Article

Socio-Cultural Barriers Influencing Unplanned Pregnancy

in Mugombwa Refugee Camp, Rwanda: Female
Adolescents’ Perspectives
Autumn Eastman 1, *, Oluwatomi Olunuga 2, * and Tayechalem Moges 3

1 Partners in Health Liberia, Monrovia 1000, Liberia

2 HACEY Health Initiative, Lagos 101283, Nigeria
3 Gender, Sexual and Reproductive Health Masters Program, University of Global Health Equity,
Kigali P.O. Box 6955, Rwanda
* Correspondence: [email protected] (A.E.); [email protected] (O.O.)

Abstract: Female adolescents experience exacerbated vulnerability to the effects of gender inequities
in refugee settings, where there is often a lack of protective societal structures and the politicization
of their access to sexual and reproductive health (SRH) services, which result in an increase in
teenage pregnancy as compared to non-refugee settings. In the Mugombwa refugee camp in Rwanda,
there were 47 adolescent childbirths in 2021 alone. This study explores the perspectives of female
adolescents on the barriers underpinning adolescent unplanned pregnancy in the Mugombwa
refugee camp. Focus group discussions were conducted with 16 adolescent girls between the
ages of 10 and 19. The findings were analyzed using inductive and deductive thematic analysis.
Barriers at the individual, interpersonal, communal, and institutional levels underpin unplanned
adolescent pregnancy. Socio-cultural barriers of poverty and transactional sex, poor knowledge of
contraceptives, negative peer influence, sexual coercion, poor parent–adolescent communication,
negative health worker attitudes, selective SRH community outreach, and the inaccessibility of
contraceptives emerged as themes influencing the sexual behavior of adolescents and unplanned
pregnancies. The socio-cultural barriers and systemic facilitators of gender inequality associated
Citation: Eastman, A.; Olunuga, O.;
with being an adolescent female in a refugee camp must be prioritized to alleviate adolescent
Moges, T. Socio-Cultural Barriers
unplanned pregnancy.
Influencing Unplanned Pregnancy in
Mugombwa Refugee Camp, Rwanda:
Female Adolescents’ Perspectives.
Keywords: adolescent health; sexual and reproductive health; unplanned pregnancy; refugee camp;
Adolescents 2023, 3, 259–277. https:// sociocultural factors; Rwanda; gender equity
doi.org/10.3390/adolescents3020019

Academic Editors: Laura L. Hayman,

Elizabeth Reed, Rebecka Lundgren
1. Introduction
and Kathryn M. Barker
The sexual and reproductive health of adolescents, particularly in developing coun-
Received: 30 January 2023 tries, is one of the key public health and development concerns of governments, non-
Revised: 17 March 2023 governmental organizations, policymakers, and state actors worldwide. Sexual and re-
Accepted: 10 April 2023
productive health (SRH) is vital to ensure the highest well-being of adolescents across
Published: 17 April 2023
genders. The World Health Organization (WHO) states that reproductive health “is a state
of complete physical, mental, and social well-being and not merely the absence of disease or
infirmity in all matters relating to the reproductive system and its functions and processes
Copyright: © 2023 by the authors.
. . . ” [1]. Adolescents, as defined between the ages of 10 and 19, represent a particularly
Licensee MDPI, Basel, Switzerland.
vulnerable population due to their entry into puberty and sexual experiences [2,3]. Puberty
This article is an open access article
and early sexual experiences inform adolescents’ sexual and reproductive health for a
distributed under the terms and lifetime [4]. Early sexual experiences are predictive of future sexual behaviors, including
conditions of the Creative Commons contraceptive use, sexual agency and decision-making, sexual health-seeking behavior,
Attribution (CC BY) license (https:// and outcomes relating to unintended pregnancies, sexually transmitted infections (STIs)
creativecommons.org/licenses/by/ including human immunodeficiency virus (HIV), and sexual subjugation [4]. Adolescents
4.0/). in low-middle-income countries (LMIC) possess the largest global burden of poor SRH

Adolescents 2023, 3, 259–277. https://doi.org/10.3390/adolescents3020019 https://www.mdpi.com/journal/adolescents

Adolescents 2023, 3 260

outcomes, including unplanned pregnancies, unsafe abortion, and HIV/STIs [5].Globally,

adolescents face disproportionate sexual and reproductive health burdens. In several
countries, 10–15% of the total annual fertility is from adolescent pregnancies between the
ages of 15 and 19 [4]. In 2016, an estimated 777,000 births occurred among young adoles-
cent females, out of which 58% of births took place in Africa [5]. In sub-Saharan Africa
(SSA) specifically, most unintended pregnancies are adolescent pregnancies, where one in
five adolescents become pregnant during their adolescent years [4,6]. The susceptibility
of female adolescents to poor SRH outcomes is underpinned by gender-based violence,
gender norms, and unequal power relations [7,8].
Refugee settings exacerbate adolescent SRH risks and challenges due to a lack of
protective societal structures and transient resources [8,9]. The United Nations High
Commissioner for Refugees (UNHCR) conducted an inter-agency global evaluation of re-
productive health services for refugees and internally displaced persons in 2004 and found
that most people affected by conflict lack adequate SRH care and adolescents specifically
are often underserved [9,10]. Refugee camps experience constrained access to education,
employment, participation, and protection, which puts adolescent refugees at the mercy of
what is provided in the camp itself [10,11]. Adolescents experience compounded vulnera-
bility in refugee settings, where there is often a lack of emphasis on their SRH rights and
the politicization of SRH issues and access to services [8,10,11]. Refugee settings experience
increased instances of rape, trafficking, sexual exploitation, child marriage, and maternal
death [8,10,12,13]. Moreover, 50% of refugees worldwide are adolescents, demonstrat-
ing the breadth of the need to address adolescent SRH needs and challenges in refugee
settings [8].
Adolescent females experience distinct marginalization owing to their gender and age,
which exacerbates their SRH issues. Adolescent refugee girls are at an increased risk of
gender-based violence, sexual abuse, and unplanned pregnancy in refugee settings [10,11].
A study in a refugee setting in Uganda found that 25% of adolescents between 13 and
18 had ever had sex [14]. While a proportion of adolescent sexual activity is consen-
sual, systematic reviews of sexual violence in refugee settings have found that one in
five refugees experience sexual violence [15]. The literature also shows that there is
a higher incidence of teenage pregnancy in refugee settings compared to non-refugee
settings [12,16–18]. Furthermore, pregnant mothers in refugee settings are at an increased
risk of complications and maternal mortality, unsafe abortion, prolonged labor and deliv-
ery, and preterm birth [19,20]. Compounding the health risks associated with adolescent
pregnancy is the context of living in a refugee setting. Studies show that pregnancies in
refugee settings experience greater adverse outcomes [21]. A maternal death review report
of refugee camps in 10 countries found that unsafe abortion accounts for 78% of all maternal
mortality among refugee women [22]. Furthermore, adolescent motherhood perpetuates a
cycle of poverty by increasing the likelihood of dropping out of school, reducing career
progression and economic empowerment [23,24]. From an intersectional feminist lens,
it becomes clear that social categories, in combination with structures of power, create a
unique experience of SRH for adolescents.
Preventing adolescent pregnancies requires a contextual understanding of the factors
contributing to them to design interventions and policies that capture adolescents’ SRH
needs and challenges [25,26]. Despite the availability of research on the determinants
of adolescent pregnancy, research on adolescent pregnancy in refugee settings remains
minimal. Refugee settings act as unique ecosystems, harboring sub-cultures, practices,
and customs that require a context-specific analysis to understand the determinants of
adolescent pregnancy. Rwanda has been the home to 127,000 refugees from neighboring
countries across six refugee camps since 1997 [27]. A study in the Gihembe and Nyabiheke
refugee camps assessed the social and economic vulnerabilities of female adolescents and
found that lack of economic opportunity, female gender norms, material deprivation, and
vulnerability led to transactional sex and exploitation within and around the camps [10].
Another study conducted by the UNHCR in the Gihembe and Kiziba refugee camps in
Adolescents 2023, 3 261

Rwanda identified that early pregnancy and prostitution were the top harms that girls
face [12]. Similarly, a study in the Kigeme refugee camp in Rwanda found that sexual
abuse such as rape, unwanted physical touching, sexual exploitation, commercial sex, early
marriage, and girl trafficking, were facilitated by the camp conditions, lack of security, and
adolescent developmental stage [13].
The Mugombwa refugee camp, established in 2016, currently hosts approximately
11,304 refugees primarily from the Democratic Republic of the Congo, of whom 18.4% are
between the ages of 12 and 17 [28]. In 2021 alone, there were 47 births from individuals
below 20 years of age in the Mugombwa refugee camp [29]. From January to of June of 2022,
there were 25 births from individuals below 20 years of age [29]. Research conducted in six
camps in Rwanda in 2015, including the Mugombwa refugee camp, showed that overall
reproductive health service utilization was low among adolescents [23]. A similar study
in 2016 found that gender gaps existed in all sectors across camps, including conditional
pregnancy to increase family size and sex in exchange for basic needs [24]. However,
limited published research exists concerning the SRH of adolescent female refugees in
the Mugombwa refugee camp, and more specifically on the socio-cultural barriers across
socio-ecological layers that influence teenage pregnancy. This study aimed to explore the
sociocultural barriers underpinning adolescent unplanned pregnancy to inform the imple-
mentation of holistic approaches that alleviate the disparities in the sexual and reproductive
health outcomes of female adolescents, especially regarding teenage pregnancy.

1.1. Positionality Statements

1.1.1. Autumn Eastman
I am a 26-year-old white female from a small rural town in Vermont in the United
States. Having grown up in the United States, I do not have an intimate relationship with
the Rwandan context, nor do I share the same experiences as refugee adolescents. My
nationality and race often place me in a position of power and influence how people interact
with me. For this reason, I occupy the position of an outsider in most facets of this research.
Professionally, I have developed an intersectional feminist lens.I work with an ideology
of emancipation from patriarchal structures and norms within which people socialized as
women are subordinated.

1.1.2. Oluwatomi Olunuga

I am a 24-year-old black female from Lagos, Nigeria—an urban area. As an African, I
am able to understand the Rwandan context in general, but Ifable to relate to the refugee
experience. I mentor adolescents, which may help me understand adolescent behavior.
My income and culture also differ from that of the target population, creating a gap in my
understanding of their experience. As a result, I am an outsider in many ways in this study.
However, because of my training in feminist research and intersectionality, I would be able
to analyze and present the findings of this study from a feminist perspective.

2. Materials and Methods

2.1. Study Setting
This research study took place in the Mugombwa Refugee camp in Gisagara District,
Southern province of Rwanda. Mugombwa was established in 2016 and is the home of
11,304 refugees, the majority of whom are from the Democratic Republic of the Congo
(DRC) [28]. The camp is divided into eight quarters neighboring a local host community.
Congolese refugees fled the DRC in the mid-1990s due to conflict between government
forces and armed groups. The instability of state institutions, chronic violence, and re-
maining conflict over land ownership and citizenship prevent Congolese refugees from
returning home [30]. Refugees in the Mugombwa camp, therefore, depend on support for
their basic needs. UNHCR, in collaboration with African Humanitarian Action (AHA),
works to provide refugees with essential services, including but not limited to sexual and
reproductive health services [28]. AHA currently provides refugees with contraception,
Adolescents 2023, 3 262

antenatal and postnatal care, and access to safe labor at their health center. Addition-
ally, AHA conducts monthly community-based SRH awareness sessions for refugees and
health professionals.

2.2. Study Design and Sampling

A qualitative descriptive study design was employed utilizing focus group discussions.
Purposive sampling was used to select 16 adolescent girls between the ages of 10 and 19
from primary and secondary schools living in the Mugombwa refugee camp, using the
attendance sheets provided by school authorities. Consent and assent were obtained from
the adolescents and their parents/guardians.

2.3. Data Collection

Two separate focus group discussion sessions were conducted with eight 10–14-year-olds
and eight 15–19-year-olds using a semi-structured interview guide developed to understand
the socio-cultural barriers influencing unplanned pregnancy among female adolescents in the
Mugombwa camp. The adolescents were separated into two groups to investigate potential
differences in perspectives between early adolescents and late adolescents. Additionally, as
research often overlooks the voices of those aged 10–14 years, we deliberately included them
while taking measures to prevent any influence from the 15–19-year-old adolescents on their
responses. The interview guide consisted of open-ended questions to allow adolescents to
freely explain themselves, followed by probes. The interview guide included the following
topics: prevalent health concerns in the refugee camp, teenage pregnancy, the use of and
accessibility of SRH services, factors influencing sexual behavior, satisfaction with SRH
services available, and desires as it relates to the availability, appropriateness, and quality
of SRH services. The interview guide was developed in English and translated by a native
Kinyarwanda speaker from the University of Global Health Equity. The interview guide was
also pretested by having one native Kinyarwanda speaker back-translate the questionnaire
for accuracy. Two female data collectors, concordant with our study population, were trained
over 4 h to use the interview guide and conduct the focus group discussions.
Data collectors acquired informed consent and assent before the interviews. In the
event that a research participant and or their parents were illiterate, the data collector
verbally explained the research study and consent form to the participant in Kinyarwanda
and acquired signed consent. Participants who consented to participate were invited to
a private, spacious, and easily accessible location provided by the schools for the focus
group discussion. Each focus group discussion lasted approximately 90 min. The focus
group discussions were conducted and recorded in Kinyarwanda. The recordings were
also transcribed in Kinyarwanda and then translated into English for data analysis. Upon
preliminary data analysis, the principal investigators deemed that data saturation had
been reached.

2.4. Data Analysis

The data were coded manually using inductive and deductive coding. To ensure
an intersectionality-informed analysis, a two-step hybrid approach developed by Sirma
Bilge was used to analyze this data [31]. In the first step, two principal investigators
independently manually reviewed each transcript and conducted open and axial coding
of the qualitative data in order to identify emergent themes, patterns, and connections.
In the second step, the principal investigators deductively reinterpreted the data using
an intersectionality-focused analysis and the socio-ecological model to identify factors
influencing unplanned pregnancy [31]. The investigators collaboratively compared the
codes, which led to the collaborative deductive creation of themes under broad socio-
ecological levels (individual, interpersonal, communal, institutional) based on their relation
to unplanned pregnancies.
 led to the collaborative deductive creation of themes under broad socio-ecological levels
(individual, interpersonal, communal, institutional) based on their relation to unplanned
pregnancies.
Adolescents 2023, 3 263
3. Results
The demographic characteristics of participants and the themes that emerged from
the FGDs are presented below.
3. Results
The demographic
3.1. Characteristics characteristics of participants and the themes that emerged from the
of Participants
FGDs are presented below.
A total of 16 girls from the age groups of 10–14 and 15–19 participated in two separate
FGDs. Two separate
3.1. Characteristics FGDs were conducted to create a welcoming environment for both
of Participants
early and late adolescents to express their thoughts freely without the potential inhibition
A total of 16 girls from the age groups of 10–14 and 15–19 participated in two separate
of the other age group since early and late adolescents have the potential to influence each
FGDs. Two separate FGDs were conducted to create a welcoming environment for both
other’s responses. All of the adolescents spoke Kinyarwanda and their parents were orig-
early and late adolescents to express their thoughts freely without the potential inhibition
inally
of thefrom
otherthe DRC.
age groupAll since
participants lived
early and in adolescents
late the Mugombwa haverefugee camp but
the potential attended
to influence
one
eachofother’s
two schools locatedAll
responses. outside
of thethe refugee camp
adolescents spokewhich are integrated
Kinyarwanda with adoles-
and their parents
cents from the host community.
were originally from the DRC. All participants lived in the Mugombwa refugee camp but
attended one of two schools located outside the refugee camp which are integrated with
3.2. Unplanned
adolescents Pregnancy
from the hostascommunity.
a Leading Health Concern for Adolescents
When asked about what the primary health concerns are of an adolescent living in
3.2.Mugombwa
the Unplanned Pregnancy as a Leading
refugee camp, Health frequently
participants Concern for responded
Adolescents with unplanned preg-
nancy:When asked about what the primary health concerns are of an adolescent living in the
Mugombwa refugee camp, participants frequently responded with unplanned pregnancy:
“Something that I realized, many adolescents from our camp get pregnant at an early
“Something that I realized, many adolescents from our camp get pregnant at an early age.”
age.” (10–14 years old girl)
(10–14 years old girl)
The
The FGDs
FGDsrevealed
revealedsociocultural
socioculturalfactors
factorsat
atthe
theindividual,
individual,interpersonal,
interpersonal,communal,
communal,
and institutional levels that influence adolescent unplanned pregnancy
and institutional levels that influence adolescent unplanned pregnancy (Figure 1).

Figure
Figure1.
1.Socio-ecological
Socio-ecologicalmodel
modelof
ofsociocultural
socioculturalbarriers
barriersinfluencing
influencingunplanned
unplannedpregnancy
pregnancyamong
among
adolescents in the Mugombwa refugee camp, Rwanda.
adolescents in the Mugombwa refugee camp, Rwanda.

3.3. Individual-Level Factors

At the individual level, four major themes arose: (1) poverty and transactional sex,
(2) drug and alcohol use, (3) lack of knowledge about contraceptives, and (4) fear of
contraceptive side effects.
Adolescents 2023, 3 264

3.4. Poverty and Transactional Sex

Adolescents overwhelmingly described how poverty challenges the lives and deci-
sions of adolescents. Participants specifically described a causal model of how poverty
contributes to the high prevalence of transactional sex, which is frequently accompanied
by unplanned pregnancies. Transactional sex was spoken of as a necessity to meet an
adolescent’s basic needs:
“You may be at home with a problem of poverty that you feel will be solved if you go into
prostitution. You feel like that bad idea will help you to have a better tomorrow.”
(15–19 years old girl)
“Most of the difficulties that people of our age encounter in our community is poverty.
Sometimes you can find your family being poor and not having the ability to afford
all your needs and this leads to prostitution. This bad thinking and decision can ruin
your future.”
(15–19 years old girl)
The other side of the conversation on the prevalence of transactional sex also high-
lighted how adolescents not only use transactional sex for basic needs but also as a source of
income to have the freedom to satisfy the desire to have materialistic pleasures. While this
was not a pervasive narrative, some participants explained that their peers feel hopeless in
the camp setting.

3.5. Drug and Alcohol Use

Participants identified the connection between the use of drugs and alcohol and
unplanned sexual behavior. They shared that drug and alcohol use influences risky sexual
behavior use such as the non-use of condoms, which leads to unplanned pregnancies and
HIV/AIDS.
“My point of view is that there are some girls from our age who get pregnant and are
affected by HIV/AIDS due to using alcohol and drugs.”
(10–14 years old girl)
The discussions revealed that adolescents perceive alcohol and drug use to be a
gateway to unplanned pregnancies as a result of impaired judgment to protect oneself
during intercourse. Participants also illustrated a connection between drug and sexual
assault perpetrated by boys in their community. They shared that, when the boys take
drugs, its effect on them could lead to nonconsensual sex on a female.
“Some of the boys involve or engage in taking drugs like Marijuana and many others.
After using drugs many of them think that what is next is having sex. Sometimes this
may result into rape or sexual exploitation. That is my personal view.”

3.6. Lack of Knowledge about Contraception

A common theme among participants was the issue of lack of knowledge on SRH.
Adolescents described a lack of knowledge and awareness on contraception to be a reason
for the prevalence of unplanned pregnancies:
“Sometimes adolescents don’t have enough knowledge on contraception and STIs. When
they have bad habits of having sex, they may have early pregnancy or be STI positive.”
(15–19 years old girl)
“Many adolescents don’t have knowledge on sexual and reproductive health. They are
sometimes ashamed of asking for information about that, thinking that people will laugh
at them which leads them to do what they don’t know.”
(15–19 years old girl)
Participants described how, if adolescents had more knowledge about contraceptive
use, for example, they would be able to prevent pregnancy better. In discussions about
Adolescents 2023, 3 265

condom use, participants commonly shared that adolescents do not know how to use
condoms properly and therefore fear using them:
“Some people our age fear to use condoms on account of not having adequate knowledge
about the use of them. They fear negative effects that may result from using a condom
improperly.”
(10–14 years old girl)
Participants shared that having improved SRH knowledge and regular interaction
with SRH information would enable them to better navigate their own SRH.

3.7. Fear of Contraceptive Side Effects

The fear of side effects was the most common reason adolescents shared for not using
contraceptives. Participants shared how negative perceptions of contraceptive methods
result in unprotected sex and unplanned pregnancy:
“Sometimes you feel like you want to have sex, but you immediately hear bad things
about those contraceptive methods. You feel like you cannot use them. You choose to do
unprotected sex and get pregnant. So, we need many people who come to us for advice.”
(15–19 years old girl)
“We have been told that using IUD (intrauterine device) can bring negative effects to
females. In addition to this, when a young girl engages in using contraceptive methods,
this will cause ruin her life, and you may end up losing fertility. That is how I understand
about that topic.”
(15–19 years old girl)
Adolescents explained that those who have a fear of side effects from contraceptives
feel more comfortable using condoms, cycle tracking, or unprotected sex.
“As far as I am concerned, many girls don’t prefer to use implants and injections; instead,
they prefer using condoms for the sake of avoiding unintended pregnancies as well as the
sexually transmitted diseases.”
(10–14 years old girl)
“Some people in our community think that using IUDs can cause them to become sterile.
Which is the inability to produce a child. Apart from that, the IUD can cause other serious
problems. Another method that you didn’t mention is that girls should know how to
count their monthly periods. This will help them to avoid unwanted pregnancies.”
(15–19 years old girl)

3.8. Interpersonal-Level Factors

At the interpersonal level, three themes were present: (1) peer pressure and influence,
(2) sexual coercion, and (3) parent–adolescent relationships.

3.9. Peer Pressure and Influence

Adolescents’ peer groups and spheres of social influence frequently appeared through-
out the discussions on sexual behavior. Adolescents described their peers as either major
enablers or disablers of their sexual and reproductive health. While many adolescents
reported their peers to be useful sources of their conversations about SRH, the majority of
adolescents also stated that it was important for them to avoid negative peer influence to
avoid sexual relations and unplanned pregnancy and to reach their dreams:
“Challenges people of my age or adolescents that we commonly face in our community
is peer pressure. When those adolescents have bad friends, they sometimes engage in
sexual relations. This contributes to the increase in the number of pregnancies in our
community.”
(15–19 years old girl)
Adolescents 2023, 3 266

Respondents revealed the importance of peers in adolescent SRH wellness. While

some adolescents cited their colleagues and friends as their major source of information,
others spoke about the risks of their peer groups. Several participants described how boy
peer pressure puts adolescent girls at a unique risk of unintended pregnancy by influencing
boys to sexually coerce or rape girls:
“Based on what I see in our community, boys of our age are affected by peer pressure
groups. In that group, some of them have girlfriends, and others don’t. Those who have
girlfriends teach their colleagues some methods/techniques that they can use in order to be
accepted. Some of them use alcoholic drinks as the best option of not being feared. Others
advise them that if she refuses, take her by force. This will lead to impregnating that girl
or getting HIV/AIDS. So boys have the problem of peer pressure.”
(15–19 years old girl)

3.10. Sexual Coercion

Participants, most notably between the ages of 15 and 19, also described the issue of
sexual coercion in the context of intentional contraceptive misuse as a factor of unplanned
pregnancy. Participants explained that boys coerce girls into having sex without a condom
or purposely damage or manipulate condoms during sexual intercourse, which predisposes
girls to unplanned pregnancies. One of the female participants explained:
“ . . . There is a time when you can have sex with a boy thinking that you are using
a condom while a boy has already made a hole at the head of the condom, aiming to
impregnate that girl. So as girls, we have to make decisions for ourselves. About having
sex, I still have enough time. It is better to do that with my own husband. About using
condoms properly, it is better that a girl can be aware of checking if the condom is safe.”
(15–19 years old girl)
Participants felt that educating girls on sexual and reproductive health would protect
them from contraceptive misuse.

3.11. Parent–Adolescent Relationships

Participants shared how the openness of communication between adolescents and
parents about SRH topics is an important determinant of an adolescent’s SRH. Participants
expressed that they feel most trusting of their parent’s ability to give them accurate and
trustworthy information. However, adolescents shared that parents often avoid conversa-
tions about SRH with their children:
“Some of our parents when you ask them about sexual and reproductive health questions,
they take you as a prostitute.”
(15–19 years old girl)
“For me, you can not engage yourself to ask something to your mom while she has never
asked you to have conversations related to that topics. Some of us have the chance of
having educated parents. When they are educated, they are aware of that and you can
ask everything that you don’t know. But imagine having uneducated mom and you are
willing to discuss with her about sexual activities topics. I think she cannot even allow
you to discuss on that.”
(15–19 years old girl)
A prominent desire among adolescents was to have community health workers train
their parents so that they could be able to actively participate in preventing unplanned
pregnancies. An adolescent explained:
“I would recommend the health workers to talk to our parents so that they can spare time
with their children in terms of talking to them about sexual reproductive health. This will
reduce unintended pregnancies, the STI, and the HIV.”
(10–14 years old girl)
Adolescents 2023, 3 267

“My point of view, it could be better if the well-trained health workers from our com-
munity approach our parents and teach them how useful it is to talk to their kids about
sexual reproductive health. This is because many adolescents at our age get pregnant, and
I think this is because many parents in our community don’t spare time with their kids in
teaching them about sexual reproductive health.”
(10–14 years old girl)

3.12. Communal-Level Factors

At the communal level, three themes emerged: (1) selective SRH outreach, (2) miscon-
ceptions about contraceptive use, and (3) abstinence as morally superior.

3.13. Selective SRH Outreach

Participants, primarily in the 15–19 age group, shared that, while community health
workers do some community SRH outreach, community health workers cater to pockets of
the population and lack comprehensive coverage of the adolescent population. Adolescents
explained that this leads to large pockets of the population without SRH knowledge:
“Sometimes the community health workers make injustice while choosing girls in our
quarters. They are used to choosing the same girls while we have so many girls in our
quarter. The rest of the other girls will never have that knowledge because they train the
same ones.”
(15–19 years old girl)
“What can be changed in our community is that community health workers are so
selective. This is where they always choose the same person on every training. I think
they should take all the girls in our quarter.”
(15–19 years old girl)
Participants also expressed how younger adolescents are often left out of community
health worker SRH outreach activities. Adolescents between the ages of 10 and 14 are
not often thought of as being sexually active, but participants explained that some in the
camp are, which predisposes them to unplanned pregnancies when they are not included
in outreach:
“My opinion is that people under fourteen years old are neglected, and based on my expe-
rience, a large number of adolescents in Mugombwa refugee camp that are impregnated
are those of fourteen. This should be changed, and take from ten years then above, because
there are some girls who start their monthly period at twelve.”
(15–19 years old girl)

3.14. Misconceptions about Contraceptive Use

Condoms were the most widely discussed contraceptive method used among ado-
lescents. However, several adolescents explained that there are general communal mis-
conceptions about condoms that prevent adolescents from using protection during sex. A
common belief shared among adolescents was that if a condom is used it will get lost inside
the vagina:
“For me, the only thing I can share is that we need a lot of information about reproductive
health so that you don’t get sick or get pregnant. Because sometimes we hear false
information. For example, when a virgin uses a condom, that can get inside the sex. The
injection also causes disease. In general, we need enough information on these things to
teach our peers.”
(15–19 years old girl)
Adolescents 2023, 3 268

“ . . . There are some girls or boys who decide not to use condoms during sex due to some
speculations in our camp that say that once a condom is misused, it may stay in a girl’s
private part.”
(10–14 years old girl)
For some adolescents, the fear of misusing a condom renders unprotected sex more
appealing than using protection.

3.15. Abstinence as Morally Superior

Adolescents shared that they believe abstinence is the superior method of contraception
as compared to other hormonal contraceptives. Participants shared that abstinence is the
surest and best way to avoid unintended pregnancies, HIV, and STIs. A participant explained:
“For me to reach out to my dream, I have to apply abstinence by avoiding unintended
pregnancies.”
(10–14 years old girl)
“My recommendation is that; they can reinforce adolescents to have abstinence for
themselves. If not possible they can then use condom. But the first is abstinence.”
(15–19 years old girl)
The primary belief in abstinence reveals itself as a deterrent to utilizing other contracep-
tive methods. Many adolescents only endorsed the use of contraceptives once abstinence
failed. The use of contraception among adolescents was viewed as a result of failing to
abstain. One participant narrated:
“The reasons why people with our age but different sex apply birth control it’s because
they fail with abstinence.”
(10–14 years old girl)
Failing to abstain was also referenced in a negative light as the result of not being able
to control oneself. It was clear through the discussions that engaging in sexual intercourse
as an adolescent is stigmatized based on the belief that abstinence is superior.

3.16. Institutional-Level factors

At the institutional level, three themes emerged: (1) inaccessibility of contraceptive
services, (2) negative attitudes of health workers, and (3) insufficient health workers and
gender representation.

3.17. Inaccessibility of Contraceptive Services

A common concern among adolescents was the location of SRH services. Adolescents
explained that contraceptives are largely centralized in the health center, which prevents ado-
lescents from accessing them due to the fear of communal judgment. A participant explained:
“I really feel like we must find people here in the camp who will go and talk to the youth
every week. Because young people are afraid to go to the hospital. And questioning is
important to us, and it makes them less likely to engage in sexual activity.”
(15–19 years old girl)
“According to me, people from our community are used to seeking condom services at our
health center. It could be better if condoms are distributed in public bathrooms so that they
can be available for those people who feel uncomfortable to get them at our health center.”
(10–14 years old girl)
When asked if some adolescents feel ashamed asking for contraceptives, one partici-
pant said:
“Yes, there are so many. This is where people laugh at me, imagine at my age asking for a
condom. It’s better for us to put condoms on toilets where we will get it freely.”
Adolescents 2023, 3 269

(15–19 years old girl)

“When you are a girl and using the method of counting the days [of your menstrual
cycle] will also help you. This can help you without asking for those services. You can do
it for yourself.”
(15–19 years old girl)
Overwhelmingly, participants shared their desire to have a private, youth-specific
space to discuss SRH issues and access contraceptive services privately without the fear of
judgment from other community members.

3.18. Negative Attitudes of Health Workers

When adolescents spoke about their access to SRH services, they spoke about the
large role that health professionals play in the dissemination of information and services.
However, adolescents expressed that they have experienced judgment and unwelcoming
responses from health professionals in response to their use of services, which hinders their
access to SRH services:
“There are some service providers whom you tell your problem to, and they laugh at you.
After that, you decide to never tell them all your problems.”
(15–19 years old girl)
“There is a time when you ask someone a question, and they reply ‘why are you asking
that question’? When you ask someone, and they tell you that, you immediately feel like
you will never go back.”
(15–19 years old girl)
Adolescents explained their need for receptive health professionals who are comfort-
able speaking about SRH topics to adolescents.

3.19. Insufficient Health Workers and Gender Representation

In addition to a lack of positive regard, participants explained that health professionals
are often not present or available in the health center due to large demand. They explained
how even singular negative experiences with this act as a barrier for them from utilizing
the services in the future. One participant explained:
“I feel maybe you are going to ask someone a question. You find that he/she has a lot of
things, yet you want a quick answer. When you go and ask him, there are times when he
is talking to many people.”
(15–19 years old girl)
A solution many adolescents offered to address the issues they have experienced
with health professionals is to expand the team of community health workers capable of
responding to the needs of adolescents:
“My point of view, it would be better if our health center increases the number of nurses.
I realized that a person may go to seek health services at a hospital, and it takes time to be
hosted due to a big number of people who come to seek different services at the hospital. In
addition, it would also be supportive if the number of health workers increases as well.”
(10–14 years old girl)
The majority of 10–14-year-olds expressed their appreciation for the value community
health workers bring to adolescents who need information to avoid pregnancy.
“There is a time when a girl does sex, and she doesn’t get pregnant because of the
advices obtained from a well-trained health worker. Mostly our health workers are used
to counseling about how to avoid unintended pregnancies and the sexual transmitted
diseases through using condoms.”
(10–14 years old girl)
Adolescents 2023, 3 270

Participants expressed that not only is an increase in the number of community health
workers needed, but a health workforce composition with adequate gender representa-
tion is necessary to allow both males and females to comfortably access care and ask
sensitive questions:
“In Mugombwa Health Center there is a lady called PELAGIE who is providing good
services for adolescents. Myself and my colleague wish to have many as that lady. I think
adolescents of Mugombwa refugee camp need people like her, she is flexible and we benefit
more from her. So it’s better to bring more females than men. Because adolescents are
more flexible when they are being advised by ladies. Of course, when he is a man, we
don’t feel comfortable asking some questions. We sometimes become ashamed for asking
some questions.”
(15–19 years old girl)

4. Discussion
This qualitative study sought to grant female adolescents epistemic authority to
narrate their experiences and perceptions concerning unplanned adolescent pregnancy
in the Mugombwa refugee camp in Rwanda. Each year, several dozen adolescents fall
pregnant in the Mugombwa refugee camp. The findings present important insights into the
sociocultural barriers influencing unplanned adolescent pregnancy at four socio-ecological
levels: individual, interpersonal, communal, and institutional. Each year, several dozen
adolescents experience unplanned pregnancies in the Mugombwa refugee camp, which
imposes massive effects on their health, economic stability, school status, and future
trajectory [21,23,24,29,32].
Adolescents painted a glaring picture of how poverty influences adolescent girls’
decision to engage in transactional sex. Most of the narratives appeared to indicate that
transactional sex was used to compensate for a lack of access to basic needs. Several other
studies, including some in Rwanda, have highlighted the presence of transactional sex and
sexual violence in refugee settings in exchange for food, menstrual hygiene products, money,
and other goods [13,15,33,34]. The body of literature echoes how poverty influences the
acquisition of unplanned pregnancies, STIs, and HIV through prostitution [32,35,36]. These
findings demonstrate how poor socio-economic status directly predisposes adolescents
to sexual abuse and unplanned pregnancy. In Rwanda, the age of consent for sex is set
at 18 years of age, whereas the age of marriage is 21. The age of consent for sex has a
close-in-age exception for consensual sex between two adolescents above the age of 14 and
below the age of 18 [37]. The Rwandan law criminalizes forced prostitution, trafficking,
and exploitation of others. Law No. 51/2018 defines sexual exploitation as “the obtaining
of financial or other benefits through the involvement of another person in prostitution,
sexual servitude or other kinds of sexual services, including pornographic acts or the
production of pornographic materials” [38]. Article 12 of the same Law No. 51/2018 also
establishes special assistance to the child victim [38]. Subjecting children to prostitution is
also an offense under the Law Regulating Labour No. 13/2009 [39]. Although the UNHCR
sets standards to prevent sexual abuse of minors in refugee settings for organizations
working with this key population that seek to implement different components of child
protection mechanisms, including appointment and training of child protection officers,
child-friendly reporting mechanisms, response and support services, and an accountability
mechanism for perpetrators, the efficacy of these mechanisms within the Mugombwa
refugee camp is not well understood [40]. Furthermore, access to comprehensive services
for survivors of gender-based violence is only via a “One-Stop” center at a district-level
hospital that is located 20 km outside of the Mugombwa refugee camp [41]. Our results
highlight that adolescents do not perceive prostitution as child sexual abuse, but rather
as a means to acquire their basic needs within the refugee camp. The availability of
economic opportunities is a strong determinant of engagement in transactional sex [10].
Therefore, there is a strong need to inject robust income-generating activities in the camp as
well as comprehensive education around sexual consent, exploitation, coercion, and child
Adolescents 2023, 3 271

sexual abuse, and systematized measures that safeguard refugees from sexual violence and
effective early intervention and therapeutic healing opportunities.
Drug and alcohol use was also identified in our results and in the literature as a
risk factor for sexual violence and unplanned pregnancy [36]. A sense of hopefulness
about life’s trajectories significantly impacts drug and alcohol use and sexual behavior. A
study on the psychosocial indicators of adolescent risk behaviors showed that adolescents
with higher perceived social mobility were less likely to report alcohol consumption and
engagement in compensated sex and they were more likely to use a condom during sexual
intercourse [42]. The hopelessness and lack of perceived social mobility that a refugee
setting can confer for adolescents is an important area of further research and intervention to
prevent drug and alcohol abuse, transactional sex, and risky sexual behavior. It is therefore
crucial that research and interventions consider the intersectionality of an adolescent who
is also a refugee since adolescent refugees experience more transient social statuses, which
predisposes them to greater risk factors for unplanned pregnancy [8,10–12,16–18,24].
This study also demonstrated the important role of parents in adolescent SRH and
preventing unplanned pregnancies. Adolescents reported that their parents are their most
trusted sources of SRH information and advice. Similar studies in other humanitarian
settings have shown similar findings that mothers and fathers are a significant source of
SRH information [43–45]. Furthermore, other research points to poor parent-child commu-
nication regarding SRH matters as an interpersonal barrier to accessing contraceptives [46].
A major recommendation among adolescents was to have community health workers
train their parents so that parents are equipped with more information on SRH to educate
their adolescents. The literature supports this recommendation, showing that open discus-
sion about SRH topics between parents and adolescents positively influences adolescents’
perceptions and sexual behavior [36,46,47].
Furthermore, participants described the issue of negative peer influence and a wealth
of unreliable information from peer groups that contribute to poor sexual choices and
unplanned pregnancies. Consistent with our findings, several studies have also shown
how an adolescent’s social environment, specifically peers, greatly influences contraceptive
utilization [48–50]. Peers can therefore serve as promising champions of SRH change.
Future SRH outreach in the Mugombwa Camp may consider tapping into this powerful
communication channel between peers to target contraceptive awareness raising.
The results of our study show that adolescent females have inadequate exposure and
access to sexual and reproductive health information, especially as it pertains to contra-
ceptive use. The literature corroborates our finding that adolescent girls frequently lack
SRH information [43]. Myths and misconceptions about contraceptives proved to be a
large communal barrier to contraceptive utilization. Poor knowledge of contraceptive use
influences myths and misconceptions about contraceptives and unprotected sex [48,51,52].
Furthermore, research has shown that knowledge of contraceptive use greatly influences its
utilization [48,53]. Our findings indicate an urgent need for regular training on how to use
contraceptives to mitigate unplanned pregnancies. Furthermore, participants explained
how adolescents commonly fear side effects associated with hormonal contraceptive meth-
ods. This finding is similar to a large body of research in several regions that have also
shown that fear of side effects is one of the leading barriers to using hormonal contracep-
tive methods [33,52,54,55]. The fear of side effects, as highlighted by our results, is the
result of both colloquially inherited myths and personal experience. Fear of side effects
is largely analyzed in the literature from the lens of misinformation [33,56]. However,
personal narratives and scientific literature demonstrate the pervasiveness of side effects
from hormonal birth control [33,55,56]. These findings highlight the need to use informed
consent by expanding education on the mechanisms of contraceptive action and providing
accurate information on both the possible side effects and benefits of available methods
during contraceptive counseling.
Our findings also highlight disparities in access to SRH information among adolescents.
The participants explained that SRH outreach is selective to only certain sections of the
Adolescents 2023, 3 272

camp quarters and frequently neglects 10–14-year-olds. The younger adolescent age
group is frequently neglected in SRH programming [57]. Although our findings did
not focus on macro-level political factors, the Rwandan laws and policies on refugees do
not address how age and gender impact access to opportunities and the well-being of
adolescents [58,59]. Policies without an intersectional lens create gaps in the solutions they
inform in addressing the diverse needs of adolescents in the Mugombwa camp itself [58].
In the Mugombwa refugee camp, the information, education, and communication (IEC)
materials used to sensitize younger adolescents between the ages of 10 and 14 on SRH
are produced by the Rwanda Ministry of Health (MOH). Currently, IEC materials for
10–14-year-olds only contain information on puberty, menstruation, and available SRH
services, excluding information on contraceptive use, which the older adolescents’ IEC
materials contain [60]. Furthermore, the situational analysis guiding Rwanda’s 2018 Family
Planning and Adolescent SRH policy strategic plan, which was led by the MOH, does
not include gaps faced by adolescents living in refugee camps, nor does it include the
needs of 10–14-year-olds [59]. The poor inclusion of adolescent refugees and younger
adolescents in this policy may limit the development of IEC materials used to sensitize
younger adolescents in the Mugombwa refugee camp. This gap may contribute to the
increase in teenage pregnancy among younger adolescents in the camp. More than one-
third of births to mothers younger than 15 in developing countries are unplanned [5]. It
is important that all stakeholders involved in adolescent SRH in the refugee camp setting
ensure the full involvement of younger adolescents in the planning and implementation of
SRH programs.
At the institutional level, negative attitudes of health workers and minimal health
workforce capacity were prominent barriers to accessing and utilizing contraceptives.
It is well understood in the literature that shame, stigma, and judgmental attitudes of
health workers towards adolescents predict low SRH service utilization, including con-
traceptives [36,54,61,62]. Creating a safe and welcoming environment for adolescents
significantly contributes to their acceptability and accessibility to SRH services. Adoles-
cents also recommended increasing the number of health workers so that adolescents
have a variety of individuals they can approach whom they are comfortable with. In the
Mugombwa refugee camp, there are approximately 23 community health workers (CHWs)
for the entire camp, and each focuses on a specific issue within the camp, whether that be
sanitation, maternal health, HIV, etc. [41]. The absence of specific adolescent SRH outreach
by CHWs could explain the gap adolescents have expressed. There is a need to assess the
human health resource capacity within the camp to ensure that there are adequate numbers
of health professionals available to conduct outreach comprehensively on SRH topics.
While sexual and reproductive health services are vital to preventing unplanned
pregnancy among adolescents in the Mugombwa refugee camp, our findings demonstrate
that sociocultural factors at each socio-ecological level underpin adolescent sexual behavior
despite the provision of these services. Adolescents’ main recommendations were to have
a private, youth-friendly space, bolster health worker capacity in the camp, and train
adolescents and parents regularly on SRH topics. These recommendations align with other
literature on adolescent service utilization that shows that adolescent-friendly spaces, peer
workers, school-based activities, and involving young people in programming increase
intervention utilization [63]. Each of these recommendations offers an opportunity to
improve the accessibility, acceptability, adequacy, and appropriateness of SRH services for
adolescents in the Mugombwa camp to prevent unplanned pregnancy.
The risk factors surrounding adolescent females in a refugee setting cannot be dis-
cussed independently of gendered roles that influence each socio-ecological layer and
the power dynamics that subject adolescent females to sexual violence and unplanned
pregnancy. While this study sought to centralize the voices of female adolescents to grant
them epistemic authority, our results also have the potential to overstate the control and
power they have over their decision making. The refugee setting and pervasive cultural and
gender norms often confer female adolescents with a lower social status, lack of decision-
Adolescents 2023, 3 273

making autonomy, dependency on men, and vulnerability to gender-based violence [7]. In

other words, female adolescents are not inherently vulnerable unless the socio-ecological
conditions and instability in refugee settings permit that vulnerability. Our results in the
context of the socio-ecological model demonstrate how the agency and decision making
power of female adolescents is complexed by social and political forces that supersede
individual health behavior and hinder the sexual and reproductive agency of adolescent
females [64].

5. Study Limitations and Strengths

This study faced some challenges and limitations. Language differences between the
principal investigators, study participants, and enumerators limited the data quality checks
performed during and after data collection. The selection criteria for participants were
purposive and information was self-reported, which could have led to information bias.
This study could have also been affected by social desirability bias due to the focus group
environment. Given the potentially sensitive nature of this topic, participants may have
responded with answers to appeal to the moderator or peers. This study’s findings are also
not generalizable to all adolescent experiences within the Mugombwa refugee camp, nor in
other refugee camps in or out of Rwanda. Focusing our sampling strategy on adolescents in
school was also a limitation of this study, however, since the refugee camp is a well-defined
cohesive setting with internal migration, adolescents whether in or out of school are likely
exposed to many different experiences that inform their perspectives as it relates to teenage
pregnancy. In this study, we centralized the voices of female adolescents to grant them
epistemic authority surrounding the narratives on unplanned pregnancy. Therefore, this
study did not take into account the perspectives of other individuals who play a role in
the issue of unplanned pregnancy such as parents, camp stakeholders, partners, health
workers, government officials, etc. Although there may have been enablers present within
the camp to prevent teenage pregnancy, our study solely focused on examining the barriers
that contribute to an unplanned pregnancy.
Despite its limitations, the main strength of this study is its focus on centralizing
the voices of female adolescents who live within the vulnerable context of the refugee
camp. This approach not only expands our understanding of the challenges faced by these
often-neglected groups living in refugee camps but also has the potential to inform policy
and program development that offers superior support to this population. Additionally,
centering the voices of themarginalized or overlooked is an important step toward achieving
greater equity and social justice.

6. Recommendations
Our recommendations seek to transform the power relations and systemic facilitators
of gender inequalities within the Mugombwa refugee camp to reduce unplanned pregnancy
using the socio-cultural barriers that emerged from this study. The results of this study de-
mand a holistic model of sexual and reproductive health that addresses social determinants
of adolescent pregnancy. We recommend that interventions and policies aim to improve
the capacity of health professionals to deliver contraceptive services, involve adolescents
and parents as principal stakeholders in program design and implementation, and target
SRH outreach specifically to “invisible groups” such as those between the ages of 10 and
14. Furthermore, an analysis of the responsiveness of UNHCR child sexual abuse policies
merits further investigation to modify or design interventions including community health
workers, men, and boys to prevent, intervene, and respond to adolescent sexual abuse.
Interventions aimed at engaging men and boys to promote SRH services use should also
be designed and implemented in the refugee camps.
In the future, there is also a need to explore the SRH needs of people with multiple
marginalized identities such as those with disabilities, and male adolescents within the
camp setting. Additionally, further exploration is needed on the efficacy of SRH sensiti-
Adolescents 2023, 3 274

zation and information delivery mechanisms within the camp to establish more rigorous
channels of communication about SRH topics to adolescents.

7. Conclusions
This study provides insights into the SRH experiences of adolescent girls living in
the Mugombwa refugee camp in Rwanda. Its findings present an understanding of the
sociocultural barriers contributing to unplanned pregnancies among adolescents. Despite
the provision of SRH services in the camp, adolescent females experience context-specific
barriers to accessing SRH services on the individual, interpersonal, community, and macro-
social levels. The adolescents’ main recommendations for improving SRH services for
adolescents were to offer youth-specific services outside of the health center, increase the
regularity of SRH training, increase health worker capacities, and train parents and youth
as SRH stakeholders. Our findings demonstrate that SRH interventions must address these
socioecological determinants to robustly protect adolescent sexual and reproductive health.

Author Contributions: Conceptualization, A.E. and O.O.; methodology, A.E. and O.O.; formal
analysis, A.E. and O.O.; investigation, A.E. and O.O.; data curation, A.E.; writing—original draft
preparation, A.E.; writing—review and editing, A.E., O.O. and T.M.; visualization, A.E.; supervision,
T.M.; project administration, A.E. All authors have read and agreed to the published version of
the manuscript.
Funding: This research was funded by the University of Global Health Equity: Grant ID 5572.01.
Institutional Review Board Statement: This study was conducted in accordance with the Declaration
of Helsinki and approved by the Institutional Review Board of the University of Global Health Equity
(UGHE-IRB/2022/013 on 19 April 2022).
Informed Consent Statement: Informed consent was obtained from all subjects involved in the study.
Data Availability Statement: The data presented in this study are available on request from the
corresponding authors. The data are not publicly available due to co-ownership with UNHCR
and AHA.
Acknowledgments: We want to acknowledge the partnership of Africa Humanitarian Action, rep-
resented by Mulugeta Tena and Emmanuel Sibomana, who supported us throughout our research
process. Our special gratitude goes to Rex Wong and Tsion Yohannes for providing insightful consul-
tations along the way. We would also like to acknowledge the support of the Mugombwa Refugee
Camp, data collectors, and our adolescent participants who made this research possible.
Conflicts of Interest: The authors declare no conflict of interest. The funders had no role in the design
of the study; in the collection, analyses, or interpretation of data; in the writing of the manuscript; or
in the decision to publish the results.

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