Adolescent pregnancy and parenthood in Swaziland : Quality of care, community support and health care service needs

The aim of this thesis was to study – from different perspectives – adolescent pregnancy and parenthood in Swaziland. The specific objectives were to: i) explore maternity care practices and support for adolescent mothers during their stay in the maternity unit; ii) study the postpartum support to adolescent mothers and their newborns at home by families, communities and health professionals; iii) explore adolescents views regarding risky sexual behaviour; iv) explore adolescent boys views on adolescent pregnancy and parenthood; v) explore health care staff provision of adolescent sexual and reproductive health care services in Swaziland. Qualitative and quantitative studies were carried out in four regions in Swaziland. Observations and checklists were used to assess the maternity care practices and semi-structured interviews were held with adolescents during their stay in the maternity ward (I). Seven days after delivery adolescent mothers were visited and interviewed in their homes (II). Twenty -four Focus Group Discussions (FGDs) with adolescent girls and boys (III) and further six FGDs with Swazi adolescent boys were conducted (IV). Questionnaires were distributed to health care staff in eleven health facilities in two regions in Swaziland. Statistical software was used for analysis of quantitative data (I, II, V) and content analysis was used for analysis of qualitative data (II, III, IV). Although the pregnant adolescents perceived that they were met in a welcoming manner by the midwives, the findings from the physical examination were poorly explained to them. None of the 33 adolescents were encouraged to bring a social support person with them during labour. All the girls were admitted and started with an uneventful labour, 12 (36%) had normal deliveries; nine 11 (35%) had an episiotomy, one (2%) was delivered by vacuum extraction and nine (27%) had a lower segment caesarean section performed. Seventeen (71%) adolescent mothers started breastfeeding their babies within one hour after birth and 7 (29%) started after two hours. Most of the adolescents were told to come back for postnatal check up (I). All adolescents were aware that missing a menstrual period was indicative of pregnancy and 30 (97%) were aware of different contraceptive methods but had not used any. They had got information about contraceptives from their peers. Twenty-five (81%) did not want the pregnancy and 15 (48%) had to drop out-of-school. Twenty-six (84%) first informed the partner about the pregnancy and none initially told their parents for fear of being scolded, beaten or chased away from home. Four (13%) had been scolded by midwives. Twenty-four (77%) had been abandoned by their partners after the birth of the baby, 15 (48%) had support from their parents, 14 (45%) from other relatives and 19 (61%) were satisfied with the support they received from their parents and other relatives (II). Age at first intercourse, peer pressure and trust in the relationship were found to be important factors in decision-making for risky sexual behaviours. Participants thought that the ideal age for starting sexual activity was 16 for girls and 17 years for boys. The majority believed that condom use implies a lack of trust in a partner and that condoms should be used when people have extra marital sex e.g. with prostitutes and casual partners, infected with STI and that condom use is un-pleasurable and artificial. There were generally negative attitudes to condom use. Adolescents were influenced by their peers to engage in sexual activity and the majority agreed that sex with multiple partners was common among them (III). Boys wanted to test what it meant to have sex. The boys commonly denied the pregnancy, feared that their parents would chase them away from home and that their peers would laugh at them if they had impregnated a girl. The boys believed that unfaithfulness was common in both sexes and thus could not trust the girls. Boys were aware that adolescent mothers and their babies faced serious health and social problems. The boys asked for better sexual and reproductive health (SRH) education and lacked communication about sexuality with adults. The boys requested the Government to provide jobs for them (IV). Most common services that were provided were regarding STIs/HIV/AIDS, pre-and post-test counselling and testing on HIV, contraceptives and condom use. Half of the nurses/midwives had no continued education and lacked supervision on ASRH care. The majority had unresolved moral doubts, negative attitudes, values and ethical dilemmas towards abortion care between the law, which is against abortion, and the reality of the adolescents’ situation. Forty-four participants wanted to be trained on post abortion care while eight on how to perform abortions (V). Implications for practice: The quality of maternity care for adolescents needs attention and evidence based practices. Provision of social support should be followed, including contraceptive counselling for both girls and boys to prevent STIs/HIV and unplanned pregnancies. Nursing, midwifery curricula should integrate comprehensive ASRH. There is need for political support for the ASRH programme in Swaziland.