“Spoiled” girls: Understanding social influences on adolescent contraceptive decision-making in Kenya

OBJECTIVES: Despite significant public health emphasis on unintended pregnancy prevention among adolescent girls and young women in Sub-Saharan Africa, there is a gap in understanding how adolescents’ own reproductive priorities and the social influences on their decision-making align and compete. We examined the social context of contraceptive decision-making among Kenyan female adolescents. METHODS: Using community-based sampling, we conducted 40 in-depth interviews and 6 focus group discussions among sexually-active or partnered adolescent girls and young women aged 15–19 in the Nyanza region of Kenya. We analyzed the data in Dedoose using an inductive, grounded theory approach, and developed a conceptual model from the data illustrating social influences on adolescent contraceptive decision-making. RESULTS: Participants viewed adolescent pregnancy as unacceptable, and described severe social, financial, and health consequences of unintended pregnancy, including abortion under unsafe conditions. Yet, their contraceptive behaviors often did not reflect their desire to delay pregnancy. Contraceptive decision-making was influenced by multiple social factors, centering on the intersecting stigmas of adolescent female sexuality, pregnancy, and contraceptive use, as well as unequal power in sexual relationships. To prioritize pregnancy prevention, adolescents must navigate conflicting social norms and power dynamics, and put their perceived future fertility at risk. CONCLUSIONS: Contraceptive decision-making among Kenyan female adolescents is strongly influenced by opposing social norms within families, communities, and sexual relationships, which compel them to risk stigma whether they use a contraceptive method or become pregnant as adolescents. These findings put into perspective adolescents’ seemingly incongruent pregnancy preferences and contraceptive behaviors. Interventions to address adolescent unintended pregnancy should focus on supporting adolescent decision-making agency, addressing fertility-related contraceptive concerns, and promoting innovative contraceptive access points rather than increasing contraceptive prevalence.