Exploring challenges of teenage pregnancy and motherhood from beneficiaries and providers’ perspectives: A qualitative study in a rural area of Purba Bardhaman District, West Bengal

ABSTRACT

Context:

Teenage pregnancy and motherhood are globally important public health concerns. In India, 6.8% women between 15 and 19 years were already mothers or pregnant, whereas in Purba-Bardhaman district of West Bengal it was 21.9% (National-Family-Health-Survey-5). Challenges of teenage pregnancy and motherhood needs to be understood from beneficiaries’ and providers’ perspectives.

Aims:

This study aimed at exploring the various challenges faced by teenagers during their pregnancies and motherhood and understanding the barriers of service delivery to them in a block of West Bengal.

Settings and Design:

A qualitative study with phenomenological approach was conducted between January and June 2021 in Bhatar community development block of Purba-Bardhaman district, West Bengal.

Methods and Material:

In-depth interview (IDI) of 12 purposively selected teenage mothers and two sessions of Focus Group Discussions (FGDs) among 17 Auxiliary Nurse Midwives (ANMs) were conducted. Data was collected by audio recording the IDI and FGD sessions as well as by taking notes.

Analysis Used:

Inductive thematic analysis was done by using NVIVO software (Release 1.0, QSR International).

Results:

Throughout teenage pregnancy and motherhood, subjects were found to face various types of medical problems, lack of awareness, and non-supportive family environment. Various social constraints and psychosocial stressors emerged as significant challenges. Communication gaps, behavioural barriers, socio-cultural issues, and administrative issues were major themes emerged as barriers of service delivery.

Conclusions:

Lack of awareness and medical problems were important challenges faced by the teenage mothers whereas behavioural barriers were the most important service level barriers perceived by the grass root level service providers.

Introduction

Teenage pregnancy is a major reproductive health problem. It is far more common in developing countries including India, may be due to prevailing cultural/societal norms or practice of early marriage.[1] Adolescent pregnancies are more frequently seen in marginalized communities which suffer from poverty, lack of educational opportunity and unemployment.[2] In such communities, as motherhood is valued, limited educational and employment prospects compel the girls to choose marriage and pregnancy as a resort to sustain.[3]

Not only the adolescent girls, but their spouse, family members as well as the whole society become the victims of detrimental effects of teenage pregnancy and motherhood.[4] A physical, psychological, social and cognitive preparedness is essential for a woman in the transition to motherhood which is lacking in teenage girls.[5] As this transition occurs simultaneously with developmental changes of adolescence, teenage motherhood becomes unmanageable.[6] Concurrent adaptation of social roles of adulthood, physical changes of puberty, significant brain development, and changes related to pregnancy and motherhood make the life of teenage mothers truly challenging.[7]

Early pregnancies have major health consequences for adolescent mothers and their babies. Among girls aged 15–19 years, pregnancy and childbirth complications are the leading causes of death globally. Deaths due to such complications among women of low- and middle-income countries account for 99% of global maternal deaths.[8]

According to National-Family-Health-Survey-5, in India, 6.8% women aged between15 and 19 years were already mothers or pregnant, whereas in West Bengal it was 16.4% and in Purba Bardhaman district it was as high as 21.9% in spite of different plans and programmes to address this issue being in place.[9,10,11]

So, an in-depth understanding of the various challenges of teenage pregnancy and motherhood are required in different geographical regions for effectively addressing this health concern. Perceived barriers of service delivery to the beneficiaries (teenage pregnant women and adolescent mothers) by grass root level health workers should also be explored aiming at generating new insights for policy makers and healthcare providers. As the family physicians or primary care physicians come first to the contact of the patients, they also need to understand the socio-cultural background of a phenomenon. Unless they are aware about the various aspects of disease aetiology, addressing a community health issue is impossible. In this context, the present study was undertaken with the objectives of exploring the challenges of teenage pregnancy and motherhood both from beneficiaries and health service providers’ perspective. A comprehensive understanding of these challenges will aid the development of culturally appropriate health promotion guidelines and strategies.

Subjects and Methods

Study design, study area, and period

This is a qualitative study with phenomenological approach, conducted from January to June 2021 in Bhatar community development block of Purba Bardhaman district, West Bengal selected purposively for feasibility of the researcher. There are 6 Primary Health Centers and 38 subcentres (SC) in the block.

Study subjects, Sampling, and selection

Mothers aged 20 years or below, with at least one living child (conceived between 10 and 19 years of maternal age and within last 2 years from the date of data collection) were taken as first category of study subjects (beneficiaries). Four (10% of total 38) subcentres of Bhatar block were chosen by simple random sampling. A list of eligible teenage mothers was prepared for each selected subcentre from the eligible couple register. It was decided to purposively select at least two teenage mothers from each subcentre area, and accordingly, they were visited one after another. Data saturation was reached after interviewing 12 participants.

Auxiliary Nurse Midwives (ANMs) of Bhatar community development block were taken as second category of study subjects (service providers). It was decided to conduct focus group discussions (FGD) with this category of participants. FGD sessions were planned in a place and a date so that at least six ANMs could remain present. A list of ANMs from all the 38 subcentres was prepared and ten purposively selected ANMs were communicated for each FGD session. The sessions were continued till the point of redundancy in data and after two FGD sessions conducted among 8 and 9 ANMs (17 in total) at Bolgona and Bonpass primary health centres (PHC) respectively, data saturation was reached.

Study tools, technique, and data collection

In-depth Interview (IDI) guide, Focus group discussion (FGD) guide, and audio recorder were used as study tools.

IDI technique was used to explore beneficiaries’ perspective. For conducting the interviews among eligible mothers, their households were visited with local Accredited Social Health Activist (ASHA) worker. Informed consent was taken, and probes were used wherever necessary. Conversations during IDIs took place in Bengali and the average duration of the interviews was 45 min. They were audio-recorded maintaining anonymity.

Focus group discussion (FGD) technique was used to explore service providers’ perspective. The FGDs were conducted using the FGD guide in the presence of a moderator focusing on the difficulties faced by the participants during service delivery to the adolescent mothers. Sociograms were drawn and notes were taken during the sessions. It was taken care of that the notes should contain all relevant information provided by the participants including the nonverbal cues. The sessions were audio-recorded maintaining anonymity for verbatim generation and at the end of the session, the participants were briefed regarding the points generated during the session.

Data management and Analysis

The audio files of IDI and FGDs, saved in computer and field notes were used to prepare transcripts. Inductive thematic analysis approach was utilized for data analysis. The initial audio files of interviews were listened and were transcribed into verbatim and then it was read several times to gain a general impression. The resulting texts from the interviews were read line by line and were broken down into meaningful units (words or sentence or paragraphs), which were then condensed, abstracted, coded, and labelled.

Next, the codes were re-read in order to be arranged into categories and sub-categories based on their similarities and differences. Data coding was performed through a participatory approach along with the co-researchers. Disagreement over the coding was discussed with the co-researchers and codes were negotiated until all came to a consensus. Further data analysis was done with NVIVO software (Release 1.0, QSR International) to create hierarchy chart for qualitative data presentation. Data analysis was done continuously and simultaneously with data collection.

Ethical considerations

Ethical clearance was obtained from the Institutional Ethics Committee of Burdwan Medical College and Hospital, Purba Bardhaman, West Bengal (vide Memo No: BMC/I.E.C/001 dated 08.01.2021). Permission and cooperation for conducting the study was sought from Chief Medical Officer of Health, Purba Bardhaman. Prior to data collection informed consent was obtained from each study participants (Teenage mothers and ANMs).

Results

Challenges faced by beneficiaries (teenage mothers)

Themes generated from the analysis of the IDIs were “Medical problems”, “Lack of awareness”, “Non-supportive family environment”, “Social constraints”, and “Psychosocial stressors”. These themes, illustrated in [Table 1 and Figure 1], are discussed below.

Table 1.

Thematic representation of challenges of pregnancy and motherhood from the perspective of teenage mothers

Themes and subthemes	Sample verbatim
Medical problems
Anaemia	“After 6 months of getting pregnant, I was advised some blood tests, when I got to know that my haemoglobin was less…”
Inadequate rest	“As in that period I stayed with my husband only, so I had to do household works alone, I got less rest for first 7 months.”
Preterm labour	“As my son was born before time, his birth weight was low, and he remained in incubator for 10 days in the hospital.”
Eclampsia	“In later part of my pregnancy, my feet were swollen, blood pressure was high, … I became unconscious before delivery …. Convulsion happened….My baby was delivered by operation…”
Postpartum haemorrhage	“My baby was delivered normally but after that there was huge bleeding from the birth canal, and they had given me injections and blood for that…”
Puerperal sepsis	“After 7 days of my baby’s birth I fell ill, I was re-admitted to Burdwan hospital with high fever and severe pain in lower abdomen…there was white discharge too.”
Lack of awareness
Prevention of unplanned pregnancy	“Nobody told me about contraceptives before I became pregnant…later I came to know about condoms….”
Early detection of pregnancy	“My period started for the first time just before my marriage, it was irregular…so I had no idea how to understand that I was pregnant”
Ante-natal care	“I think 6 hours sleep is adequate…I had a lot of household works to do.”
Newborn care	“This was my first time….I didn’t know how to breast feed my baby properly…my breast milk was inadequate.”
Birth spacing	“As I was breast feeding my baby, that time I didn’t use contraceptive pill because my husband told me it could be harmful for my baby…but I became pregnant once again”
Non-supportive family environment
Partner non-cooperation	“Though I didn’t want to get pregnant early, my husband didn’t like me to take medicine for contraception….”
Lacking Family support	“When I became pregnant, I didn’t want to continue that but every one of my family, even my parents wanted me to be mother…”
Family influence	“My sister-in law told me that it is better to be mother early”
Family tradition	“Every girl in my family got married early and became mother within one year.”
Lack of authority	“I could not go for an abortion against all the elders in the family.”
Social constraints
Traditional practices	“In our community, girls get married early…and most of them become mother earlier than me.”
Religious beliefs	“I was told that in our religion contraception should not be used…but after my second childbirth my health deteriorated.”
Poor economic condition	“I didn’t want to take another child so early because my husband’s income is less…and need to take help from my brother”
Psychosocial Stressors
Marital discord	“Whole day I have to do a lot of work.my baby is small, and he comes late in a drunken state. I have nothing to do. It’s my fate” `
Familial disharmony	“My mother-in-law don’t like me…even she doesn’t take care of my baby”
Fear of criticism	“I was in fear before my delivery as if the baby was a girl.because everyone in the family was expecting a boy”
Depression due to lost job opportunity	“Now I feel bad. If I had completed my studies, I might have got a job.”
Anxiety due to financial burden	“I have a daughter of 1 year, now I’m pregnant once again… though everybody is happy in my family, I feel tensed as it will be hard for us to rear up another child…our economic condition is very poor”

Figure 1.

Sunburst chart depicting hierarchical representation of Challenges of pregnancy and motherhood from the perspective of teenage mothers.

Note: The Sunburst chart depicts relative contribution of various themes and sub-themes that emerged from analysis of IDIs. The inner circle of the chart consists of themes and the surrounded outer circle contains the deeper hierarchy level, i.e., subthemes. The angle of each segment is proportional to the representative data weightage. Each theme and the subthemes under it are different colour coded

Medical problems

Weakness was persistent and common during pregnancy, for which the mothers faced difficulty to perform household works and later they were found to be anaemic on ante-natal check-ups. Lack of adequate rest and daytime sleep during antenatal period was another common difficulty revealed in the interviews. Events like pre-term labour and babies born with low birth weight were frequently present among the study subjects. Complications like convulsion, unconsciousness, high fever, and bleeding per vagina before and after childbirth were also noted among the mothers.

Lack of awareness

Partial, inappropriate, and faulty knowledge regarding contraception resulted in unplanned pregnancies. Due to lack of awareness regarding methods for early detection, their pregnancy was detected mostly in second trimester. So, either they could not take appropriate care during early stage of the pregnancy, or they failed to terminate the unwanted pregnancy. Awareness regarding different aspects of ante-natal care like diet, rest and health check-ups were found to be deficient in teenage mothers. The mothers found it difficult to feed or give bath their babies due to lack of knowledge regarding newborn care. They were also found to have little idea regarding birth spacing and they were unaware of suitable spacing methods. Consequently, repeated pregnancy within a short gap was quite common among them which caused deterioration of their health, decrease in body weight, increased workload, and responsibilities.

Non-supportive family environment

Lack of cooperation from partner encompassed various issues like lack of partner’s emotional support, non-cooperation in household works, lack of quality time spent together, neglecting attitude of the partner, conflict between the partners, partner’s addiction in alcohol. These emerged as a significant challenge for teenage mothers. Lack of family support, experienced by the teenage mothers, occurred in various forms like opposition of decisions, non-cooperation, non-recognition etc., Influence from some family members and some family traditions pushed them towards repeated and/or unwanted pregnancies. The mothers perceived that they could not exert authority regarding decisions taken about pregnancy or childbirth, it increased cases of unplanned multiple pregnancy, improper ante-natal care, newborn care etc.

Social constraints

Social constraints emerged as an important theme in this study which added immense challenge in the journey of pregnancy and motherhood of teenage girls. In this study, it was noticed that teenage girls became vulnerable to pregnancy as they were subjected to traditionally practiced early marriage in their community, religious prohibition for contraception. In some cases, Poor economic support at the time of need endangered mothers’ life as well as that of their child.

Psychosocial stressors

Stressors are events or conditions in the surroundings that trigger stress. Five major psychosocial stressors were identified in this study which put extra pressure in already complicated life of teenage mothers. Various negative emotional states of the mothers like depression, fear, insecurity, anxiety affected their physical and mental health. Conflicts with husband or mother-in-law, inability to fulfil family expectations, financial insecurity, anxiety of delivering repeated girl child were the major reasons of the stress they had to handle during pregnancy and motherhood.

From the hierarchical classification [Figure 1], it was revealed that lack of awareness and medical problems were two most common challenges of teenage pregnancy and motherhood from beneficiaries’ perspective.

Challenges faced by service providers (Health Workers) in health care delivery

Themes emerged from analysis of the FGDs were “Communication gaps”, “Behavioural barriers”, “Socio-cultural issues”, and “Administrative issues”

These themes, illustrated in [Table 2 and Figure 2], are discussed below.

Table 2.

Thematic representation of challenges of teenage pregnancy and motherhood from the perspective of service providers

Themes and subthemes	Sample verbatim
Communication gap
Less scope for offering health education	“Sometimes parents take their girl somewhere else where the girl gets married and returns after some time, in these cases we fail to approach the girl for counselling regarding family planning”
Avoidance of communication	“When we go to counsel them regarding avoidance of unwanted pregnancy or other ante-natal care, many of them avoid us just to listen anything”
Behavioural barriers
Poor compliance of oral contraceptive pill use	“When teenage married girls are counselled and given contraceptive pills, initially they use it, but later they discontinue.”
Avoidance of using long term contraceptives	“Teenage mothers generally avoid using copper-t, many of them requests us to remove it showing lame excuses”
Poor adherence to ante-natal heath education	“In case of teenage pregnant girls, we see they are reluctant to follow the advice we give”
Poor adaptation of newborn and childcare practice	“Even after repeated counselling, they complaints for inadequate breast milk because these mothers are poor in adapting breast-feeding procedure.”
Socio-cultural issues
Family pressure	“They (teenage mothers) often are compelled to follow wrong traditional practices by their elders regarding bathing, diet etc., of newborn.”
Faulty community practice	“In a village under our subcentre girls of a particular community are got married in teenage and become pregnant and mother soon as well…. they never follow exclusive breast feeding”
Lack of community participation	“We generally don’t see any leaders in their community to get involved, so that we can manage to convince them”
Administrative issues
Poor enforcement of law	“Most of the marriage of teenage girls are unregistered, but we observe very few police activity in these cases”
Poor implementation of government project	“I’ve seen girls who got cash benefit of Kanyashree (government programme to encourage higher education of girls and to stop teenage marriage) hiding their marital status…in these cases they are also hiding their marriage and pregnancy from us”

Figure 2.

Tree map diagram showing relative importance of challenges of teenage pregnancy and motherhood from service provider perspectives.

Note: The different themes and the subthemes under each theme are nested into rectangles of different size and colour shade and the rectangular areas are proportional to specified dimension of the coded data

Communication gaps

Scope for health education regarding contraception and pregnancy issues to the newly married teenage girls before they got pregnant or in their early stages of their pregnancy was sometimes denied to the health workers because, their family hided the news of the marriage or parents took their girls somewhere else where the girls got married and returned after some time. Avoidance of service providers in the pretext of different excuses by the families was another difficulty which often hampered the communication between the service providers and teenage beneficiaries.

Behavioural barriers

Behavioural barriers lie within the response and attitude of the beneficiaries towards the service provided to them by the health workers. Poor compliance in using OCP, even after providing health education to newly married teenage girls, was emerged as a significant service barrier from health workers perspective. They found teenage girls were immature to understand the importance of contraceptive use for family planning. Avoidance of using long-term contraceptives like copper-T or injectable hormonal contraceptives increased challenges of teenage mothers as well as difficulties for service providers to execute family planning services as teenage mothers gave more priority to certain inconveniences rather than birth spacing. Rejection to tetanus toxoid injection, refusal to change habitual sleep pattern, reluctance to follow dietary advice etc., are important behavioural barrier to the ante-natal service delivery. Poor adherence to ante-natal health education and poor adaptation of newborn care or childcare practice as advised were the key barrier which gave rise to difficulties at different levels of service provision.

Socio-cultural issues

Family pressure was a common socio-cultural issue which compelled young teenage girls to follow wrong traditional practices regarding bathing, diet etc., of newborn and that is why they usually failed to get the benefits of the services. Faulty community practices like early marriage, pregnancy, noncompliant exclusive breast feeding etc., were significant service barriers. Involvement of the community leaders was found lacking which could boost confidence of the grass root level health workers to provide services efficiently to the vulnerable population as well as help them to win the trust of the family of the teenage mothers.

Administrative issues

In this study, it was emerged that there was an administrative shortcoming to stop teenage marriage which increased vulnerability of teenage pregnancy and motherhood. Instances were observed where benefit of the government programme to stop teenage marriage was received hiding the marital status of the girls. Poor enforcement of the law indulged teenage marriage and pregnancy which made the service efforts difficult.

From the hierarchical classification [Figure 2] it was revealed that behavioural barriers were the most predominant challenges of teenage pregnancy and motherhood from service providers’ perspective.

Discussion

From beneficiaries’ perspective, as this study explored, the challenges of teenage pregnancy and motherhood were medical problems, lack of awareness, non-supportive family environment, social constraints, and psychosocial stressors.

During teenage pregnancy and motherhood, mothers confront with various types of medical problems. These may arise along with physiological changes in pregnancy, as nutritional deficiencies or as a complication of pregnancy. In this study we have seen that participants faced various physical problems like anaemia, inadequate rest, pre-term labour, eclampsia, PPH, puerperal sepsis etc. In a qualitative study, Mangeli et al.[12] had also shown that physical problems caused by pregnancy, childbirth; made difficult the maternal role for teenage mothers.

Lack of awareness and knowledge is in the core of challenges faced in teenage pregnancy and motherhood. All the mothers interviewed in this study had awareness deficiency in something or the other related to pregnancy and motherhood which made their experiences full of difficulties. In a study by Siddharth A.R. et al.,[13] it was observed that low knowledge about contraceptive use was one of the common causes of getting pregnant at an early age and Oringanje C. et al.’s[14] study also showed a similar result. A qualitative study by Krugu JK et al.[15] showed similarity in findings, where lack of knowledge regarding use of condoms was stated as a reason of getting pregnant at an early age. Our study finding corroborates with the study of Parasuramalu BG et al.[16] which showed majority teenage pregnant mothers were not aware of any family planning methods either spacing or permanent methods.[16] Two studies in Tanzania also found that women who had unplanned pregnancies tend to be more hesitant to attend ANC[17,18]; this resonates with the experiences of many teenage mothers in our study, who expressed reluctance to attend ANC due to lack of awareness.

Harmful practices of the teenage mothers such as immediate bathing, application of traditional substances on the umbilical cord, delayed initiation of breast-feeding, discarding colostrum and giving pre-lacteal feed to the newborns show their lack of awareness regarding newborn care. Similar findings were found in a study by Memon, J et al.[19]

The study revealed non-supportive family environment in terms of partner non-cooperation, lacking family support, family influence and family tradition to adopt wrong family planning practices, poor decision-making power of the teenage mothers make the experience of pregnancy and motherhood far more challenging. This finding also corroborates with a study finding on Australian teenage mothers which showed that the fathers of the babies were often absent during and after the pregnancy. For the few fathers who were around, the amount of support provided - financial, emotional, or physical - to the teenage mothers and the babies were generally described as inadequate.[20] This finding was also portrayed in a qualitative study in South Africa.[21]

Findings of this study regarding social constraints faced by teenage mothers due to various faulty community practices, religious prohibitions and poor economic conditions and the stress experienced by them generated due to marital discord, familial disharmony, fear of criticism, depression due to lost job opportunity and anxiety due to financial burden are similar to the study findings of other qualitative studies.[12,20]

From service providers’ perspective, four types of service barriers were identified, these are communication gaps, behavioural barriers, socio-cultural issues, and administrative shortcomings.

Due to different socio-economic reasons or lack of knowledge and education girls of rural families get married early and the families sometimes hide this news from the health workers, they also avoid or disregard the health education. This is clear that somewhere there is a distrust between the family of the beneficiary and service providers which creates significant barrier to deliver the service at a desired level.

Family planning and birth spacing are very important for both mother and child’s health. Repeated unplanned pregnancy may jeopardize health of teenage mother and affect childcare as well. Rejection, refusal, or reluctance to health advice are certain behaviour that shows the immaturity of the teenage mothers which in turn puts significant barrier to provide them benefits of maternal and child welfare programmes. Similar findings are seen in a qualitative study by Govender D et al.[21]

Findings of this study revealed that certain cultural beliefs, customs, or traditional community practices are so enrooted in the society that teenage mothers sometimes fail to restrain the family pressure to follow wrong practices. Moreover, these girls are not mature and experienced enough to understand that these practices are detrimental to the health of mother and child, and they also lack the education and consciousness to understand it as well.

A smooth functioning of health service should always be backed by a strong administrative will and system. This study has pointed out the existing loopholes in that system.

Limitations

This qualitative study explored the challenges of teenage mothers in only one block of Purba Bardhaman district. Therefore, the transferability of findings from this qualitative work should be considered with caution.

Conclusion

Challenges of teenage pregnancy and motherhood, as explored in this study, are multidimensional and have deep socio-cultural roots. From the beneficiaries’ perspective, lack of awareness was the most common challenge, while from service providers’ perspective it was behavioural barriers. In order to secure and enhance maternal health, especially in a country where teenage motherhood is prevalent, collective efforts at individual, family, community, and societal levels are needed.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.