanda: A secondary data analysis of the 2014/2015 Rwanda demographic and health
Survey (RDHS). Journal of Management and Strategy 10 (2): 49–59.
Hall, K.S., A. Manu, E. Morhe, V.K. Dalton, S. Challa, D. Loll, J.L. Dozier, M.K. Zochowski, A.
Boakye, and L.H. Harris. 2018. Bad girl and unmet family planning need among Sub-Saharan
African adolescents: The role of sexual and reproductive health stigma. Qualitative Research in
Medicine and Healthcare 2 (1): 55.
HRW. 2018. Leave no girl behind in Africa; discrimination in education against pregnant girls and
adolescent mothers. Human Rights Watch.
Kabeer, N. 1999. Resources, agency, achievements: Reflections on the measurement of women’s
empowerment. Development and Change 30 (3): 435–464.
Kvinna. 2018. Rapid assessment baseline on the status and needs of teen mothers in Rwamagana and
Burera Districts. Kigali: Kvinna till Kvinna Foundation, Reseau des Femmes oeuvrant pour le
developpement rural.
Macleod, C.I., and T. Feltham-King. 2019. Adolescent pregnancy. In: Routledge international hand-
book of women’s sexual and reproductive health. London: Routledge.
Michielsen, K., P. Remes, J. Rugabo, R. Van Rossem, and M. Temmerman. 2014. Rwandan young
people’s perceptions on sexuality and relationships: Results from a qualitative study using the
‘mailbox technique.’ Sahara Journal 11: 51–60.
Ndayishimiye, P., R. Uwase, I. Kubwimana, J. de la Croix Niyonzima, R.D. Dine, J.B. Nyandwi, and
J.N. Kadima. 2020. Availability, accessibility, and quality of adolescent Sexual and Reproductive
Health (SRH) services in urban health facilities of Rwanda: A survey among social and health-
care providers. BMC Health Services Research 20 (1): 1–11.
NISR. 2016. Rwanda demographic and health survey. Kigali: NISR.
NISR. 2017. Poverty Mapping Report 2013/14. Kigali: National Institute of Statistics of Rwanda.
Niyonsenga, J., and J. Mutabaruka. 2020. Factors of postpartum depression among teen mothers in
Rwanda: A cross-sectional study. Journal of Psychosomatic Obstetrics and Gynecology: https://​
doi.​org/​10.​1080/​01674​82X.​2020.​17353​40.
Nussbaum, M.C. 2011. Creating capabilities: The human development approach. Cambridge: Har-
vard University Press.
Påfs, J., A. Musafili, P. Binder-Finnema, M. Klingberg-Allvin, S. Rulisa, and B. Essén. 2016. Beyond
the numbers of maternal near-miss in Rwanda—A qualitative study on women’s perspectives on
access and experiences of care in early and late stage of pregnancy. BMC Pregnancy and Child-
birth 16: 257.
Påfs, J., S. Rulisa, M. Klingberg-Allvin, P. Binder-Finnema, A. Musafili, and B. Essén. 2020. Imple-
menting the liberalized abortion law in Kigali, Rwanda: Ambiguities of rights and responsibili-
ties among health care providers. Midwifery 80: 102568.
Rulisa, S., I. Umuziranenge, M. Small, and J. van Roosmalen. 2015. Maternal near miss and mortality
in a tertiary care hospital in Rwanda. BMC Pregnancy and Childbirth 15: 203.
Ruzibiza, Y. 2020. ‘They are a shame to the community…’stigma, school attendance, solitude and
resilience among pregnant teenagers and teenage mothers in Mahama Refugee Camp, Rwanda.
Global Public Health: https://​doi.​org/​10.​1080/​17441​692.​2020.​17512​30.
Rwanda. 2015. Competence-based curriculum. Kigali: Government of Rwanda, Ministry of
Education.
Rwanda. 2017. 7 Years Government Programme: National Strategy for Transformation (NST 1) 2017–
2024. Kigali: Government of Rwanda, Ministry of Economics and Finance.
‘If She’s Pregnant, then that Means that Her Dreams Fade Away’:… 1301

Rwanda. 2018a. Fourth Health Sector Strategic Plan (HSSP IV, 2018–2024). Kigali: Government of
Rwanda, Ministry of Health.
Rwanda. 2018b. National Family Planning and Adolescent Sexual and Reproductive Health Strategic
plan 2018–2024. Kigali: Government of Rwanda, Ministry of Health.
Senderowicz, L. 2020. Contraceptive autonomy: Conceptions and measurement of a novel family
planning indicator. Studies in Family Planning 51 (2): 161–176.
Siegel, R.S., and A.R. Brandon. 2014. Adolescents, pregnancy, and mental health. Journal of Pediat-
ric and Adolescent Gynecology 27 (3): 138–150.
STPH. 2015. Adolescent and Youth Sexual and Reproductive Health Survey 2014—Rwanda Country
Report. Basel: Swiss Tropical and Public Health Institute.
Tuyisenge, G., C. Hategeka, and R.A. Aguilera. 2018. Should condoms be available in secondary
schools? Discourse and policy dilemma for safeguarding adolescent reproductive and sexual health
in Rwanda. Pan African Medical Journal 31: 173s.
Umubyeyi, A., M. Persson, I. Mogren, and G. Krantz. 2016. Gender inequality prevents abused women
from seeking care despite protection given in gender-based violence legislation: A qualitative study
from Rwanda. PLoS ONE. https://​doi.​org/​10.​1371/​journ​al.​pone.​01545​40.
Umuhoza, C., B. Oosters, M. van Reeuwijk, and I. Vanwesenbeeck. 2013. Advocating for safe abortion
in Rwanda: How young people and the personal stories of young women in prison brought about
change. Reproductive Health Matters 21: 49–56.
UNSG. 2015. Every woman every child. The global strategy for women’s, children’s and adolescents’
health (2016–2030). UNSG.
Uwizeye, D., R. Muhayiteto, E. Kantarama, S. Wiehler, and Y. Murangwa. 2020. Prevalence of teenage
pregnancy and the associated contextual correlates in Rwanda. Heliyon 6 (10): e05037.
Van Decraen, E., K. Michielsen, R. Van Rossem, M. Temmerman, and S. Herbots. 2012. Sexual coercion
among in-school adolescents in Rwanda: Prevalence and correlates of victimization and normative
acceptance. African Journal of Reproductive Health 16 (3): 139–153.
Vlassoff, M., S.F. Musange, I.R. Kalisa, F. Ngabo, F. Sayinzoga, S. Singh, and A. Bankole. 2015. The
health system cost of post-abortion care in Rwanda. Health Policy and Planning 30: 223–233.
Wesson, J., E. Munyambanza, H. Habrugira, A. Nyinawamahoro, A. Nzeyimana, C. Mugeni, and F.
Ngabo. 2011. Introducing community-based provision of family planning Services in Rwanda: A
process evaluation of the first six months of implementation. Kigali: Ministry of Health.

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Authors and Affiliations

Ernestina Coast1 · Marie Merci Mwali2 · Roberte Isimbi2 ·

Ernest Ngabonzima2 · Paola Pereznieto3 · Serafina Buzby4 · Rebecca Dutton5 ·
Sarah Baird5
Ernestina Coast
e.coast@lse.ac.uk
Marie Merci Mwali
merci@fateconsulting.com
Ernest Ngabonzima
ernest@fateconsulting.com
Paola Pereznieto
p.pereznieto@odi.org.uk
Serafina Buzby
sbuzby@laterite.com
1302 E. Coast et al.

Rebecca Dutton
rdutton@email.gwu.edu
Sarah Baird
sbaird@email.gwu.edu
1
London School of Economics and Political Science, Houghton Street, London WC2A 2AE, UK
2
FATE Consulting, 28 KG 674 St, Kigali, Rwanda
3
GAGE, Overseas Development Institute, London, UK
4
Laterite Ltd., KG 12 Ave, Kigali, Rwanda
5
George Washington University, 2121, 1 St NW, Washington, DC 20052, USA