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Perceptions of rural teenagers on teenage pregnancy.

ABSTRACT

It is important to seek an understanding of teenagers' perceptions regarding teenage pregnancy. The purpose of this study was to explore and describe the perceptions of teenagers in Bushbuckridge district in the Limpopo Province, South Africa, towards teenage pregnancy. An explorative qualitative research design was used with convenience sampling to select participants. Thirty-two teenagers participated; 10 boys and 22 girls. Face-to-face interviews were conducted to collect data. Tesch's method of data analysis was used. Three main categories emerged from the analyses of the interviews: (1) teenagers' attitudes and perceptions of teenage pregnancy, (2) teenagers' level of knowledge of contraception, and also (3) their reasons for becoming pregnant. Teenage pregnancy poses significant social and health problems in the Bushbuckridge district and has implications for all health care professionals. Given the complexity of this problem, health care professionals working with this group should develop a wide range of practical and interpersonal skills.

Keywords: teenagers; teenage pregnancy; perceptions; ignorance; coercion

ABSTRAK

Die doel van hierdie studie was om die persepsies van tieners in die Bosbokrand-distrik in die Limpopo Provinsie, Suid-Afrika, te ondersoek en te beskryf. 'n Verkennende, beskrywende navorsingsontwerp is gevolg. 'n Gerieflikheidsteekproeftrekking is gebruik om deelnemers te selekteer. Twee-en-dertig tieners het deelgeneem, 10 seuns en 22 meisies. Een-tot-een onderhoude is gebruik om die data in te samel. Tesch se metode is gebruik om die data te analiseer. Drie temas het tydens die analise van die onderhoude te voorskyn getree: die tieners se houding en persepsie van tienerswangerskap, die tiener se kennis van voorbehoedmiddels en die redes waarom tieners swanger word. Tienerswangerskap gee aanleiding tot sosiale en gesondheidsprobleme in die Bosbokranddistrik. Dit het implikasies vir alle gesondheidswerkers. Gesondheidswerkers wat met tieners werk behoort oor 'n wye verskeidenheid van praktiese en interpersoonlike vaardighede te beskik, gegewe die kompleksiteit van die probleem.

INTRODUCTION AND BACKGROUND

Teenage pregnancy is a major health problem in many communities in South Africa. The incidence of teenage pregnancy remains high amongst the teenagers in the Bushbuckridge district in the Limpopo Province, South Africa, therefore it is important to seek an understanding of teenagers' perceptions regarding this issue. The purpose of this study was to explore and describe the perceptions of teenagers in Bushbuckridge district towards teenage pregnancy. For many teenagers, sexual activities result in unplanned pregnancies, childbirth or abortion.

Current studies indicate that teenagers become sexually active in early puberty. During this time, the teenager is faced with various challenges such as the onset of menstruation in girls and wet dreams in boys (Roye & Balk, 1997:153). Compared to urban areas, the incidence of teenage pregnancy, abortion and childbirth is significantly higher in rural areas (Bloom & Hall, 1999:296). These teenagers become sexually active at an earlier stage and without using any form of contraception (Allard-Hendren, 2002:159).

Teenage pregnancy can lead to depression, poor school performance and emotional instability. The teenager develops fear of the unknown with regards to abandonment by a boyfriend, deprivation, or reduced family sanction (Bloom & Hall, 1999:297). A strong relationship between teenage pregnancy and depression can also be assumed; depression is associated with impaired decision-making, lack of motivation and a low self-esteem. Amongst girls, pregnancy reflects an attitude of passivity and of not caring about what happens in their lives. Some teenagers fall pregnant because they are not assertive (Driscoll, 1997:33).

Significance of this study

Statistics from the Tintswalo Hospital in Bushbuckridge District show that during the year 2000, 262 teenagers gave birth, 116 were admitted with incomplete abortions, and 38 had a legal termination of their pregnancies (Statistics, Bushbuckridge Health Authority, 2000). These statistics underline the importance of seeking an understanding of teenagers' perceptions, feelings and attitudes regarding teenage pregnancy and their knowledge of contraceptives.

Health care workers in the Bushbuckridge district are greatly concerned about teenagers' perceptions of teenage pregnancy. Recommendations were made for the development of intervention and health promotion programmes that could lead to a reduction in the incidence of teenage pregnancies in this region (Colucciello, 1998:14; Mwaba, 2000:32).

RESEARCH DESIGN

The purpose of the study was to explore and describe the perceptions of teenagers in the Bushbuckridge district on teenage pregnancy. The following objectives were formulated in accordance with the purpose of the study:

* to explore the perceptions of teenagers towards teenage pregnancy;

* to explore teenagers' level of knowledge of contraceptives and pregnancy; and

* to describe teenagers' reasons for becoming pregnant.

An explorative, descriptive and qualitative design was followed to reach these objectives. Such a research approach is adopted when attributes like perceptions and views of human sources are studied (Brink, 1999:11; Talbot, 1994:93).

STUDY POPULATION AND SAMPLING

The study population involved teenagers from the ages of thirteen to the age of nineteen in the Buschbuckridge district who attended an antenatal clinic, a family planning clinic, were admitted to a postnatal ward, or frequently visited a Love Live Youth Centre in the district. A convenient sampling technique was used (Brink & Wood, 2001:135). Teenagers that were available at the four sample sites and willing to participate were included. Thirty-two (32) teenagers were selected (see Tables 1 and 2).

DATA GATHERING

A face-to-face interview was conducted with each participant. An open-ended question: "What is your perception on teenage pregnancy?" was used to obtain information from teenagers on teenage pregnancy. The interviews were audiotaped and transcribed verbatim. Field notes were also taken throughout each interview in order to aid the researcher in synthesising and interpreting the data (Polit & Hungler, 1996:273).

ETHICAL CONSIDERATIONS

The Ethics Committee of the Faculty of Health Sciences at the University of Pretoria (UP), the Research and Quality Improvement Committee in the Department of Health and Welfare in the Limpopo Province and the manager of a Love-Life Youth Centre in the Bushbuckridge district granted approval for this study.

The researcher adhered to ethical dimensions such as confidentiality, anonymity (relating to participants) and freedom of participation. The benefit of participation was explained and informed consent was obtained in writing. Participants were free to terminate the interviews at any stage without any consequences. The researcher undertook to delete the audiotapes as soon as the data analysis was completed (Bierman & Muller, 1994:30). Confidentiality was ensured by protecting all data gathered and by not making the data available to outsiders.

DATA ANALYSIS

The data were analysed according to Tesch's method. It is a method of interpreting the data in the basic sense of reflecting on the data until a better understanding of what is meant, is achieved (Tesch, 1990:69). After the interviews had been transcribed, an overall impression was obtained by reading through all the transcripts. Ideas, about possible categories, were jotted in the margin as they came to mind. Similar topics were clustered together. A list of the topics was returned to the data and abbreviated as codes. The codes were written next to the appropriate segments of text. The most descriptive wording to be found was turned into categories. Related topics were grouped together to reduce the number of categories. Interrelationships between categories were identified and a final decision was taken on the abbreviation for each category.

TRUSTWORTHINESS OF THE DATA

The interviewer allowed sufficient time to establish a good rapport with the participant. The participants had ample time to respond and verbalise perceptions during interviews. Field notes were taken. The categories that emerged from the interviews were discussed with the interviewees during follow-up sessions to ensure that the information obtained was representative of what the interviewees had meant in their initial responses (De Vos, 1998:343, Polit & Hungler, 1996:304).

Transferability

Transferability refers to the extent to which the findings from the data can be transferred to other settings or groups (Polit & Hungler, 1996:307). A comprehensive description of the research design and methodology and an accompanying literature check were used to maintain clarity (Krefting, 1991:214).

Dependability

This refers to the stability of the data over time and over changing conditions. Personal notes were kept of the research process. A colleague with a master's degree in education did independent coding, followed by a consensus discussion between the researcher and the independent coder to ensure data coding agreement to iron out any disagreements in the coding.

Confirmability

This refers to objectivity of the researcher (Krefting, 1991:221). The researcher included raw material, thematic categories, interpretations and process notes to ensure that an audit is possible.

DATA ANALYSIS AND INTERPRETATION

Three main categories emerged from the analyses of the interviews:

Theme 1: The teenagers' attitudes and perceptions of teenage pregnancy.

Theme 2: The teenagers' level of knowledge of contraception.

Theme 3: The teenagers' reasons for becoming pregnant.

THEME 1: THE TEENAGERS' ATTITUDES AND PERCEPTIONS OF TEENAGE PREGNANCY

Acceptance of pregnancy

Participants were not happy about being pregnant. "This pregnancy was my biggest mistake which ever happened to me. I am not happy about it." Most pregnancies were unwanted. The teenagers were not ready to care for their babies. "I was not ready to have a baby; it was a mistake." Parents did not approve of them becoming pregnant. "My parents were very much angry with me when they found out that I am pregnant." Leishman (2004:33) confirms this statement and writes that a teenage pregnancy is usually a crisis for the pregnant girl and her family.

Teenagers who did not attend school (school dropouts) claimed to be happier about being pregnant; they wanted to have babies as they had nothing to do at home. They indicated that they had insufficient funds to pay school fees and opted to substitute schooling with having babies. Although some participants commented that they were happy being pregnant, others felt that it was undesirable unless one was older, married and wanted a child; a view that was influenced by community values. "Community members do not accept teenage pregnancy they even scold us randomly when they meet a pregnant girl."

The female participants who were pregnant or had babies, had relationships that were under strain, leading to unhappiness and an accumulation of blame between themselves and their boyfriends. "The day that I discovered that I am pregnant. I was so frustrated. I thought I should commit suicide. When I told my boyfriend he was also angry with me." Only girls who had planned pregnancies were happy, and were dismissive of the consequences of having a baby while still young and unemployed.

The status of pregnant women

One participant revealed that having a child did not raise their social status, but it was experienced as a disgrace in the eyes of their parents and the community. "Pregnancy does not give any teenager a high status. It is a big stumbling block in our education and gives our parents more financial burden." The stigma attached to teenage pregnancy tended to cling to the young mother and her family and was reinforced by giving babies names that indicated their 'illegitimate' status. "Giving birth to an illegitimate baby while at school is a disgrace to me and my parents."

Approved age for pregnancy

Participants said that their communities did not approve of women under the age of twenty having children. "I think we can start having babies at the age 20 and above but most after we have finished our studies." They indicated that an early pregnancy had prevented them from completing their studies, placing an additional financial burden on their parents. Teenage pregnancy has far-reaching consequences for the greater community. Parenthood of an adolescent jeopardises the labour market and, ultimately, leads to the persistent poverty associated with welfare assistance or low-skill jobs (Smith Battle, 2000:7) The teenagers (in the Kunene, 1995 article) felt that they should start a family once they have completed their schooling and found jobs which will financially enable them to bring up a family. This group expressed the belief that they should delay having a family until they were married.

Attitudes to abortion

Mills (1998:244) found that teenagers would rather keep an illegitimate baby than seek other solutions such as abortion or adoption. These findings were similar to findings in the present study, as the participants generally did not support abortion. The participants argued that it was better to keep the baby rather than risking not being able to have babies at a later stage. "Seeking an abortion is not a right thing to do for us teenagers. It may happen that after an abortion when in future you want a baby, you are unable to have one. It is best to keep the baby once you fall pregnant."

THEME 2: TEENAGERS' LEVEL OF KNOWLEDGE OF CONTRACEPTIVES

Poor knowledge of the use of contraception

Participants in the study knew that there were ways of preventing unwanted pregnancy apart from total abstinence from sexual activity. In a study done by Kau (1991:37) participants agreed that it was honest and morally correct to prevent pregnancy before marriage. Despite this positive attitude the participants in this study seemed to shy away from the responsibility of using contraceptives.

Teenage pregnancy is often the result of a lack of knowledge about contraception. "I take a pill when I know my boyfriends is coming and we probably going to make love. I sometimes forgot to take it before we make love so I take it after we made love." Many misconceptions existed about contraception. The girls, who had taken the injectable contraceptive, thought that it would make them gain weight. "Having an injection as a contraceptive method every time makes me gain too much weight and also have a big tummy. It's because I don't have menses every time. Maybe the blood accumulates in my abdominal cavity." Teenagers thought that contraceptives cause infertility and watery discharges. "My mother told me not to rush for contraceptives before I have a baby; they may cause future infertility." Contraceptive pills were only taken when they planned sexual intercourse or only after engagement. Most of the participants had no knowledge about emergency contraceptives. "I have never heard of the emergency contraceptives even how they are used and their effects."

Teenage boys are not seen visiting family planning clinics and are reluctant to use condoms as a form of contraceptive and a method of infection control. The teenage boys refused to use condoms because they commented that sex with a condom was not enjoyable. In a study being done by Mwaba (2000:33) teenage girls expressed a preference for receiving the injectable contraceptive and stated that condoms were not the birth control method of choice.

Poor knowledge of the physiology of conception

Participants had a poor knowledge of human physiology and were easily misled by their partners. One participant was led to believe that first-time sex could not cause pregnancy and that sexual intercourse in a standing position would prevent pregnancy. Another participant relied on the withdrawal method. "My boyfriend said when we make love for the first time I won't fall pregnant." "My boyfriend said when we make love while standing I won't fall pregnant." They were under the impression that it was unnecessary to use contraceptives if they did not have regular sex.

THEME 3: REASONS FOR TEENAGERS FALLING PREGNANT

Poor sex education

Various comments by participants pointed to a lack of quality sex education. Participants said that they had not obtained adequate knowledge about the functioning of their bodies, handling of emotions and managing relationships. It was concluded that parents neglect sexual education. Teenagers felt that sexuality education should be presented in schools as a health promotion activity. The preparation for adulthood should form part of the curriculum. They suggested that emphasis should be placed on matters such as relationships, sexual activities, pregnancy, contraception, and difficulties of single parenthood. They expressed the opinion that contraceptives should be made available freely and without parental knowledge or consent.

A perception among pregnant participants was that they fell pregnant because of no sex education at home. "Nobody at home told me about sexual matters. I only got the information from my friends and my boyfriend. He is the one who showed me how to make love." "I was not aware that I am pregnant; my mother saw me and she took me to the clinic for confirmation." The feelings of participants were that parents wished their children to complete their school education before engaging in sexual activities. "My mother told me to finish school first and not rush to do things meant for adults; my time will also come."

It seemed that parents hesitated to make sex education and contraceptives available to their teenagers out of fear that teenagers would interpret this as permission to engage in sexual activities. Okonofua (1995:433) and Wodarski and Wodarski (1995:15) emphasise that parents thought it improper to discuss sexual matters with their children. In this study (Okanofua, 1995) teenagers denied receiving sex education from their parents. They felt more comfortable talking about sex to their friends or reading about it from magazines. Setiloane (1990:47) and Schoeman (1990:15) confirm this lack of communication between young people and their parents. Youth often learnt about sex informally from their friends. These sources often spread misinformation on aspects such as contraceptives.

The media convey the message that self-esteem and socialisation between boys and girls are based on sexuality. According to Bragg (1997:578) few parents discuss media portrayals and values of sexuality with their children. Adolescents spend hours conversing with their peers and often do not talk to their parents at all. Kunene (1995:48) states that teenagers are more at risk of unplanned pregnancies if they communicate poorly with parents or are exposed to a sexual environment through the mass media.

Coercion

Participants indicated that teenage pregnancy is often the consequence of a combination of ignorance and mutual coercion into sexual intimacy. "I became sexually active when I was 15 years old. My boyfriend forced me to have sex with him." Teenage girls are easily influenced, especially by older boyfriends to have sex. "My boyfriend said we should make love to prove I really love him." They tend to accept instruction from these older boyfriends. "I wanted to show my boyfriend that I loved him, and to prove that I had sex with him. The worst part was that I felt pregnant." Mwaba (2000:33) agrees that the pressure by boys and their refusal to use condoms during sexual intercourse are the main reasons for teenage pregnancy.

Participants indicated that girls fell pregnant because their boyfriends forbade them to use contraceptives. Girls are, sometimes, given money as a thank-you gift. A study conducted by Kunene (1995:49) indicates that teenage boys revealed that girls sold sex to older men in exchange for money. This confirms the idea that teenagers are easily influenced. Teenage girls acted submissively and agreed to have sex even though they knew the consequences. Many teenagers became pregnant because they wanted to prove their womanhood. One participant fell pregnant in an attempt to keep her boyfriend. "I fell pregnant because I wanted my boyfriend to marry me."

Peer influence

Participants maintained that teenage girls fell pregnant, because they were competing for boyfriends and marriage. "My boyfriend fell in love with my best friend, so I fell pregnant to force him to marry me." They sometimes complied for fear of abandonment and experienced peer pressure to have sex. Non-school attending teenage girls thought it was worthwhile to fall pregnant. "I wanted to have a baby because I had nothing to do at home. I thought a baby would keep me busy since I was not going to school." They had the impression that childbearing gave a woman a high status and that they were bound to have children. Bacon (2000:347) confirms this finding by writing that: "... the greater the positive consequences of pregnancy to a teenager, the less likely is that [they] will engage in protective sexual activity."

Wodarski and Wodarski (1995:9) reported that girls had sex because they were unable to resist the pressure from their boyfriends. They wanted to please their partners. In this study (Wodarski & Wodarski, 1995) female participants acknowledged peer influence. They reported they had sex because they were unable to say no and that they wanted to please their partners. They had the opinion that sexual intercourse was expected of them as a way of proving love to their partner (Wodarski & Wodarski, 1995:9).

Ignorance

Ignorance amongst teenagers, the developmental urge to experiment, and feelings of rebellion associated with adolescence have an impact on teenage pregnancy rate. Ignorance about the physiological aspects of conception led them to believe that first-time sex or irregular sex could not cause pregnancy. "My friends said not having sex regularly won't make me fall pregnant." Teenagers are reluctant to take contraceptive precautions for fear of complications and parental detection. Ignorance also leads to myths such as the beliefs that the use of contraceptives may cause infertility, will make them gain too much weight and lead to 'big tummies'.

Parental influences

African cultures play a significant role in the high incidence of teenage pregnancies. Particularly, parents want their girls to be married at a very young age so that they can receive lobola (money in return for permission to marry the girl). They encourage relationships between the different sexes. They discourage school attendance as a married girl 'belongs' to the husband's family for whom she will be working. Teenage boys and girls are often sent to initiation schools, with many girls who fall pregnant as a result of the initiation. Boys tend to become sexually active after returning. The participants admitted that they were merely acting out what they had been taught at the initiation school.

In this study, participants reported that their parents had unique reactions and either became angry with their pregnant teenager and punished them or accepted their pregnant teenagers and supported them during pregnancy. "My father did not want me at home because I was pregnant. He said I didn't belong to his family anymore and would have nothing to do with me anymore." "My mother said she want to see my first baby before she dies."

Two participants said that their parents insisted that they should terminate their pregnancies as they regarded it as a disgrace. Tanga and Uys (1996:50) support these findings that teenage pregnancy is seen as a disgrace by many families. Different social groups react differently towards teenage pregnancy.

Lack of access to health services

Participants indicated that teenagers are reluctant to visit clinics for contraceptives; their anonymity is not guaranteed. A common concern is that they "can't go to a family planning clinic because I may come across my relatives and they may tell my mother I was there." According to Dreyer (1994:459) teenagers are often too shy to visit an adult family planning clinic.

Transport remains a barrier to the accessibility of the health and youth centres. "I know of the health centre in XXX, but it is far from where I stay. I cannot afford transport to go there to participate." Often contraceptives are provided, while sex education is neglected, because of the heavy workload of the staff. "There is nothing explained to us, it's just go through, what method do you want and if it's an injection they will inject you." "The nurses always look busy and we are afraid to ask questions." According to Knott and Lotter (1999:580) teenagers are afraid to make use of family planning services, are dissatisfied with the quality of communication at clinics, and perceive the staff as being unapproachable. They want health care providers to be approachable, friendly and caring.

RECOMMENDATIONS

This study was conducted among a small number of teenagers in the Bushbuckridge area in the Limpopo Province. A further study involving teenagers from other ethnic and cultural groups is recommended. Further research is needed to determine teenagers' attitudes towards termination of pregnancy and the attitudes of health workers towards teenagers.

Teaching

Teaching should be based on empowering teenagers and should aim at developing responsible attitudes with regard to sexual behaviour. This will reduce casual sex and repeated pregnancy, ensure contraceptive compliance, continuation of education or employment, if pregnant, reduce the risk of child neglect and abuse and eventual psycho-social maladjustment, and promote therapeutic abortion when the girl and her family reject the pregnancy.

Sex education should be included in the school curriculum. Sex education in schools and via other channels is a low-cost strategy for lowering the incidence of teenage pregnancy. All young people can be reached at an early age, before they become sexually active. Parents should be involved as primary sex educators. According to Wodarski and Wodarski (1995:15) sex education has to be integral to a young person's personal development and has to begin before or during puberty.

It is recommended that sex education programmes in schools be linked to the primary health care services to enhance accessibility. Sex education programmes should also be offered at venues where teenagers congregate informally. Programmes that promote abstinence should be developed. These programmes should also aim at building skills and conveying information to all teenagers (Lesser & Escort-Lloyd, 1999:298; Richter, 2000:78).

Clinical practice

Comprehensive health services should be available to all teenagers. School health services should assist with counselling and condom supplies should be readily available. Family planning services for youths should be accessible and counselling should be provided to all teenagers. Communication between health workers and teenagers should be well established, and health workers should be approachable.

The activities at the youth centres should be decentralised in order to reach the youth in all areas of the district. Health workers should be working with the centres in order to provide services to teenagers. Condoms should be distributed in all places where youths congregate.

LIMITATIONS

The study was contextual in nature and the findings cannot be generalised to other populations.

CONCLUSION

Teenagers perceive teenage pregnancy as something which is unintended. They associate it with individual characteristics such as knowledge, maturity, skill, and age at first intercourse. Misconceptions about sex and contraceptives are still evident in most teenagers.

Teenage pregnancy poses significant social and health problems in the Bushbuckridge district and has implications for all health care professionals. Given the complexity of this problem, health care professionals working with teenagers should develop a wide range of practical and interpersonal skills.

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MS Richter

DCur (RAU)

Assistant Professor, Faculty of Nursing, University of Alberta, Canada (During the course of this study: Lecturer:

Department of Nursing Science, University of Pretoria, South Africa)

Corresponding author: solina.richter@ualberta.ca

GT Mlambo

MCur student, University of Pretoria
Table 1: Age distribution

Age Number of participants (n=32)

Thirteen to fourteen (13-14) 11
Fifteen to sixteen (15-16) 11
Seventeen to eighteen (17-18) 7
Nineteen (19) 3

Table 2: The number of interviews

 Number of
 interviews (n=32)

Convenience sampling Boys Girls

Youth centre 10 7
Family planning clinic 5
Antenatal clinic 5
Postnatal ward 5
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