This brief highlights insights from a study to uncover the complex individual, interpersonal, community, and structural influences that shape adolescent pregnancy and childbearing as a main driver of persistent global acute malnutrition. A desk review of existing literature, a landscape analysis, and stakeholder mapping were conducted to understand the causes and mitigating factors of pregnancy and childbirth among adolescent girls. Insights include the existence of a system of contradictions and the shame, fear, and uncertainty it produces and that restrict adolescent girls’ agency over sexual and reproductive health. In addition, the social isolation of pregnant, parenting, and/or married adolescent girls is a key barrier to the sustainable reduction of persistent global acute malnutrition. Accurate knowledge about sexual and reproductive health and positive relationships with parents are critical to adolescents’ ability to make positive choices, but may be insufficient to protect and improve sexual and reproductive health outcomes for those from poor socio-economic backgrounds. Limited and unequal access to educational opportunities have created significant vulnerabilities to risky sexual behavior and early pregnancy, and could reverse gains in education and socio-economic development more broadly. Finally, health services should be positioned to respond to adolescents’ varied and dynamic needs.