Globally, COVID-19 has had a negative impact on health systems and health outcomes, with evidence of differential gender impacts emerging. The COVID-19 timeline of events spanning from closures and restrictions to phased reopenings is well-documented in Kenya. This unique COVID-19 situation offered us the opportunity to study a natural experiment on pregnancy trends and outcomes in a cohort of Kenyan adolescent girls and young women (AGYW), enrolled in the KENya Single-dose HPV-vaccine Efficacy (KEN SHE) Study. The KEN SHE Study enrolled sexually active AGYW aged 15–20 years from central and western Kenya. Pregnancy testing was performed at enrollment and every 3 months. We determined pregnancy incidence trends pre- and post-COVID-19 lockdown, pregnancy outcomes (delivery, spontaneous, or induced abortion), and postabortion and postpartum contraceptive uptake. Kaplan–Meier survival estimates of incidence rates were used to estimate the cumulative probability of pregnancy during the study period. Cox regression was used to investigate factors associated with pregnancy incidence. Of the 2,223 AGYW included in the analysis, median age was 18.6 IQR (17.6–20.3), >90% had at least secondary school education, 95% were single at the time of enrollment, and 82% had a steady/primary sexual partner. Pregnancy incidence peaked at 2.27 (95% CI [1.84, 2.81])/100 women-years of observation at the end of the first quarter of 2020, a period coinciding with the government-imposed lockdown. AGYW had 60% increased risk of being pregnant during the lockdown when compared to prelockdown period (HR = 1.60, 95% CI [1.25, 2.05]). Among the 514 pregnancies reported, 127 (25%) ended in abortion, of which 66 (52%) were induced abortions. Our findings demonstrate the adverse sexual and reproductive health (SRH) consequences of the COVID-19 pandemic and the lockdown measures among AGYW. As services continue to be disrupted by the pandemic, there is an urgent need to strengthen and prioritize AGYW-centered SRH services, including contraception and safe abortion.

The COVID-19 pandemic has had a negative impact on health systems and health outcomes globally, with increasing evidence of differential gender implications [1, 2]. Government and policy organization projections and media reports suggest COVID-19-related disruptions to health systems and restrictions in the movement are leading to worsening health outcomes for women and girls globally. Reports indicate increased violence against women, increased maternal morbidity and mortality, and a lack of access to essential sexual and reproductive health (SRH) services [3]. In resource-limited settings, the combination of school closures and interruptions in access to SRH services has uniquely impacted adolescent girls and young women (AGYW) [4].

Pregnancy among Kenyan adolescent girls is a complex and “multidimensional” social and public health issue [5]. Data suggest approximately 1 in every 5 girls between 15 and 19 years is either pregnant or already a mother [6]; this age-group accounts for 14% of all births in Kenya [7]. Adolescent pregnancy is a key risk factor for school dropout, which is associated with lifelong social, economic, and health consequences, including higher maternal and infant health risks and HIV acquisition [8]. Furthermore, over 60% of adolescent pregnancies are estimated to be unintended, of which 35% are estimated to end in abortion. Research suggests pregnant adolescents may face social stigma, isolation, worsening poverty, and associated poor mental health outcomes; they are also at risk of complications of unsafe abortion practices in settings with restricted abortion access, such as in much of sub-Saharan Africa [9, 10].

Media reports at the height of COVID-19 pandemic called attention to a spike in the number of teenage pregnancies in Kenya and attributed them to government-mandated COVID-19 containment measures such as school closures [11]. Despite significant concern about rising teen pregnancies during the COVID-19 pandemic, there are few sources of high-quality data [12, 13]. From January to June 2020, Nairobi County recorded a higher number of adolescent pregnancies compared to the prior year, though the analysis was limited to those presenting to government health centers [14]. A recent analysis from western Kenya concluded that compared with historical controls, female secondary school students who were out of school for at least 6 months had twice the pregnancy risk and were 3 times more likely to drop out of school [15].

In this study, we evaluated incident pregnancy trends and outcomes in a large cohort of Kenyan AGYW, pre- and post-government lockdown during the COVID-19 pandemic. We aim to contribute to the body of literature demonstrating the gendered impacts of the COVID-19 pandemic, which has further limited progress toward realizing the Sustainable Development Goal 5 on gender equality [16].

Study description and population

The COVID-19 timeline of events spanning from closures and restrictions to phased reopenings is well-documented in Kenya. This unique COVID-19 situation offered us the opportunity to study a natural experiment on pregnancy trends and outcomes in a cohort of Kenyan AGYW, enrolled in the KENya Single-dose HPV-vaccine Efficacy (KEN SHE) Study.

The KEN SHE Study is an individual randomized controlled trial to evaluate whether a single dose of the bivalent or nonavalent HPV vaccine prevents persistent HPV infection, a surrogate marker for precancerous lesions, and cervical cancer [17]. Briefly, between December 2018 and November 2019, the KEN SHE Study enrolled girls and young women aged 15–20 years in a double-blind randomized clinical trial testing the efficacy of a single-dose bivalent and nonvalent HPV vaccination as a catch-up strategy for cervical cancer prevention. Girls and young women from Thika, Nairobi, and Kisumu were eligible to participate if they were HIV-negative, reported 1 to 5 sexual partners in their lifetime, were not pregnant, and had a uterus and cervix. Study exclusion criteria included history of HPV vaccination, allergies to vaccine components or latex, hysterectomy, or history of immunosuppressive conditions [17].

KEN SHE Study locations

The study was conducted at 3 Kenya Medical Research Institute (KEMRI) clinical sites in Thika, Nairobi, and Kisumu. All participants, and their parents/guardians in the case of minors, provided informed consent/assent, which included counseling about randomization, risks and benefits of participation, study procedures, and their rights as research participants. Thika is a rapidly growing industrial city of 280,000 people, in Kiambu County, lying 40 km northeast of Nairobi. The Nairobi study site is located near to the Kibera slum area; Nairobi is a multiethnic city with a population over 4 million. Kisumu is the third-largest city in Kenya with a population of 610,000 people and is situated on the shores of Lake Victoria in Western Kenya.

KEN SHE Study procedures

Participants in this study are offered SRH services (contraception, sexually transmitted infection diagnosis and treatment, and HIV pre-exposure prophylaxis) at enrollment and every visit. Questionnaires are conducted using electronic case report forms (eCRFs; DF/Net Research, Inc.©, Seattle, WA, USA).

Participants are followed up at month 1, and thereafter, every 3 months, during which they have comprehensive assessment including genital swab collection. Providers administer clinical questionnaires at each visit. Pregnancy testing was done at enrollment, every 3 months, and when clinically indicated. Pregnant participants were followed-up and monitored to the end of pregnancy when the outcome was established. All these data were available for the analysis presented in this article.

COVID-19 lockdown and pregnancy estimation

Kenya reported its first case of confirmed COVID-19 on March 12, 2020, and the government closed all learning institutions from March 13, 2020, to as one of the measures to curb viral spread. An estimated date of fertilization (EDF) was computed as the first day of last menstrual period (LMP) plus 14 days to determine whether the pregnancy occurred before or after initiation of lockdown measures (pre- or post-COVID lockdown). Participants whose EDF fell after March 13, 2020, were considered to have a pregnancy that occurred post-COVID lockdown; this is equivalent to LMP on or after March 1, 2020. See the definition of independent variables in the Supplementary Tables 1 and 2.

Measures and statistical analysis

Person-time started on December 20, 2018, and observations were censored on March 31, 2021, or the last time the person participated in the study. Person-time ended at date of pregnancy, lost to follow-up, or end of the study period (March 31, 2021), whichever occurred first. If individuals came back to the study, they reentered the cohort (open cohort). Cumulative probabilities of pregnancy were estimated using Kaplan–Meier (K–M) method. Pregnancy trends were determined among this cohort, pre- and post-COVID-19 lockdown (March 13, 2020). Pregnancy incidence rates were computed using number of pregnancies as the numerator and person-time in follow-up as the denominator. Pregnancy rates per 100 person-years observation were determined by pre-/post-COVID-19 lockdown, study site, and quarterly. Supplementary Figure 1 shows goodness-of-fit and model diagnostics.

We assessed (1) pregnancy outcome (term delivery defined as delivery ≥37 weeks of gestational age, spontaneous or induced abortion, ongoing or undetermined) and (2) postabortion and postpartum contraceptive uptake. We used a Cox proportional hazards model to investigate factors associated with pregnancy incidence and binary logistic regression to determine factors associated with postabortion contraceptive initiation during the pandemic period.

Variables significant at <0.2 level in the univariable analysis or set a priori underwent further examination using a multivariable regression. Potential confounding effect of each covariate and a 2-way interaction were addressed, and we obtained final variable selection by applying backward elimination method. Analysis and comparisons were done at 5% level of significance. The analyses were completed using STATA version 16.1 (STATA Corporation, College Station, TX, USA).

Our analysis was restricted to 2,223 participants with complete information on pregnancy. Overall, median age of the participants was 18.6 years, IQR (17.6–20.3); girls and young women aged ≥18 years were slightly more than a half (55%). Majority of the participants were single (95%) at the time of enrollment, with majority of them reporting secondary school level as the highest at the time of enrollment (73%). Approximately 81.6% of girls reported a main or steady sexual partner, while approximately 3-quarters of the participants (75%) reported owning a mobile phone. Only 13% of the girls and young women earned their own income in the last 12 months.

A total of 519 incident pregnancies were recorded over 2 years of follow-up. Baseline characteristics by pregnancy status are presented in Table 1. The overall pregnancy incidence rate was 21 pregnancies per 100 woman-years of observation (95% CI [20, 23]). Nairobi and Thika had a higher risk of pregnancy in comparison to Kisumu as shown by the K–M curves in Figure 1. There was a steady increase in pregnancy incidence rates toward the end of the last quarter of 2019, this trend peaked at the end of first quarter of 2020, corresponding to declaration of COVID-19 lockdown measures in Kenya. A steady, though not statistically significant, decline in pregnancy rate is shown between the third quarter of 2020 and first quarter of 2021. Pregnancy rates in Kisumu were significantly lower post-COVID-19 lockdown (Figures 2 and 3), whereas in Thika, there was a significant increase in rates post COVID-19 lockdown. Nairobi showed a slight reduction, which was not statistically significant.

Table 1.

Baseline sociodemographic characteristics of the study population

VariablesN%
Study area 
 Kisumu 1,168 52.5 
 Thika 768 34.5 
 Nairobi 287 12.9 
Do you have a main or steady sex partner?   
 No 402 18.4 
 Yes 1,781 81.6 
Age-group in years   
 <18 years 998 44.9 
 ≥18 years 1,225 55.1 
Education level   
 None/Primary incomplete 162 7.3 
 Secondary 1,614 72.6 
 Tertiary/University 447 20.1 
Marital status   
 Single 2,102 94.7 
 Married 96 4.3 
 Divorced/separated/widowed 22 
Number of sexual partners   
 One 1,567 95.1 
 Two or more 80 4.9 
Condom use last sex   
 No 876 53.2 
 Yes 771 46.8 
Earned income in the last 12 months   
 No 1,928 86.7 
 Yes 295 13.3 
Own a phone   
 No 418 24.6 
 Yes 1,283 75.4 
Do you smoke?   
 No 2,212 99.5 
 Yes 11 0.5 
Take alcohol   
 No 2,102 94.6 
 Yes 121 5.4 
VariablesN%
Study area 
 Kisumu 1,168 52.5 
 Thika 768 34.5 
 Nairobi 287 12.9 
Do you have a main or steady sex partner?   
 No 402 18.4 
 Yes 1,781 81.6 
Age-group in years   
 <18 years 998 44.9 
 ≥18 years 1,225 55.1 
Education level   
 None/Primary incomplete 162 7.3 
 Secondary 1,614 72.6 
 Tertiary/University 447 20.1 
Marital status   
 Single 2,102 94.7 
 Married 96 4.3 
 Divorced/separated/widowed 22 
Number of sexual partners   
 One 1,567 95.1 
 Two or more 80 4.9 
Condom use last sex   
 No 876 53.2 
 Yes 771 46.8 
Earned income in the last 12 months   
 No 1,928 86.7 
 Yes 295 13.3 
Own a phone   
 No 418 24.6 
 Yes 1,283 75.4 
Do you smoke?   
 No 2,212 99.5 
 Yes 11 0.5 
Take alcohol   
 No 2,102 94.6 
 Yes 121 5.4 

N = 2,223.

Figure 1.

Kaplan–Meier curves for the cumulative risk of pregnancy by the study site.

Figure 1.

Kaplan–Meier curves for the cumulative risk of pregnancy by the study site.

Close modal
Figure 2.

Pregnancy rate for all sites combined.

Figure 2.

Pregnancy rate for all sites combined.

Close modal
Figure 3.

Overall pregnancy incidence rate pre- and post-COVID-19 lockdown.

Figure 3.

Overall pregnancy incidence rate pre- and post-COVID-19 lockdown.

Close modal

Kisumu cohort pregnancy outcomes were (67%) term live birth, induced abortion (24%), and spontaneous abortion (6%). In Thika, 60% had term live birth and 51% were spontaneous abortions (Figure 4). Nairobi had 60% term live births, 21% elective abortions, and 11% spontaneous abortions.

Figure 4.

Overall pregnancy outcomes.

Figure 4.

Overall pregnancy outcomes.

Close modal

In adjusted analysis (Table 2), pre-/post-COVID-19 lockdown, study site, age, education level, and condom use independently predicted pregnancy incidence among girls. In the post-COVID-19 lockdown period, girls and young women from Nairobi and Thika had higher risk of being pregnant, compared with pre-COVID-19 lockdown (HR = 2.29, 95% CI [1.17, 4.48], P = 0.016 and HR = 3.10, 95% CI [1.76, 5.62], P = 0.016, respectively). Condom use at last sex was associated with 71% reduced hazard of pregnancy (HR = 0.29, 95% CI [0.18, 0.46], P < 0.001); however, participants aged ≥18 years who reported having used a condom during last sexual intercourse were more likely to be pregnant compared to minors (HR = 2.00, 95% CI [1.14, 3.50], P < 0.015). Participants in secondary school were nearly 3 times more likely to get pregnant during the COVID-19 lockdown period compared to those in primary school or those with no education (HR = 2.49, 95% CI [1.37, 4.53], P < 0.003), while those in postsecondary education were twice as likely to get pregnant compared to those with primary or no education (HR = 2.06, 95% CI [1.11, 3.81], P < 0.021). (Univariate analysis of factors associated with pregnancy incidence are contained in Supplementary Table 3.)

Table 2.

Factors associated with pregnancy incidence among girls aged 15-20 years

Unadjusted HRAdjusted HR
FactorHR[95% CI]P ValueHR[95% CI]P Value
COVID-19 lockdown 
 Pre-COVID-19 lockdown Ref      
 Post-COVID-19 lockdown 1.32 [1.10, 1.57] 0.003 0.72 [0.46, 1.12] 0.147 
Interaction (pre–post#Site) 
 Post Covid#Thika    2.82 [1.59, 4.99] <0.001 
 Post Covid#Nairobi    2.09 [1.07, 4.07] 0.029 
Study area 
 Kisumu Ref      
 Thika 1.46 [1.21, 1.78]  <0.001 0.84 [0.59, 1.21] 0.366 
 Nairobi 2.4 [1.90, 3.03]  <0.001 1.56 [0.95, 2.54] 0.074 
Age-group in years 
 15–17 Ref      
 18–20 1.26 [1.05, 1.50] 0.011 0.76 [0.58, 1.09] 0.157 
Marital status 
 Single Ref      
 Married 0.83 [0.54, 1.27] 0.392    
 Divorced/separated/widowed 1.05 [0.52, 2.10] 0.894    
Highest education level 
 None/primary incomplete Ref      
 Secondary 1.43 [1.00, 2.05] 0.052 2.45 [1.35, 4.45] 0.003 
 Tertiary/university 1.68 [1.14, 2.48] 0.009 2.04 [1.11, 3.77] 0.023 
Number of sexual partners 
 One Ref      
 Two or more 0.85 [0.52, 1.37] 0.500    
Do you have a main or steady sex partner? 
 No Ref      
 Yes 1.08 [0.84, 1.38] 0.549    
Own a phone 
 No Ref      
 Yes 1.38 [1.07, 1.76] 0.011 1.16 [0.82, 1.63] 0.382 
Condom use last sex 
 No Ref      
 Yes 0.41 [0.33, 0.52]  <0.001 0.28 [0.18, 0.45] <0.001 
Interaction (condom use last sex# age-group) 
 >18 years#Yes    2.06 [1.18, 3.59] 0.010 
Do you smoke? 
 No Ref      
 Yes 0.48 [0.07, 3.47] 0.467    
Take alcohol 
 No Ref      
 Yes 1.04 [0.72, 1.51] 0.842    
Unadjusted HRAdjusted HR
FactorHR[95% CI]P ValueHR[95% CI]P Value
COVID-19 lockdown 
 Pre-COVID-19 lockdown Ref      
 Post-COVID-19 lockdown 1.32 [1.10, 1.57] 0.003 0.72 [0.46, 1.12] 0.147 
Interaction (pre–post#Site) 
 Post Covid#Thika    2.82 [1.59, 4.99] <0.001 
 Post Covid#Nairobi    2.09 [1.07, 4.07] 0.029 
Study area 
 Kisumu Ref      
 Thika 1.46 [1.21, 1.78]  <0.001 0.84 [0.59, 1.21] 0.366 
 Nairobi 2.4 [1.90, 3.03]  <0.001 1.56 [0.95, 2.54] 0.074 
Age-group in years 
 15–17 Ref      
 18–20 1.26 [1.05, 1.50] 0.011 0.76 [0.58, 1.09] 0.157 
Marital status 
 Single Ref      
 Married 0.83 [0.54, 1.27] 0.392    
 Divorced/separated/widowed 1.05 [0.52, 2.10] 0.894    
Highest education level 
 None/primary incomplete Ref      
 Secondary 1.43 [1.00, 2.05] 0.052 2.45 [1.35, 4.45] 0.003 
 Tertiary/university 1.68 [1.14, 2.48] 0.009 2.04 [1.11, 3.77] 0.023 
Number of sexual partners 
 One Ref      
 Two or more 0.85 [0.52, 1.37] 0.500    
Do you have a main or steady sex partner? 
 No Ref      
 Yes 1.08 [0.84, 1.38] 0.549    
Own a phone 
 No Ref      
 Yes 1.38 [1.07, 1.76] 0.011 1.16 [0.82, 1.63] 0.382 
Condom use last sex 
 No Ref      
 Yes 0.41 [0.33, 0.52]  <0.001 0.28 [0.18, 0.45] <0.001 
Interaction (condom use last sex# age-group) 
 >18 years#Yes    2.06 [1.18, 3.59] 0.010 
Do you smoke? 
 No Ref      
 Yes 0.48 [0.07, 3.47] 0.467    
Take alcohol 
 No Ref      
 Yes 1.04 [0.72, 1.51] 0.842    

We demonstrated that the Government of Kenya-mandated COVID-19 lockdown, which included movement restriction and closure of schools starting in March 2020, was temporally associated with a rise in the hazard of pregnancy among AGYW in central and western Kenya. These findings correlate with the spike in teenage pregnancy that was publicized by media and programmatic organizations in the wake of the COVID-19 lockdown [11]. The pregnancy incidence rate differed by site, which we hypothesize is related to regional secular adolescent pregnancy trends as well as geographically specific COVID-19 movement restrictions, as Thika and Nairobi were put under more stringent lockdown measures. This is consistent with experience from previous public health crises, such as recent Ebola outbreak in Liberia and Sierra Leone, which demonstrated reduced access to essential SRH and other health services [18, 19].

Our study demonstrates a rise in pregnancy incidence during the COVID-19 lockdown period when compared to the pre-COVID-19 period. AGYW constitutes a special population who already face social, developmental, and health systems barriers to accessing quality SRH care, including contraception, abortion, screening and treatment for sexually transmitted infections, and obstetric care [20, 21, 22]. These barriers to access and quality care expose adolescents to negative health and life-altering socioeconomic consequences: consequences that are even more pronounced in times of crisis such as disease outbreaks or war, when data suggest they are disproportionately affected. Furthermore, prior studies suggest that school closures, lack of comprehensive sexuality education, and increased risk of violence against girls and young women put them at higher risk of unintended pregnancy. A recently published study from rural western Kenya compared school drop-out and pregnancy rates pre- and post-COVID-19-related school disruptions and found a 3-fold increase in school drop-outs and a 2-fold increase in pregnancy among secondary school students whose school was disrupted, which is similar to our study findings [15].

The study population had 1 abortion for every 4 pregnancies, with 19% being induced abortions. The consequences of an unwanted pregnancy may be devastating for many adolescents, which may lead them to seek abortion in unsafe circumstances, particularly in countries where abortion is highly restricted [23, 24]. Based on extensive clinical experience in the region and confirmed reports of induced abortion in this cohort, our team suspects a far higher proportion of abortions were induced, often without a skilled provider or using practices known to be harmful [25]. Our data underscore the known high unmet need for contraception among girls and young women in sub-Saharan Africa [26] and the need to protect these services in times of crisis.

Our study has a number of strengths, including its innovative leverage of a natural experiment and use of a multisite design representing urban and rural settings in Kenya with very low loss to follow-up. We had laboratory ascertainment of pregnancy status with routine pregnancy tests done quarterly. While the present study had a number of advantages because of the availability of a well-studied cohort, this feature was also a limitation of the study because the girls and young women in the cohort had continued, though disrupted, access to SRH care including contraceptive counseling and provision of STI treatment throughout the COVID-19 lockdown due to study participation. It is likely, therefore, that age-matched girls and young women who were not members of the cohort had a higher pregnancy risk than we report, and thus, the pregnancy incidence rates may not be generalizable to nonstudy participants’ risk. We did not collect repeated measures of pregnancy intentions and the consistency of condom use, which limit our understanding of these factors as influences on pregnancy risk. Finally, our study design cannot completely account for age as a time-varying confounder of pregnancy incidence.

In conclusion, our findings contribute to the evidence empirically demonstrating the social and health consequences of the COVID-19 pandemic, which widen already-existing SRH inequities confronting AGYW. We demonstrate that despite frequent contact and comprehensive contraceptive care offered through the study clinic, girls and young women in this cohort had a similar pregnancy rate to the general aged-matched population in Kenya, many of whom did not have adequate access to SRH services during COVID-19 containment measures. Given the many barriers to contraceptive use among this age-group, ongoing investigation into their unique contraceptive needs and fertility desires, power in sexual relationships, and agency in reproductive decision-making is critical to improving adolescent SRH outcomes.

The main study that provided data for this paper is ongoing; data can be accessed by writing to RVB.

The supplemental files for this article can be found as follows:

Table 1. Independent variables (demographic characteristics).

Table 2. Independent variables (sexual behavior practices).

Table 3. Univariate analysis of factors associated with pregnancy incidence.

Figure 1. Goodness-of-fit and model diagnostics.

We thank the young women who participated in this study for their motivation and dedication and the communities that supported this work.

The KEN SHE Study was funded by the Bill & Melinda Gates Foundation (OPP1188693) and the University of Washington King K. Holmes Endowed Professorship in STDs and AIDS. The content is solely the responsibility of the authors and does not necessarily represent the views, decisions, or policies of the institutions with which they are affiliated or the KEN SHE Study funders. The funders had no separate role in the study design; data collection, analysis, and interpretation; writing of the report; or in the decision to submit for publication. The corresponding author had full access to all the data in the study and had final responsibility for the decision to submit for publication.

The authors have no competing interests to declare.

The KEMRI Scientific and Ethics Review Unit (SERU), in Kenya, and the University of Washington Institutional Review Board, Seattle, WA, approved this study. The study was registered at ClinicalTrials.gov, number NCT03675256.

All participants provided written informed consent, which included counseling about randomization, the vaccine used in each study group, strategies for cervical cancer prevention, and their rights as research participants.

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How to cite this article: Congo O, Otieno G, Wakhungu I, Harrington EK, Kimanthi S, Biwott C, et al. Pregnancy trends and associated factors among Kenyan adolescent girls and young women pre- and post-COVID-19 lockdown. Adv Glob Health. 2022;1(1). https://doi.org/10.1525/agh.2022.1811306

Editor-in-Chief: Craig R. Cohen, University of California, San Francisco, CA, USA

Senior Editor: Sarah Ssali, Makerere University, Kampala, Uganda

Section: Achieving Gender Equality

This is an open-access article distributed under the terms of the Creative Commons Attribution 4.0 International License (CC-BY 4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. See http://creativecommons.org/licenses/by/4.0/.

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