Adolescent Pregnancy and Parenting: Perceptions of Healthcare Providers.

BACKGROUND: Adverse maternal and child health outcomes due to adolescent pregnancy are central to public health research and practice. In addition, public health has emphasised that the care rendered by healthcare providers plays a pivotal role in the health and well-being of pregnant and parenting adolescents. Healthcare providers may differ in the ways they interpret adolescent pregnancy and parenting and consequently, this may have profound implications for healthcare decision making. The aim of this study was to explore the multiple perspectives of a diverse group of healthcare providers' delivering services and engaging with pregnant adolescents and adolescent mothers at a district hospital in Ugu, KwaZulu Natal, South Africa.
METHODS: This descriptive qualitative study used semi-structured interviews (n=33). Healthcare providers rendering care to pregnant and parenting adolescents were recruited from the maternity, antenatal, paediatrics, psychology, dietetics, physiotherapy and social work departments, as well as from the HIV/AIDS, STIs and TB (HAST) programme. The data were analysed using thematic analysis.
RESULTS: The healthcare providers acknowledged that adolescent pregnancy is a problematic issue in Ugu district. Furthermore, they felt that the postpartum sexual-related and reproductive health of adolescent mothers was not given priority. In the healthcare providers' view, the problems experienced by pregnant and parenting adolescents were school dropout, financial constraints, breakdown of relationships, abandonment, stigmatisation, parenting and child rearing difficulties, and both physical and mental health problems.
CONCLUSION: This study highlights that the issue of sexual- and reproductive-related outcomes of adolescent pregnancy and parenting is not given priority. In addition, the findings also highlighted the need for a multidisciplinary approach to the care of pregnant and parenting adolescents. Multidisciplinary communities of practices as interventions can be used to generate and share knowledge, capacitate healthcare providers and improve clinical practice. The training of healthcare providers, provision of non-judgemental counselling and tailored services for pregnant adolescents and adolescent mothers are essential. When appropriately disseminated, the findings will assist relevant healthcare providers, administrators in healthcare institutions, policymakers, and officials of the Department of Health and the Department of Education in South Africa to address the lack of appropriate care for pregnant and parenting adolescents.

Background

The phenomenon of adolescent pregnancy and parenting has attracted much attention as a global public health and social problem.1,2 Several studies have reported various adverse maternal and child health outcomes due to adolescent pregnancy.3–6 In particular, adolescent childbearing has a negative impact on the educational opportunities of young women.1 More than 90% of adolescent pregnancy occurs in low and middle income countries,7 with sub-Saharan Africa bearing the largest burden of adolescent childbearing where it is further compounded by socio-economic constraints and the HIV/AIDS epidemic.7 The pooled prevalence of adolescent pregnancy in Southern Africa is 20.4% (95% CI: 18.9, 21.7) while the overall rate in Africa is 18.8% (95% CI: 16.7, 20.9).7

In many low and middle income countries, adolescent pregnancy contributes to ill-health in women,8,9 while South African adolescent girls have an increased risk of mortality due to pregnancy related complications.10 Factors contributing to maternal mortality among South African adolescents include: pregnancy induced hypertension, obstetric haemorrhage, medical and surgical haemorrhage, and non-pregnancy related infections such as TB and pneumonia that occur as a result of HIV/AIDS.10,11

Pregnant and parenting adolescents are stigmatised by society and many healthcare providers,12–15 and this reduces their willingness to access healthcare services.12,13 Furthermore, pregnant and parenting adolescents may face rejection from their families and partners which impacts on both maternal and child health outcomes.13 The reported utilisation rate of family planning is low among South African adolescents9 and many have limited knowledge of sexual and reproductive health,9 which are realities in many sub-Saharan African countries as well.9 It is undeniable that the care rendered by healthcare providers is pivotal to the health and well-being of pregnant and parenting adolescents.13,16 However, utilising the assistance of healthcare providers as a source of sexual and reproductive health information seems to be low among adolescents in general.9

Preliminary research in Ugu, KwaZulu Natal, South Africa, revealed that no specific health care services existed for the distinctive needs of pregnant adolescents and adolescent mothers.13 While nurses and midwives are the first line of care for pregnant and parenting adolescents, other healthcare providers should also be part of the multidisciplinary team involved in the healthcare of these young girls.13 Govender et al13 found that nurses supported a multidisciplinary approach to the care of pregnant and parenting adolescents as they argued that healthcare providers such as clinical psychologists, dieticians, social workers, physiotherapists, occupational therapists and speech therapists should work collaboratively. However, limited research has been done to elicit the perception of adolescent pregnancy and parenting among the various healthcare providers who comprise the multidisciplinary team. The purpose of this study was therefore to fill this knowledge gap by obtaining rich information by exploring various healthcare providers’ perceptions towards adolescent pregnancy and parenting.

Cognisance was taken of evidence that suggests that holistic care that combines medical, educational and psychosocial components improves maternal and child health outcomes.14 Healthcare providers may differ in the ways they interpret adolescent pregnancy and parenting and consequently this may have profound implications for healthcare decision making. The premise of this study was located in the socio-ecological model.17 According to the socio-ecological model, individuals are positioned in social, institutional and physical environments and the interactions between the individual and the forces in these environments has a profound influence on health and well-being.17 The socio-ecological model engages the following five specific levels: individual, interpersonal, organisational, community and policy. This qualitative study explored healthcare providers’ interactions with pregnant adolescents and adolescent mothers at the interpersonal level. Understanding the multiple perspectives of various healthcare providers of pregnant and parenting adolescents is an essential step in improving maternal and child health service delivery.

Methods

Design and Setting

The study has an explorative qualitative study design. The current study formed part of a mixed-methods action research (MMAR) project that was part of a larger doctoral study. The purpose of doctoral mixed methods action research project was to develop and implement a multidisciplinary Community of Practice model that would serve as a framework for addressing the challenges and needs of pregnant adolescents and adolescent mothers. Although this article focuses on the healthcare providers’ perspective of adolescent pregnancy and parenting, focus group discussions were held with adolescent mothers and will be reported on in a separate publication. The study was conducted in a medium size district hospital in the Ugu district in southern KwaZulu-Natal, South Africa. Medium size district hospitals have a minimum of 150 beds and a maximum of 300 beds. The hospital provides paediatric health services, obstetrics and gynaecology, internal medicine, general surgery and emergency health services. The adolescent delivery rate in the district hospital is 23%.13 Ugu is a predominantly rural area with only 16% of the population residing in the urban coastal strip.18 The district is home to predominantly poor communities who have limited access to basic services.

Study Participants and Recruitment

Healthcare providers who rendered care to pregnant and parenting adolescents were targeted from various divisions in the selected district hospital. Participants were recruited strategically based on experience and type of profession from the maternity ward, the antenatal clinic, paediatrics, psychology, dietetics, physiotherapy, social work, and the HIV/AIDS, STIs and TB (HAST) programme. In total, a sample of 33 healthcare providers participated in the study. The recruitment of participants from these various divisions ensured that a diversity of views, opinions and experiences could be explored to further illuminate the phenomenon of adolescent pregnancy and parenting. The study participants were approached face to face by the research team who invited them for the semi-structured interviews.

Data Collection

Semi-structured in-depth individual interviews were conducted with the participants between January and March 2018. The advantages of interviews in the qualitative strand of the comprehensive mixed-methods action research is that they elicit rich accounts of first-hand experiences of the phenomenon.19 Interviews are also effective in exploring the experiences and views of key informants and stakeholders, especially in contexts where individuals may not be comfortable participating in group.19 Interviews are thus useful as sources of primary or supplementary data in mixed-methods action research.19 An interview guide was developed in collaboration with the Clinical Manager of the maternity ward and a clinical midwife at the hospital. Although the interview guide was not piloted but it was thoroughly examined by the research supervisors (SN and MT). The interview guide covered the following: experiences with pregnant and parenting adolescents; perceptions and understanding of the community beliefs about adolescent pregnancy; poor uptake of healthcare services; and suggestions to improve healthcare services for pregnant adolescents and adolescent mothers. Field notes were made during and after the interview by a research assistant.

All the interviews were conducted in privacy in the health institution. Written informed consent was provided by all the participants prior to the interviews that were conducted by the first author (DG) in English. DG is a physiotherapist at the hospital and she has had over ten years of clinical experience of attending to client referrals from the maternal and child health divisions and has insight into the care of pregnant and parenting adolescents. DG is also a doctoral candidate with experience in conducting qualitative research. The participants granted permission to record the interviews using a Dictaphone. They were advised that they could request the interviewer to switch the Dictaphone off at any time they felt uncomfortable during the interview. The duration of each interview ranged from 30 to 45 minutes. Data saturation was reached with the 33rd participant.

Data Analysis

Verbatim transcriptions of the recorded interviews were made by three research assistants. The transcriptions were also checked for accuracy against the recordings by the research team. The stages of thematic analysis as proposed by Braun and Clark were followed.20 These six stages were to read and become familiar with the transcribed data; coding; searching for themes; reviewing themes; defining and naming themes; and writing the report. The transcribed data were also shared with the participants to ensure confirmability and the coded data were cross-checked by the research team to ensure the accuracy and credibility of the transcriptions. The process of developing and generating themes involved collaboration with and checking by the research supervisors (SN and MT). Themes and subthemes were identified and detailed and thick descriptions of the study methods are provided by the authors for transferability. Verbatim quotes are provided to support the trustworthiness of the data. We followed the Consolidated criteria in Reporting Qualitative Research (COREQ) checklist in reporting our research.

Ethical Considerations

Ethical approval was received by the Bioethics Research Committee of the University of KwaZulu-Natal (ref no: BFC553/16), the KwaZulu-Natal Department of Health (ref no: KZ_2016RP26_545), and the Chief Executive Officer of the hospital. Informed written consent was also obtained from all the participants.

Results

Profile of the Participants

Relevant details of the participating healthcare providers are provided in Table 1. The majority (93.9%) of the participants was female and their mean age was 31.4 years. The sample included three medical doctors, a clinical psychologist, a social worker, a dietician, a physiotherapist, a physiotherapy technician, two HIV counsellors, and 23 nurses.

Table 1

Profile of the Participants (n=33)

Pseudonym of Participants	Age	Gender	Profession
1. Ally	33	Female	Physiotherapist
2. Beauty	40	Female	Professional Nurse (General stream)
3. Brenda	44	Female	Medical Doctor (Maternity)
4. Constance	37	Female	Professional Nurse (General Stream)
5. Celine	34	Female	Medical Doctor (Maternity)
6. Frank	41	Male	Professional Nurse (Psychiatry)
7. Heidi	32	Female	Professional Nurse (Paediatrics)
8. Hillary	38	Female	HIV counsellor
9. Ian	43	Male	Physiotherapy Technician
10. Kate	31	Female	HIV counsellor
11. Maggie	35	Female	Professional Nurse (Midwifery)
12. Matilda	34	Female	Enrolled Nurse
13. Merri	38	Female	Professional Nurse (Midwifery)
14. Mpho	39	Female	Professional Nurse (Midwifery)
15. Neri	37	Female	Medical Doctor
16. Nonnie	35	Female	Dietician
17. Nora	39	Female	Professional Nurse (Paediatrics)
18. Norma	36	Female	Professional Nurse (General Stream)
19. Pippa	32	Female	Professional Nurse (Midwifery)
20. Roslyn	53	Female	Professional Nurse (Midwifery)
21. Sandra	46	Female	Professional Nurse (General Stream)
22. Sarah	34	Female	Clinical Psychologist
23. Shaz	35	Female	Professional Nurse (Midwifery)
24. Shelly B	38	Female	Professional Nurse (Paediatrics)
25. Shola	37	Female	Professional Nurse (Midwifery)
26. Sophia	47	Female	Social Worker
27. Sumeera	40	Female	Professional Nurse (General Stream)
28. Talmay	28	Female	Professional Nurse (General Stream)
29. Tazz	43	Female	Enrolled Nurse
30. Tina	53	Female	Professional Nurse (Primary Healthcare)
31. Valerie	53	Female	Professional Nurse (General Stream)
32. Zoe	43	Female	Professional Nurse (Midwifery)
33. Zuzi	39	Female	Professional Nurse (Midwifery)

Nine themes emerged: decoding adolescent pregnancy, Decoding healthcare providers’ perceptions and understanding of the community beliefs about adolescent pregnancy, personal experiences with pregnant and parenting adolescents, perceived challenges experienced by pregnant and parenting adolescents, the essential needs of pregnant and parenting adolescents, the availability of services for pregnant adolescents, issues regarding the poor uptake of healthcare services by pregnant and parenting adolescents, suggestions for improving healthcare services for pregnant and parenting adolescents, and personal and institutional efforts to support pregnant and parenting adolescents. The discussion of these themes and their related subthemes is supported by verbatim quotes.

Themes

Theme 1: Decoding Adolescent Pregnancy

Decoding for the purpose of this study is defined as interpreting and making sense of a situation. The participating healthcare providers provided their own interpretations of adolescent pregnancy but they all decoded adolescent pregnancy as a problematic issue and that repeat adolescent pregnancy was common in the district. Moreover, adolescent pregnancy was perceived as a risk factor for acquiring HIV/AIDS and STIs as well as a means of acquiring financial support. Some participants also linked the marginalisation of sexual and reproductive health in education programmes with adolescent pregnancy.

Subthemes

Adolescent Pregnancy is a Problematic Issue

The healthcare providers claimed that that adolescent pregnancy is currently a problematic issue. The psychosocial and medical issues related to adolescent pregnancy surfaced during the interviews. Healthcare workers expressed the first-hand evidence of the burdens attributed to adolescent pregnancy.

Sarah, a clinical psychologist, stated:

Well, I think adolescent pregnancy is an important subject. It is quite a big problem we are dealing with currently. There are too many girls affected and they are far too young. They are having babies that they cannot afford to look after. They are also not emotionally able to look after these babies. I have seen adolescent mothers who are having their second or third child. They have dropped out of school. The pregnancies are creating a ripple effect in their lives. It is a huge problem that needs to be dealt with in the public sector.

Furthermore, the healthcare providers also expressed their concern about the increase in the adolescent pregnancy rates. In addition, they said that early childbearing and parenting poses as a challenge for young women.

Brenda, a Medical Doctor, stated:

Adolescent pregnancy is a huge problem. It has been an ongoing challenge. I have worked in the maternity component for more than five years. It is one of the areas that we have not really made an impact on because looking at the data in our institution, our adolescent pregnancy rates, especially the repeat pregnancies, have been increasing. For me as a healthcare provider, a mother and community member, I know exactly how difficult it becomes for them to raise a child and attend to all their responsibilities.

Heidi, a Professional Nurse in Paediatrics, said:

Adolescent pregnancy is most definitely a huge problem. I have seen the pregnant and parenting adolescent mothers in our institution. They face so many problems and are afraid to speak to healthcare providers. Most of the pregnant adolescents are involved with older men for financial reasons. These adolescent girls are fighting for their survival and to meet their basic needs. Pregnancy only fuels their existing problems

The Prevalence of Adolescent Repeat Pregnancies

Healthcare providers stated that adolescent repeat pregnancies are an issue for adolescent women. A diversity of viewpoints was expressed by healthcare providers regarding adolescent repeat pregnancies.

Ally, a Physiotherapist, commented:

Adolescent repeat pregnancy is common. I have seen many adolescent mothers coming to this institution with a repeat pregnancy. I think that adolescent mothers have not learnt from their first experience. Some adolescents are not keen to use contraception postpartum

According to Ally, the resistance to using contraception postpartum could be contributing to adolescent repeat pregnancy. Healthcare providers also suggested that adolescent repeat pregnancies may be attributed to financial gain among adolescent mothers.

Matilda, an Enrolled Nurse, said:

I saw a 17-year-old adolescent delivering her second baby and an 18-year-old delivering the third baby last month. This is not a shock to me because if you look at the monthly statistics of the labour ward then you’ll see that there is always an adolescent repeat pregnancy. The adolescent mothers need money for support so they have more than one child. I don’t know if they care about how they will manage to look after their children.

Nonnie, a Dietician, stated:

Yes, adolescent repeat pregnancy is common. I interact with adolescent mothers when they come to me if their infants or children are malnourished. In my clinical experience, I have seen some adolescent mothers with more than one child. It is worrying because the first pregnancy and raising one child is such a struggle. The second and third pregnancies during adolescence are a reality for some of these girls.

Nonnie acknowledged the struggles of adolescent repeat pregnancy. The understanding demonstrated by Nonnie that adolescent repeat pregnancy negatively impacts on the lives of both the adolescent mother and her child is evident from her first-hand clinical experiences.

Other participants commented as follows:

Adolescent repeat pregnancy is a common thing. The parents get worried if their adolescent girls don’t have children. They will compare why their adolescent daughters don’t have children and why other adolescent girls have. The child grant is also enticing parents to ask their adolescent daughters to have children because the grant feeds the family. (Tina, Professional Nurse, PHC)

Adolescent repeat pregnancy is very common. When you see an adolescent mother, you have to ask if it is their first or a repeat pregnancy. (Celine, Medical Doctor)

High Risk for Contracting HIV and STIs

This subtheme explored the health risks associated with adolescent pregnancy. Healthcare providers expressed their concern that adolescent pregnancy increased the risk of HIV and STI infection.

Adolescents girls are involved with older men. These older men are not only impregnating them but also infecting them with HIV and STIs. (Norma, Professional Nurse, General Stream)

Adolescent pregnancy is a scary issue. Well, it is a consequence of unprotected sex. This means the risk of acquiring HIV and STIs is high. (Pippa, Professional Nurse, Midwifery)

One healthcare provider suggested that HIV and STI compounded the health problems of pregnant adolescents and adolescent mothers. The stigma associated with HIV and STI prevents pregnant adolescents and adolescent mothers from seeking appropriate medical treatment and defaulting prescribed treatment.

These adolescent mothers are at high risk of acquiring HIV and STIs. I have noticed that some pregnant adolescents are in denial about their HIV status. They are afraid of the stigma. They don’t take their prescribed medication. They become so ill that they struggle to take care of themselves and their babies. (Shelly, Professional Nurse, Midwifery)

Adolescent pregnancy is a risky issue because from the clinical point of view, there is HIV infection and cervical cancer. (Tina, Professional Nurse, PHC Stream)

Adolescent Pregnancy as a Means of Obtaining Financial Support

Healthcare providers expressed their personal viewpoints that adolescent pregnancy was a means of obtaining financial support. The child support grant was labelled as a “source of income” and an “incentive”.

This is my personal view. Adolescent pregnancy is complex. The government is providing an income through child support grants. Most adolescent mothers obtain the grant but they are not looking after their babies. The babies are left with the grandmothers. The adolescent mothers use the grant money to do their hair at the salons, buy cellphones and airtime. (Valerie, Professional Nurse, General Stream)

Valerie shared her viewpoint that the child support grant provided for the personal indulgence of adolescent mothers. This perception was also echoed by other healthcare providers.

I am sure that the child support grant is also promoting adolescent pregnancy. I have seen the adolescent mothers in my community using the grant money to do their hair and nails at the salon. The grannies are looking after the babies using their pension money. (Zuzi, Professional Nurse, Midwifery)

The child support grant is an incentive to the adolescent mothers. The taxpayers have to support them in order for the government to give them the child support grant. This is a burden on the economy. (Mpho, Professional Nurse, Midwifery)

The Marginalisation of Sexual and Reproductive Health Issues

Healthcare providers were concerned about the marginalisation of sexual and reproductive health.

From these responses, it can be inferred that healthcare providers acknowledged the lack of comprehensive sexual and reproductive health. Furthermore, the sexual and reproductive health of postpartum adolescent women is also side-lined.

I don’t think there is much done for adolescent pregnancy. The issues of adolescent pregnancy are not managed comprehensively. Sexual and reproductive health is not emphasized. We focus on adolescent girls but we are not addressing the issue of the men who impregnate these girls. When the adolescent mother leaves the hospital after delivery, she is forgotten. Her postpartum sexual and reproductive health is sidelined once again. I do not think we do justice to sexual and reproductive health education because there are time constraints and shortages of staff as well. That is the reason we will attend to many adolescent repeat pregnancies (Beauty, Professional Nurse, General Stream)

In addition, one healthcare provider, acknowledged the restrictions placed on the provision of comprehensive sexual and reproductive health at schools by the school governing bodies. Traditional viewpoints were also noted as a factor that impeded sexual and reproductive health issues.

The issues of sexual and reproductive health are shunned. That’s the reason we are plagued by adolescent pregnancy. There are school governing bodies that will not allow for comprehensive sexual and reproductive health to be taught at schools and the topic of adolescent pregnancy is not confronted. Sometimes parents do not want to accept that their children are sexually active at a young age and therefore they will not acknowledge that adolescent pregnancy is a reality. We also have a shortage of nursing staff and struggle to impart the much needed sexual and reproductive health education. (Talmay, Professional Nurse, General Stream)

I would like to point out that due to customs and traditions sex is not discussed in families and communities. We know that unprotected sex can result in HIV infection, STIs and pregnancy. But families and communities are not realizing the importance of talking about sexual and reproductive health. People often think that educating young people on sexual and reproductive health is promoting them to be sexually active and increasing adolescent pregnancies. However, this not the reason why we educate young people on sexual and reproductive health but to ensure that young people make informed decisions. (Frank, Professional Nurse, Psychiatry)

Theme 2: Decoding Healthcare Providers’ Perceptions and Understanding of the Community Beliefs About Adolescent Pregnancy

Within this theme, the healthcare providers expressed their opinions of the community beliefs about adolescent pregnancy. Their opinions of how the community perceived adolescent pregnancy varied. Some participating healthcare providers argued that the community regarded adolescent pregnancy as a norm, while others felt that adolescent pregnancy was deemed unacceptable. Some believed that community members were divided in their views about adolescent pregnancy.

Healthcare providers described that adolescent pregnancies were commonly occurring in the communities. In this regard, healthcare workers were of the opinion that adolescent pregnancies were accepted as a norm within communities.

It is a Norm

I truly believe that adolescent pregnancy has become a norm in our communities. Even in the religious sectors or the very traditional sectors, we seem to have adopted the style that adolescent pregnancy is okay. In schools, it has become normal to venture into sexual activities and have babies. (Brenda, Medical Doctor)

Brenda expressed that she personally believes that the within the religious, traditional and school domains, adolescent pregnancy has become an acceptable standard. Furthermore, healthcare providers expressed that the high rates of adolescence pregnancy were indicative of it being an accepted norm within communities.

Adolescent pregnancy is a norm within communities. I think families have accepted the occurrence of adolescent pregnancy. This could be the reason for the high adolescent pregnancy rates. (Sumeera, Professional Nurse, General Stream)

Adolescent pregnancy is not an isolated issue. It is an ‘in thing’ so everybody accepts it. There is nothing abnormal about adolescent pregnancies in the community. (Maggie, Professional Nurse, Midwifery)

Communities have accepted adolescent pregnancy. It is the norm. Everyone in the labour ward gets shocked if they see a 30-year-old coming to deliver. They think they are old and should not have conceived. Communities do not have an issue with adolescents having babies but the issue is with older women getting pregnant. (Frank, Professional Nurse, Psychiatry)

Frank voiced his opinion on the communities’ acceptance of childbearing in adolescent women and the shunning of pregnancies in older women. According to Frank, adolescent childbearing is socially acceptable whereas late motherhood is unacceptable in communities.

It is Unacceptable

According to the opinions of healthcare providers, communities perceive adolescent pregnancy as socially unacceptable. The healthcare providers stated that communities perceive adolescent pregnancy as a social disadvantage associated with poverty and school dropout.

Adolescent pregnancy is considered as a burden by many communities and totally unacceptable. The community perceives that adolescent pregnancy is a serious matter. Parents are totally embarrassed and they have to face financial problems. The girls drop out of school and poverty increases in communities. (Ian, Physiotherapy Technician)

… adolescent pregnancy is such a challenge in the communities. Most community members are worried about this issue and do not condone adolescent pregnancy. No one is happy to see a child pregnant at the age of 14 years. (Sophia, Social Worker)

I think the community ostracises pregnant and parenting adolescent girls. They do not condone adolescent pregnancy because it is an embarrassment to families. In fact, other children are advised not to befriend pregnant and parenting adolescents. I have seen this in my own community where my grandmother did not want my siblings and I to associate with adolescent girls who were pregnant or parents. (Zoe, Professional Nurse, Midwifery)

According to Zoe’s viewpoint, the social isolation of pregnant adolescents and adolescent mothers is indicative that the community perceives adolescent pregnancy to be an embarrassment and unacceptable.

Perceptions About Adolescent Pregnancy are Ambivalent

Healthcare providers were of the opinion that the community had mixed feelings about adolescent pregnancy and parenting. These mixed feelings ranged from initial anger to acceptance.

I think its two fold. The community’s perception is that it is okay because it seems to be happening so much. But I also hear that a lot of the parents of these adolescent girls get incredibly angry because the girls engaged in premarital sex and lost their virginity. So there is initial anger and then it’s accepted. Everyone calms down and moves on. (Sarah, Clinical Psychologist)

The community is generally divided in their perceptions of adolescent pregnancy. Some treat adolescent childbearing as a norm and then the very traditional and strict members do not accept adolescent pregnancy. (Kate, HIV Counsellor)

Kate stated that in her opinion, the community members are divided regarding their perceptions of adolescent pregnancy. Some community members may view adolescent pregnancy as a social norm whereas others believe that adolescent childbearing is unacceptable. One healthcare provider felt that the community members had different perceptions about family planning and childbearing.

The community’s perception of adolescent pregnancy is a complex issue and there are different perspectives. Premarital sex angers the elders. They do not accept adolescent pregnancy. In fact, the parents and the older generation are against family planning. They believe contraception causes sterility. They also perceive that family planning is encouraging adolescents to have sex. However, there are members of the community who accept adolescent pregnancy and associate childbearing with both womanhood and motherhood. (Shaz, Professional Nurse, Midwifery)

Theme 3: Personal Experiences with Pregnant and Parenting Adolescent Women

This theme explored the healthcare providers’ personal experiences with pregnant and parenting adolescent women. Some participants described their experiences with pregnant and parenting adolescents as difficult while others felt overwhelming empathy.

Pregnant and Parenting Adolescents are Difficult

Healthcare providers considered pregnant and parenting adolescents to be difficult with regards to accepting healthcare advice. One healthcare provider mentioned that adolescent mothers do not always disclose the truth about their children’s medical history. A common complaint among the healthcare providers is that pregnant adolescent and adolescent mothers do not seem to listen to them

The adolescent mothers in the paediatric ward are very troublesome as they do not accept our health education. They feel that we are forcing our advice on them. Some adolescent mothers are not honest with healthcare providers, especially when they gave herbal medication to their children. (Heidi, Professional Nurse, Paediatrics)

In the labour ward, I find that the pregnant adolescents are difficult patients. When I try to speak to them, I find that they are not listening to me. (Merri, Professional Nurse, Midwifery)

The adolescent mothers can be very difficult as they do not want to be counselled about family planning. They are very reluctant and their attitudes are not good. (Neri, Medical Doctor)

Pregnant adolescents do not listen to healthcare providers. They are difficult and they not follow healthcare advice. (Hillary, HIV Counsellor)

In the labour ward, we experience difficulties with pregnant adolescents. Even though they attend antenatal care and they receive education from the midwives, they are still not co-operative and are difficult. The midwives have difficulties delivering the babies of adolescents. Sometimes they do not understand the instructions or they do not want to follow instructions. We understand the pain is overwhelming but we need these adolescents to co-operate with us. (Sandra, Professional Nurse, General Stream)

Expressions of Overwhelming Empathy

Healthcare providers were also empathetic and sensitive to the struggles and experiences of pregnant and parenting adolescents. The statements made by healthcare providers suggest that empathy allowed them to connect emotionally with pregnant and parenting adolescents.

I found pregnant adolescents to be co-operative when I was educating them about their pregnancy. I understand that they are young and they do not have the same knowledge as adult mothers. They have difficulties taking care of themselves. They are also vulnerable. I have empathy for these mothers. (Tazz, Enrolled Nurse)

My experiences have been overwhelming and such an eye opener to the difficulties experienced by these mothers. I have seen adolescent mothers that have no support. They do not even have clothes for their newborns. We just see incidences of adolescent pregnancy but not the person or human being who is going through emotional turmoil. (Sophia, Social Worker)

I felt that I could relate to the pain that adolescent mothers were experiencing during counselling sessions. When I spoke to them, I found that they just needed someone to talk to and not someone who would judge them. (Tina, Professional Nurse, PHC)

My experiences have been positive. I can empathise with adolescent mothers because they are humans and they do show remorse. They do listen to me when I advise them about postpartum contraception. (Constance, Professional Nurse, General Stream)

Theme 4: Perceived Challenges Experienced Pregnant and Parenting Adolescents

According to the participants, they perceived the following as challenges experienced by pregnant and parenting adolescent women: returning to school and completing their schooling, finances, relationships, abandonment, social interaction and stigmatisation, parenting and childrearing, and physical and mental health.

Difficulty Returning to School and Completing Their Education

Healthcare providers acknowledged that adolescent pregnancy disrupted the education of young women negatively. School dropout was considered common among pregnant and parenting adolescents.

The pregnant adolescents’ girls usually drop out of school. Then they have difficulty returning to school and completing their education. They also have problems seeking employment due to their low educational levels. (Celine, Medical Doctor)

I know of many adolescent mothers who dropped out of school. They are well spoken and intelligent individuals who are aware of the benefits of completing school and obtaining tertiary education. However, due to the responsibilities of raising a child, they drop out of school and this closes the door to a brighter future. (Heidi, Professional Nurse, Paediatrics)

I think schooling is a challenge. Early pregnancy is affecting their education. They may drop out of school or complete school at a later stage. (Sarah, Clinical Psychologist)

Financial Issues

Healthcare providers cited financial issues as a common challenge among pregnant and parenting adolescents. Pregnant and parenting adolescents were described as unemployed and from a low socio-economic background.

Finances are an issue for adolescent mothers. They don’t have the financial backup to look after their babies. (Pippa, Professional Nurse, Midwifery)

Most adolescent girls who are pregnant or mothers do not have an income. The financial difficulties result in frustration. (Sophia, Social Worker)

The adolescent mothers face financial problems. Most of them are unemployed. They are from poverty stricken families. (Constance, Professional Nurse, General Stream)

Issues Involving Relationships, Abandonment, Social Interaction and Stigmatisation

Within this subtheme, healthcare providers portrayed the negative social impact of adolescent pregnancy and parenting in terms of dysfunctional relationships, abandonment and stigmatisation. According to healthcare providers, adolescent pregnancy and parenting has a ripple effect on the relationships with partners and family members

Adolescent mothers have to deal with stigma. They are treated poorly at home and abandoned by their partners and family members. In fact, the relationships become so strained that the family members tell these mothers to look after themselves and their babies. The families are tired of the responsibilities of looking after young mothers and their children. The community members do not interact with them. (Mpho, Professional Nurse, Midwifery)

There are many social problems that pregnant and parenting adolescent girls experience. They are abandoned by their partners. Their family relationships break down. Parents remain angry with these girls for falling pregnant. Some of these girls will leave home and live with other relatives. They will also find it difficult to interact with other girls of the same age in the community. Society looks down upon adolescent mothers. (Tina, Professional Nurse, Primary Healthcare)

Tina’s response suggests that dysfunctional relationships, abandonment and social isolation can be very distressing for the pregnant and parenting adolescent girls. The emotional turbulence experienced by pregnant and parenting adolescent girls is further heightened by the stigmatisation.

I think the pregnancy affects these adolescents’ relationships with family members, other men and their friends. They face issues of abandonment and also stigma. (Sarah, Clinical Psychologist)

Issues Associated with Parenting and Childrearing

Healthcare workers acknowledged that adolescent mothers experience challenges with parenting and childrearing. The lack of parenting skills and poor social support linked to difficulties with parenting and childrearing. One healthcare provider stated that poor parenting was detrimental to the health outcomes of children born to adolescent mothers.

The adolescent mothers find it difficult to raise their children. They do not have parenting skills. These young mothers are children themselves. (Beauty, Professional Nurse, General Stream)

If you attend the paediatric ward, you often find adolescent mothers with malnourished babies. This is a problem that could have been avoided. The young mothers are also unaware of child development. (Ian, Physiotherapy Technician)

The parenting part for adolescent mothers is difficult as most of them do not have good support structures at home. Sometimes adolescent mothers are not raising their own children but leave them with their grandmothers. This is a huge burden for grandmothers. Grandmothers have only their pension money to survive and sometimes they run out of money for baby formula and nappies. (Sandra, Professional Nurse, General Stream)

According to Sandra, some adolescent mothers did not assume the responsibility for parenting and rearing their children. In these circumstances, grandmothers took on the parenting and child rearing responsibilities.

Issues Associated with Physical and Mental Health

Healthcare providers maintained that pregnant adolescents and adolescent mothers also experience physical and mental health problems. Postpartum blues and depression was cited as a common mental health problem that affects adolescent mothers. Psychological distress such as guilt and embarrassment also contributed to mental health issues. Obstetric fistulas and sexually transmitted infections were cited as some of the issues affecting the health of pregnant and parenting adolescent girls.

Adolescent mothers also experience postpartum blues and depression. These young mothers are not able to understand the emotions they are experiencing. In the African culture, mental health issues are poorly understood. Adolescent mothers who are depressed experience a reduction in breast milk production. They may also abandon their babies. (Frank, Professional Nurse, Psychiatry)

Pregnant and parenting adolescent girls are often infected with sexually transmitted diseases. They do not take care of their health and default treatment. They become physically ill and are unable to care for their children. (Nora, Professional Nurse, Paediatrics)

Most adolescent girls do not understand pregnancy. They do not understand the physical changes in their bodies. Their bodies are not even physically mature for a pregnancy. I have seen adolescents sustaining complications such as obstetric fistulas. It is a very distressing complication. These girls with obstetric fistulas are teased because they smell of faeces and urine. Their peers shun them. (Roslyn, Professional Nurse, Midwifery)

Psychologically, adolescent mothers are not able to fit into society. They experience emotions such as guilt and embarrassment and do not feel good about themselves. Physically, they are not proud of their bodies because they are no longer virgins. They also have to deal with sexually transmitted diseases (Tina, Professional Nurse, Primary Healthcare.)

Tina stated that in her opinion, adolescent mothers are outcasts in society and this results in psychological distress.

Theme 5: The Essential Needs of Pregnant and Parenting Adolescent Women

According to the healthcare providers psychosocial, family and partner support; antenatal and postnatal support; financial support; encouragement; acceptance; and personal empowerment are essential needs for pregnant and parenting adolescent women.

Psychosocial, Family and Partner Support

Healthcare providers maintained that pregnant and parenting adolescents needed psychosocial, family and partner support. One healthcare provider clarified that family support should be the first line support for pregnant and parenting adolescents.

I think parental support is necessary for pregnant and parenting adolescents followed by support from healthcare providers. The social worker and psychologist play an essential role in providing psychosocial services. (Maggie, Professional Nurse, Midwifery)

The support of parents and partners is very important to help pregnant and parenting adolescents to look after themselves and their children. Pregnant adolescents need to be able to turn to their parents or caregivers to talk to them about their problems. (Neri, Medical Doctor)

Families should be the first line of support for pregnant adolescents. Psychosocial support without a doubt is so important in adolescent pregnancy. We also refer pregnant adolescents to a social worker and psychologist. (Sandra, Professional Nurse, General Stream)

Sandra recognised the importance of the social worker and psychologist in facilitating psychosocial support for pregnant and parenting adolescents. The important of the multidisciplinary support structure in the healthcare setting for adolescent pregnancy and parenting was re-iterated as a vehicle for psychosocial support.

Adolescent mothers need a lot of family support. I personally believe that partner support is also essential. A multidisciplinary support structure at the hospital with social workers and psychologists is also important. (Sumeera, Professional Nurse, General Stream)

Antenatal and Postnatal Support

Healthcare providers echoed the need for antenatal and postnatal support for pregnant adolescents and postpartum adolescents. One healthcare provider called for non-judgemental antenatal care.

Antenatal and postnatal care is so important. Most of the pregnant adolescents cannot talk to their family members about their pregnancy. I also think they need to have access to clinics where nurses do not treat them in an angry manner because the pregnancy has happened. In order to safeguard the adolescents from pregnancy complications, they need good antenatal support. (Sarah, Clinical Psychologist)

Antenatal care is important for pregnant adolescents. Many hide their pregnancies and do not attend antenatal clinics. Adolescent girls have high risk pregnancies so it is important for them to be monitored in antenatal care. Postnatal care is also essential because adolescent mothers don’t take care of their physical health. They need counselling on postpartum contraception. (Beauty, Professional Nurse, Midwifery)

Beauty emphasised the high risk nature of adolescent pregnancies and the importance of regular antenatal care. She also expressed that adolescents’ girls needed counselling on postpartum contraception.

Apart from family, social, emotional and community support, pregnant adolescents need good antenatal care and support. At the antenatal clinic, they should be counselled on the upbringing of the baby and breastfeeding. Postpartum care must also reinforce child care and contraception. (Frank, Professional Nurse, Psychiatry)

Similarly, Frank also reiterated that postpartum care should include contraception. He also emphasised the comprehensive antenatal care that includes child development and breastfeeding.

Financial Support

Healthcare providers argued that the financial support of pregnant and parenting adolescents is an important issue that needs be addressed. One healthcare provider indicated that financial constraints hampers the lives of both the adolescent mothers and their children.

The financial needs of adolescent mothers cannot be underestimated. The child support grant is inadequate. (Kate, HIV Counsellor)

Financial support is important because I have seen adolescent mothers who do not have clothes for their babies. They do not have transport money either. We have to ask for donations for these mothers. (Matilda, Enrolled Nurse)

Encouragement, Acceptance and Personal Empowerment

Healthcare providers assert that pregnant adolescents and adolescent mothers need encouragement, acceptance and personal empowerment to improve their own lives. Education was emphasised as a stepping stone to a positive future.

I think pregnant and parenting adolescents need to forgive themselves. They also need acceptance in society and not to be punished. They need to pick themselves up and further their education. They need to move on in life and achieve a brighter future. (Pippa, Professional Nurse, Midwifery)

I think it would be wonderful to empower young mothers to take charge of their lives. We need to teach them to be hands-on parents so that they will appreciate parenting and this can prevent repeat pregnancies. They need to be encouraged to set goals for themselves and these should include their education. They also need acceptance. (Merri, Professional Nurse, Midwifery)

Theme 6: The Availability of Healthcare Services for Pregnant Adolescents and Adolescent Mothers

Within this theme, the availability of healthcare services for pregnant adolescents and adolescent mothers were explored. Some healthcare providers mentioned that healthcare services were freely available and accessible for pregnant adolescents and adolescent mothers. However, some argued that these services were generic and not channelled to serve the needs of pregnant adolescents and adolescent mothers.

Availability of Services

Some of the healthcare providers maintained that healthcare services are available to pregnant adolescents. The healthcare services were reported to be free and available 24 hours at local clinics. Taking this further, one healthcare provider felt that pregnant adolescents and adolescent mothers received more support from the healthcare system than their adult counterparts.

In my opinion, healthcare services are available to pregnant adolescents. The clinics are now operating 24 hours. These healthcare services are also free and serve pregnant adolescents. (Sandra, Professional Nurse, General Stream)

The healthcare services are available for pregnant and parenting adolescents. In fact, I think they receive more support than adult mothers. I do not think that they should not receive special treatment or attention. (Valerie, Professional Nurse, General Stream)

Lack of Support Services for Adolescent Mothers

Some healthcare providers expressed their concern that healthcare services were not specific to the needs of pregnant adolescents and adolescent mothers. In addition, the healthcare providers went ahead to suggest that healthcare providers needed to be specifically trained to handle tailored services for pregnant adolescents and adolescent mothers.

I do not think that healthcare services are channelled towards pregnant adolescents but are channelled towards pregnant mothers in general. So there are no specific services available to pregnant adolescents. I think there should be something quite specific for adolescents because the way you explain to them, teach and handle them is very different to how you would handle adult women. Pregnant and parenting adolescents are slipping through the cracks in the system and, as a result, they are getting pregnant again. (Sarah, Clinical Psychologist)

The services are not tailored for pregnant adolescents. They sit together with pregnant adult women. If I had my way, there would be a separate adolescent pregnancy clinic. I would make sure the nurses are trained to handle pregnant adolescents. (Tina, Professional Nurse, Primary Healthcare)

Tina emphasised the need for a competent health workforce with training in adolescent pregnancy and parenting as step towards adolescent responsive healthcare.

The healthcare services or maternity services are generalised. There is no clinic that caters for pregnant and parenting adolescents. Even at family planning, you will see an elderly lady telling adolescents that they are too young to be engaging in sex. The pregnant adolescents need specific services and trained healthcare providers that can deal with the needs of adolescents. (Frank, Professional Nurse, Psychiatry)

Frank alluded that generic family planning and maternity services may not be appropriate to the pregnant adolescents and adolescent mothers as they may be subjected to criticism from older women.

Theme 7: Issues Associated with the Poor Uptake of Healthcare Services by Pregnant and Parenting Adolescent Women

The healthcare providers suggested that issues such as embarrassment, fear, the need for confidentiality, the attitude of healthcare providers, difficulties with transport, distances to clinics, and a preference for the services of traditional healers impacted adolescent young women’s decision to access healthcare services.

Embarrassment, Fear and the Need for Confidentiality

Healthcare providers described how embarrassment, fear and the need for confidentiality limited the uptake of healthcare services by pregnant adolescents and adolescent mothers. They stated that pregnant adolescents and adolescent mothers felt vulnerable attending local health services as they would be exposed to other community members also utilising the same healthcare services. In this regard, pregnant adolescents and adolescent mothers felt that their confidentiality was threatened.

I think that pregnant and parenting adolescents are afraid to use our services because of stigma. They are also embarrassed because a lot of the healthcare services are in their communities which means most people working there know their parents or guardians. They are scared that they will be reported if they are using our services. They are scared that they are going to be reprimanded so they rather stay away. (Roslyn, Professional Nurse, Midwifery)

Pregnant adolescents are so scared that there will be a lack of confidentiality in clinics and the hospital. They are embarrassed and fear that their relatives or neighbours will see them accessing such services. They are also scared that people will gossip about them. (Merri, Professional Nurse, Midwifery)

Most adolescents hide their pregnancies and do not tell their families. They are scared and embarrassed to be seen at a clinic. The community is small and it’s possible that they will meet relatives and neighbours at the hospital. Confidentiality is also an issue. (Shelly, Professional Nurse, Midwifery)

The Negative Attitude of Healthcare Providers

Healthcare providers believed that the negative attitudes of healthcare staff at clinics presented as a barrier to the uptake of healthcare services among pregnant adolescents and adolescent mothers. Furthermore, healthcare providers highlighted the discrimination and fear that pregnant adolescents and adolescent mothers have to contend with when seeking healthcare services at clinics.

Pregnant and parenting adolescents are scared of the nurses at the clinic because they shout at them. (Shola, Professional Nurse, Midwifery)

The attitudes of healthcare providers are negative towards pregnant and parenting adolescents. This chases pregnant and parenting adolescents away. (Tina, Professional Nurse, Primary Healthcare)

Pregnant and parenting adolescents fear being shouted at by healthcare providers. There are healthcare providers who get very angry at adolescent girls for getting pregnant. So instead of helping them, they frighten them. Healthcare providers often believe that adolescents should be punished for falling pregnant. (Sarah, Clinical Psychologist)

According to Sarah, healthcare providers are more likely to instil fear in pregnant and parenting adolescents rather than providing them with the much needed assistance.

It is the shameful attitudes of healthcare providers. We discriminate against pregnant and parenting adolescent mothers. We shout at them and scare them. (Kate, HIV Counsellor)

Difficulties with Transport to and from Clinics

The other barrier to the uptake of healthcare services among pregnant adolescents and adolescent mothers projected by healthcare providers included transport. Moreover, the healthcare providers described the long distances and geographical location of the clinic as factors contributing to the high transportation fees.

Apart from healthcare providers’ negative attitudes, another issue is transportation problems. The clinics are far and the transportation costs are high. The hours of service delivery also restrict access. Taxi fares are expensive, especially when the girls have to travel from rural areas. (Brenda, Medical Doctor)

The distance from home to the clinic is far for most pregnant or parenting adolescents. Sometimes there is no transport available, especially in deep rural areas. In most rural areas, you take three taxis to reach this hospital which may cost approximately R120 a day. (Frank, Professional Nurse, Psychiatry)

There are people who live very far from the clinics and the hospital. There is a lack of transportation as well. If transport is available, the transportation fees are expensive. The girls have to walk long distances to the clinic if they cannot afford the fee. (Tazz, Enrolled Nurse)

Preference for Care by Traditional Healers

According to healthcare providers, pregnant adolescents and adolescent mothers preferred healthcare services rendered by traditional healers. They perceived this preference for traditional healthcare as a reason for the limited uptake of services at established healthcare settings. Healthcare providers described that the use of herbal medication by adolescent mothers resulted in the hospitalisation of children for herbal intoxication. They felt that family members encouraged pregnant adolescents and adolescent mothers to seek traditional healers. One healthcare provider believed that pregnant adolescents were using traditional medication to induce their labour

It appears that pregnant and parenting adolescents prefer care that is rendered by a traditional healer. I have seen pregnant adolescents using herbal medication during their pregnancy. In the paediatric wards, the children of adolescent mothers are [often] hospitalised for herbal intoxication. (Neri, Medical Doctor)

These adolescents listen more to their parents and other family members. They are going to traditional healers as their first preference. Pregnant adolescents take medication supplied by traditional healers to induce pregnancy. They also consult traditional healers for child-related illnesses. (Shola, Professional Nurse, Midwifery)

Theme 8: Suggestions for Improving Healthcare Services for Pregnant and Parenting Adolescents

Healthcare providers suggested a number of ways to improve healthcare services for pregnant and parenting adolescents. Some suggested that closing the gap between the Department of Health and the Department of Education would improve the healthcare services for pregnant and parenting adolescents. Others suggested that tailoring healthcare services to accommodate pregnant and parenting adolescents would lead to improvement in the services rendered to these young women. Home visits, community outreach programmes, collaboration with traditional healers and NGOs, and support groups were additional suggestions for improving healthcare services for pregnant and parenting adolescents.

Closing the Gap Between the Department of Health and the Department of Basic Education

Healthcare providers acknowledged the important roles of the Department of Health and the Department of Basic Education with regards to improving the healthcare services for pregnant adolescents and adolescent mothers. The Department of Health and Department of Basic Education were described as departments working in silos rather than collaboratively. In addition, healthcare providers felt that antenatal and postnatal care needs to be accessible to pregnant learners through school health nurses. According to the views of healthcare providers, as a way to bring health care closer to pregnant adolescents and adolescent mothers, the gap between the Department of Health and the Department of Basic Education needs to be closed.

I think schools have an important role in educating adolescents about pregnancy and sexual and reproductive health through the Life Orientation programme. The Department of Health should also collaborate with the Department of Education. Adolescents need to know about the services that are available. In fact, antenatal and postnatal care needs to be accessible through school health nurses so that these adolescents do not fall through the cracks in the system. (Sarah, Clinical Psychologist)

We need to take healthcare services to the schools. The Department of Health must approach schools. The school healthcare nurses need to help and liaise with antenatal healthcare nurses. (Beauty, Professional Nurse, General Stream)

The gap needs to be closed between the Department of Health and Department of Education. If both these government departments can work hand in hand, we would be able to strengthen adolescent pregnancy prevention and ensure the dignity and well-being of pregnant and parenting adolescents. Nurses should be allowed into schools to educate learners about pregnancy and encourage those who are already pregnant to use antenatal services. (Maggie, Professional Nurse, Midwifery)

Maggie reiterated the need for a collaborative relationship between the Department of Health and Department of Basic Education with regards to improving adolescent pregnancy prevention and the health and wellbeing of pregnant and postpartum adolescents.

Prioritising Healthcare Services That are Tailor-Made for Pregnant and Parenting Adolescents

Healthcare providers suggested that healthcare services must be tailored to the needs of pregnant adolescents and adolescent mothers. Another aspect that healthcare providers emphasised included the training of healthcare service providers in adolescent health issues.

I would suggest a tailored clinic for pregnant and parenting adolescents. The staff must be well trained in adolescent health issues and be able to communicate with adolescents at their level of understanding. (Nonnie, Dietician)

We need specialised adolescent antenatal and postnatal clinics. Pregnant and parenting adolescents’ issues are different from those of adult mothers and they need specific services. (Shaz, Professional Nurse, Midwifery)

Shaz reiterated that the healthcare service needs of pregnant and parenting adolescents are significantly different from pregnant adults and adult mothers. In this regard, healthcare services needed to be responsive and geared up for pregnant adolescents and adolescent mothers.

Home Visits and Community Outreach Programmes

Healthcare providers acknowledged the importance of home visits and community outreach programmes with regards to healthcare services for pregnant and parenting adolescents. One healthcare provider believed that community outreach services would improve the access of healthcare services to pregnant adolescents and adolescent mothers. Community health workers and mobile clinics were also considered as the means to providing home visits and community outreach services to pregnant adolescents and adolescent mothers.

I think home visits and community outreach [programmes] can help pregnant and parenting adolescents. We have community healthcare workers who can be trained to help educate these girls. We can also use mobile clinics to do community outreach. (Constance, Professional Nurse, General Stream)

We should be accessible to pregnant and parenting adolescents outside the formal setting. We should consider community outreach programmes. It would be ideal to conduct home visits to educate and support these adolescents. (Heidi, Professional Nurse, Paediatrics)

For the TB programme, we have staff that go out and trace patients. I think we can extend this to the care of pregnant adolescent girls. We should be able to go into the communities and provide antenatal care. We can also trace pregnant women who default antenatal care. (Kate, HIV Counsellor)

Kate described a cascade of care that can be rendered to pregnant adolescents through a tracing programme of those who default antenatal care. Her suggestion also emphasises the continuum of care for the pregnant adolescent. The aim of an antenatal tracing programme would be to return pregnant adolescents to care and improving maternal and child health outcomes.

Collaboration with Traditional Healers

Healthcare providers acknowledged that pregnant and parenting adolescents consulted traditional healers for maternal and child health. One healthcare provider suggested the need for collaboration between traditional healers and the biomedical health system in order to improve the outcomes of healthcare to pregnant and parenting adolescents

I think we need to communicate with traditional healers and also learn from each other. We need to educate traditional healers about the medical management of pregnancy. This is a necessary step because we know that pregnant and parenting adolescents consult traditional healers. (Neri, Medical Doctor)

Collaboration with NGOs

Healthcare providers suggested that non-governmental organisations (NGOs) have a significant role in enhancing the healthcare services for pregnant adolescents and adolescent mothers. One healthcare provider emphasised the importance of the provision of psychosocial services by NGOs.

I think a downfall in the healthcare system is the lack of collaboration with NGOs and youth empowerment organisations regarding adolescent pregnancy. I just think of the anxiety that a 15-year-old pregnant adolescent experiences when sitting with a group of 30-plus-year-old mothers who are in their third pregnancy. I wish there was a non-governmental organisation that could quietly and confidentially support these adolescents. The adolescent girls will be more likely to report their pregnancies instead of aborting or self-aborting. They could also be counselled on how to disclose their pregnancy to their parents. I often find that they come in and they haven’t told their parents or caregivers. It is a frightening situation for them. So if they could have that support, maybe we could promote family involvement. (Sarah, Clinical Psychologist)

Support Groups

The healthcare providers suggested that support groups would help provide an opportunity for pregnant adolescents and adolescent mothers to share personal experiences and coping strategies. The support groups would fill the gap between the medical treatment and the need for social and emotional support

I would approach school health services and establish a support group. I would use the support group to empower pregnant and parenting adolescents (Frank, Professional Nurse, Psychiatry)

Frank commented that the school health services should be instrumental in forming support groups to empower pregnant and parenting adolescents.

We need to establish support groups for pregnant and parenting adolescents. (Shelly, Professional Nurse, Midwifery)

Theme 9: Personal and Institutional Efforts to Support Pregnant and Parenting Adolescents

The healthcare providers mentioned that counselling and health education formed part of their personal and institutional efforts to support pregnant and parenting adolescent women.

Counselling

Most healthcare providers were involved in the provision of counselling services to pregnant and parenting adolescents. These counselling services were provided within the institution and during community outreach programmes.

I conduct counselling during community outreach programmes. I counsel the adolescent mothers on returning to school and completing their secondary education. (Shaz, Professional Nurse, Midwifery)

We provide counselling to the pregnant adolescents on all the available pregnancy options. We also counsel adolescent mothers that are experiencing a crisis. We also extend our services during community outreach programmes. Counselling is provided during pregnancy and after birth as required. (Sophia, Social Worker)

When the pregnant adolescent mothers are referred to us, we counsel them. We discuss if they have disclosed their pregnancy to their family. Then we discuss issues regarding how they are going to care for the child. We discuss their school attendance and future goals. I also try to place emphasis on the road ahead because it is going to be a difficult road to travel. We reassure them that we are always available if they need to talk to us. We also counsel them on family planning in order to prevent repeat pregnancies. (Sarah, Clinical Psychologist)

Sarah described comprehensive counselling services which included family planning, school attendance, future goals and parenting for pregnant and parenting adolescents.

Health Education

Healthcare providers mentioned that health education was part of their personal and institutional efforts to support pregnant and parenting adolescents. The health education focused on teaching pregnant and parenting adolescents the skills to make healthy choices for themselves and their children

I provide pregnant adolescents with nutritional education with regards to a healthy pregnancy. I also have to educate adolescent mothers on how to care for their children who suffer from malnutrition. (Nonnie, Dietician)

I conduct health education on pregnancy, sexual and reproductive health. The pregnant adolescents need health education to make informed decisions. (Zoe, Professional Nurse, Midwifery)

I conduct health education in the antenatal clinic. I enjoy talking to pregnant adolescents. I have also done health education talks in the communities for adolescent mothers. (Tina, Professional Nurse, Primary Healthcare)

Discussion

This qualitative study explored the perceptions of adolescent pregnancy and parenting amongst a diverse group of healthcare providers (multidisciplinary team) in a district hospital in rural southern KwaZulu Natal, South Africa. The healthcare providers’ comments underscored the fact that adolescent pregnancy is a problematic issue. Similarly, previous research has shown that most healthcare providers view adolescent pregnancy and parenting as a challenging public health issue.13,21 Adolescent repeat pregnancy is defined as two or more pregnancies for an adolescent woman before she is 20 years of age.22 The participants unanimously acknowledged that repeat pregnancies were not surprising as they witnessed this on a daily basis. According to Govender et al,13 nurses in a similar field of study area also reported that repeat adolescent pregnancy was a common occurrence that negatively impacted the lives of these girls.

Healthcare providers’ perceptions of the community beliefs regarding adolescent pregnancy and parenting were also explored. In terms of the healthcare providers’ perception and understanding of the community beliefs of adolescent pregnancy and parenting, the following subthemes emerged: it is a norm, it is unacceptable, and it is an ambivalent (two-fold) issue. The beliefs of the community regarding adolescent pregnancy and parenting may impact on the care and attitudes towards pregnant adolescents. Erasmus et al23 found that community and societal beliefs influenced adolescents access to antenatal care services in South Africa. Adolescent pregnancy is often met with disapproval because of premarital sexual activity.23 The ability of healthcare providers to perceive and understand the community beliefs is an important facet of compassion and patient centred care. Individualism underpins the Western approach in medical practice but in Africa, the collectivist approach is dominant.24 Individualism places emphasis on the individual goals and rights whereas collectivism focuses on the group. In the collectivist societies, people belong to a group and are rewarded for their loyalty.24 The beliefs of the community and society influences medical decision making.24 Taking into consideration community beliefs may provide insight into the conceptualisation of adolescent pregnancy and motherhood and how access to healthcare services can be affected. A study by Phaswana-Mafuya et al25 among community members in other regions of South Africa found that it was accepted as a norm and had become “fashionable”. Similar to the current study, views about the acceptability of adolescent pregnancy were also ambivalent.

The threat of contracting HIV is six times higher for adolescent women than it is for adolescent men.26 In the current study, the participants expressed their concern that pregnant and parenting adolescents were at high risk of contracting HIV and STIs due to unprotected sex. The issue of transactional sex was raised by some participants who mentioned that older men were not only seducing and impregnating younger women, but they were also infecting them with HIV. Hodes27 found that in some communities within South Africa, there was a consensus that pregnancy is a profit as adolescents are falling pregnant for the child support grant. The sentiment that pregnancy is a profit positions young women as squanderers and abusers of the state and welfare system.27 The belief about pregnancy as a material gains not only widens the gender discrepancies between men and women but also diminishes women’s identities and values as mothers.27 It is important to note that the idea that the child support grant encourages adolescent pregnancy is the perceptions of healthcare providers and not a finding of this study as this study does not aim to provide definitive evidence on this.

The marginalisation of the importance of adolescent sexual and reproductive health education was underscored as a concern and many participants argued that the postpartum sexual and reproductive health of these mothers was not given any priority. Ramraj et al28 revealed that adolescent mothers in South Africa had almost three times fewer planned pregnancies than adult mothers. The literature revealed that adolescent sexual and reproductive health disparities exist globally.29 According to Muller et al,29 nurses in the Western Cape expressed their frustration about not having adequate time to conduct sexual and reproductive health education due to staff shortages, and the participants in the current study also lamented that fact that a shortage of staff limited efforts to forefront the sexual and reproductive health of adolescents.

Some of the participants stated that they had had negative personal experiences with pregnant and parenting adolescents while some had experienced overwhelming empathy. Until this study, limited reports had been published about healthcare providers’ personal clinical experiences with pregnant and parenting adolescents. Existing literature revealed that research tended to focus on pregnant and parenting adolescents’ experiences of healthcare services and their interactions with healthcare providers rather than healthcare providers’ experiences with this group. One study reported that healthcare providers in Thailand, which included obstetricians, midwives and social workers, acknowledged that caring for pregnant adolescents was very challenging as they struggled to instil an awareness of self-care during pregnancy in these young women.30 Some of the participating healthcare providers in the current study also stated that adolescents did not follow their advice and instructions in the labour ward, which seemed to frustrate them. However, the literature also revealed instances where healthcare providers had empathy for adolescent mothers. According to a study conducted by Burrowes et al31 in Ethiopia, the participants in a maternity setting argued that good clinical care was associated with empathetic healthcare providers.

The healthcare providers stated that pregnant and parenting adolescents experienced challenges in various areas such as when returning to school, completing their schooling, financial constraints, relationships, abandonment, social interaction, stigmatisation, parenting and child rearing, and physical and mental health. Similarly, Kumar et al21 found that caregivers and healthcare providers perceived school dropout, financial constraints, dysfunctional relationships, stigmatisation, stress, parenting and childrearing as challenges that affected pregnant and parenting adolescents in Kenya. In the South African context, nurses participating in a study that investigated the multidisciplinary approach of care for adolescent mothers stated that these mothers experienced poor family support, poor parenting, negative attitudes of healthcare providers, poverty, peer pressure, high HIV risk, poor partner support, depression, and dysfunctional parent-adolescent communication as barriers.13 It has also been argued that adolescent women are likely to experience excessive and persistent anxiety during pregnancy, which is a risk factor for postnatal depression32 and can affect parental bonding.21 The current study considers the role of psychosocial assistance, family support, partner support, financial support, and antenatal and postnatal support as essential for pregnant and parenting adolescent mothers. The literature emphasises that pregnant and parenting adolescents need family support33 and that these mothers also want non-judgmental antenatal and postnatal healthcare.34 On the other side of the coin, however, the data revealed that healthcare providers perceive that many adolescent women deliberately fall pregnant to gain access to government funds for child support, but that these funds are misappropriated for personal grooming purposes.

Research has reported that pregnant adolescents underutilise antenatal healthcare services in South Africa.35 For example, pregnant adolescents in Maputle’s35 study cited the following reasons for not attending an antenatal clinic: fear of discrimination by healthcare providers, emotional vulnerability, and an unawareness of the pregnancy itself. Maternal, newborn and child health programmes are essential for adolescent mothers as they address prenatal, postnatal and family planning issues.36 Many healthcare providers in the current study felt that encouragement, acceptance and personal empowerment support pregnant and parenting adolescents. Moreover, empowerment, encouragement and the affirmation of their strengths and aspirations also have a positive effect on reducing adolescent mothers’ sexual risk taking behaviour and improving their self-care and their care of the child.37

The current study also explored healthcare providers’ perceptions about the availability of healthcare services for pregnant and parenting adolescents. Some of the participants argued that healthcare services were sufficiently available for pregnant and parenting adolescents while others felt that the available services were not channelled towards adolescents. Prior studies noted the importance of tailor-made healthcare services for pregnant and parenting adolescents.13,30 For example, healthcare providers in Thailand underscored the importance of specialised clinical services for pregnant and parenting adolescents.30 Healthcare programmes tailored to the needs of pregnant and parenting adolescents have resulted in improvements in infant care, school enrolment, and in the reduction of adolescent repeat pregnancies.16

The current study found that issues impacting pregnant and parenting adolescents’ willingness to seek healthcare assistance included embarrassment, fear and confidentiality, the negative attitude of healthcare providers, difficulties with transport, long distances to and from clinics, and a preference for the services of traditional healers. Kumza and Peters38 also found that concerns regarding confidentiality, communication and trust prevented adolescents from using sexual and reproductive healthcare services. According to the healthcare providers in our study, pregnant adolescents are afraid to be seen in local health institutions as family and community members might identify them. Likewise, a study among South African nurses who provided sexual and reproductive health services in the Western Cape reported that, in small communities, these nurses knew the parents of most adolescents and this situation made the girls reluctant to use their services.39 A study in Uganda by Rukundo et al40 also found that adolescents were afraid to access antenatal services due to fear of stigmatisation.

The impact of the attitude of healthcare providers is strongly underscored by the literature as a barrier to the utilisation of healthcare services by pregnant and parenting adolescents.12,13 Adolescents in South Africa reported that nursing staff were often judgmental and indiscrete, whereas nursing staff noted the vulnerability and fear of adolescents and their reluctance to access sexual and reproductive health services.39 Geographical locations and the costs of transport are also barriers to maternal and child healthcare in low and middle income countries.41–43 The current study found that girls’ preference for using traditional healers was also a factor that affected their willingness to access healthcare services. The preference for using traditional healers is often cited in the literature44,45 as approximately 80% of people in Africa use traditional medication, especially for maternal and reproductive health issues.44

The participants suggested that the healthcare of pregnant and parenting adolescent mothers should be improved by bridging the gap between the Department of Health and the Department of Education, by prioritising tailor-made healthcare services for young mothers, home visits, community outreach programmes, collaboration with NGOs and traditional healers, and the formation of support groups. The participants were clearly conscious of the importance of various stakeholders in the care of pregnant and parenting adolescents. Likewise, Du Preez et al46 argue that collaboration between the Department of Health and the Department of Education is required to improve the care of pregnant adolescent learners and to enhance the skills of educators to cope with these girls. Skobi and Makofane47 report that networking and collaboration with NGOs and faith-based organisations also play a fundamental role in preventing adolescent repeat pregnancies. Home visits and community outreach services have been acknowledged in the literature as crucial to public health interventions, especially in maternal child health programmes.48 Support groups are also strategic in helping pregnant and parenting adolescents who are often isolated and stigmatised.49 The use of traditional healthcare is prevalent in sub-Saharan Africa,44 and thus engagement with traditional healers is important in harnessing their role in efforts to enhance the care of pregnant and parenting adolescents.

The study explored both personal and institutional efforts to support pregnant and parenting adolescents. Some participants reported that they provided counselling while others emphasised their focus on the health education of this group. Perumal et al50 highlight the importance of counselling and education delivery in maternal health programmes and argue that these services need to be delivered in an empathetic and non-judgmental manner. Health education in school settings is also strongly recommended by the World Health Organisation to assist in curbing health-compromising behaviours that are prevalent during adolescence.51

A limitation of this study was that it was confined to one institution in one rural district. The transferability of the findings is thus limited to similar settings. Another limitation was that only two male healthcare providers participated in this study. This was due to the limited number of males in the healthcare professions that were targeted. Moreover, the study focused on healthcare providers’ perceptions of pregnancy and parenting with regards to adolescent women, and future research needs to take into account the perceptions of pregnancy and parenting with regards to adolescent men in order to consider a holistic view of the subject.

Conclusion

This study elicited significant insights into healthcare providers’ perceptions about adolescent pregnancy and parenting. Furthermore, our study is unique in the sense that we have attempted to provide a holistic perspective of adolescent pregnancy and parenting in terms of the diverse interactions. Our study will add to the body of related literature as it explored the perceptions of adolescent pregnancy and parenting of a diverse group of healthcare providers. It is also essential for public health research to disclose multiple perspectives on adolescent pregnancy and parenting in order to develop an understanding of healthcare service delivery. The findings could assist healthcare providers, administrators in healthcare institutions, policy makers, the Department of Health and the Department of Education in South Africa to address the many gaps that exist in the care of pregnant and parenting adolescents. Our findings also underscore the need for a multidisciplinary approach to the care of pregnant and parenting adolescents in the form of a Community of Practice. According to Wenger et al52

Communities of Practice are groups of people who share a concern, a set of problems, or a passion about a topic, and who deepen their knowledge and expertise in this area by interacting on an ongoing basis. (p.4)

A Community of Practice model can integrate the clinical and psychosocial services in a healthcare setting and such a model includes problem solving, knowledge sharing, time saving, access to expertise, and professional development.53