Perception and experience of relatives of pregnant teenagers: A qualitative study in the North and Northeast departments of Haiti

Abstract

Teenage pregnancy remains a global problem because of its consequences for the teenager, her child, her family, and society. In Haiti, this type of pregnancy burdens the family economy. In addition, the adolescent fertility rate is still high, despite efforts to reduce it. This article aims to analyze the perception and experiential experience of relatives of pregnant adolescents in Haiti. A qualitative study design based on Dewey's social survey was conducted. Data were collected from 17 relatives (partners, parents, guardians, and others) of pregnant adolescents in Haiti's North and Northeast departments. These data were analyzed using thematic analysis. According to the results, teenage pregnancy is seen as a disaster or a social problem in Haiti. It leads to many psychosocial and economic difficulties for the relatives, who are the only source of economic and social support for pregnant adolescents. Considering the vulnerability of relatives, policies, and interventions aimed at reducing the negative consequences of teenage pregnancy should consider this group of individuals.

Introduction

In low-and middle-income countries, adolescents are vulnerable to sexual and reproductive health risks (1). Most of them are sexually active. A situation that puts many adolescents at risk for sexually transmitted infections or unintended pregnancy (2). 95% of teenage pregnancies occur in these countries (3). Like all low-income countries, adolescent fertility is still high in Haiti. According to statistics, 10% of adolescent girls aged 15-19 have had at least one child, and 1% of Haitian women have already given birth to at least one child before age 15 (4).

Studies have shown that pregnant adolescents face physical, emotional, cognitive, social, economic, and cultural challenges: a lack of physical maturity (5), psychological problems (5-7), economic difficulties (8), social and family isolation (6) health problems (9), family conflicts (10), parental support needs (11), and undernutrition (12). Furthermore, the negative consequences of this type of pregnancy are not only limited to pregnant adolescents but also affect their partners, parents, and society in general (2,13). For example, a recent study found that the US government's care of pregnant teens costs taxpayers $9.4 billion (14). In addition, more than 75% of teen mothers receive public assistance within five years of giving birth (15).

Furthermore, it appears challenging to estimate the real cost of this type of pregnancy to society in low-income countries, as public and social assistance are almost non-existent. In the case of Haiti, it is the immediate entourage of adolescents who assume the costs of managing this type of pregnancy (16). As a result, the negative consequences have strongly impacted those relative to pregnant adolescents. Thus, this study aims to analyze the perception and experiential experience of the relatives of pregnant adolescents in Haiti.

Theoretical perspective

This study used two theoretical perspectives: intersectionality (17,18) and social justice theory (19,20) to construct the interview guide and structure the data analysis. The use of intersectionality in research offers the opportunity to address an issue beyond individual characteristics, such as sex or gender. It emphasizes the influence of sociostructural factors (21) while considering the heterogeneity of all groups of individuals (22). The feminist social justice author has made a three-dimensional conception of this theory: recognition, redistribution, and representation (19). This three-dimensional conception of social justice allows us to analyze injustice on multiple levels in our contemporary society. Redistribution addresses economic injustices, recognition focuses on cultural or symbolic injustices, and representation seeks to understand the barriers to individual participation in the debate that affects them, all encompassed by the normative principle of parity of participation (19,23).

Materials and methods

Design

A descriptive, exploratory qualitative research design guided data collection and analysis. The qualitative method allows for exploring people's experiences, representations, personal conceptions of their actions, history, interpersonal relationships, and more (24). This method is also relevant when there is little data on the phenomenon under study (25). The literature search conducted in several databases (PubMed, CINHAL, Cairn, LILACS, PsycNET, Google Scholar, and Érudit) did not reveal any Haitian studies on the topic, so the qualitative method proves to be essential to explore the issue.

Furthermore, John Dewey's pragmatism based on the logic of social inquiry was used as an epistemological anchor to guide this research. In the process of social inquiry, the investigator of a given field uses the experiences of communities to construct knowledge about a phenomenon (26). Social inquiry helps to reconstruct the problematic situation using several realities and validity tests (27). Moreover, inquiry reveals itself to be more of a logic of creation than discovery (28).

Location and population of the study

This study was conducted in the North and Northeast departments of Haiti. The survey was conducted in nine health institutions in both departments between October 2020 and January 2021. The population of this study was composed of 17 relatives of pregnant adolescents. The term ‘relative’ here means people who play a direct emotional and social role during teenage pregnancy (e.g., partners, parents, guardians, and others responsible for the pregnant teen). The term ‘relative’ here means people who play a direct emotional and social role during teenage pregnancy. Inclusion and exclusion criteria were considered in the study. All relatives of pregnant adolescents living in the North and Northeast departments were eligible. Individuals had to be in an emotional and social role with a pregnant adolescent to be included in the study. Partners of pregnant teens under the age of 18 were excluded.

Data collection procedure

The study used a semi-structured individual interview guide as the primary data collection instrument. Because Haitian women often come to the prenatal clinic alone (29), the snowball method was used to recruit relatives. During prenatal clinic visits, pregnant adolescents were given a letter and a summary of the study to invite one of their relatives to participate in this research. Interested relatives were introduced to the health institution where their pregnant adolescent was contacted on the date specified in the invitation letter. Before the meeting, relatives were given more information about the study, and those who wished to continue were interviewed. The interviews were conducted in Creole, the language spoken by all Haitians. The interview guide was developed around three themes: the participant's socio-demographic profile, his or her perception of teenage pregnancy and motherhood, and his or her contributions during the pregnancy of his or her teenage girl. Interview sessions ranged in length from 60 to 70 min. All interviews were audio recorded.

Data processing and analysis

The recordings were listened to and transcribed in verbatim form. The primary researcher read and reread the verbatims to identify relevant themes and subthemes and the other authors cross-checked his work. After verification and validation, the verbatims were exported to QDA Miner version 6.0.5 software for coding.

A thematic analysis of the data following the approach of Braun and Clarke (2006) was preferred. It is done in six main steps, involving: 1) reading and rereading the verbatims to become familiar with the data, 2) developing initial codes (coding), 3) searching for themes (collecting all relevant data for each of the potential themes), 4) a review of the potential themes (checking the functioning of the themes against the excerpts from the verbatims, 5) defining and naming the themes (a content analysis to refine the specifics of each theme), and 6) producing the report (selecting the vivid and compelling excerpts) (30). The results will be presented as descriptive narrative texts with verbatim excerpts. Note that all authors were involved in each step of this analysis process.

Ethical consideration

This study was approved by the Ethics Committee of Université Laval (No: 2020-253/04-11-2020) and by the Haitian National Bioethics Committee (No: Ref.1921-1). Participants have been informed that their participation is entirely voluntary and they can withdraw from the study without prejudice. In addition, before the interviews, all participants signed a consent form. In or-der to maintain confidentiality, each participant was issued a unique study identification number and data was entered into a password-protected computer.

Results

Overall, the population of this study consisted of 17 participants, 13 females and four males. Most participants (n=10) were mothers of pregnant adolescents. More than one-third of the participants (n=7) were unemployed at the time of the study. Ten of the women were single or widowed. The demographic characteristics of the participants are presented in the following Table I.

Three general themes emerged from the data analysis: relatives' perceptions of teenage pregnancy, relatives' difficulties during their teenage daughter's pregnancy, and relatives' support for the teen during the transition to motherhood and after delivery.

Relatives' perceptions of teenage pregnancy

Based on their experience and observation of teenage fertility in Haiti, the participants in this study perceived the following: teenage pregnancy as a problem with multiple determinants, teenage pregnancy as a social problem in Haiti, and the various negative consequences of teenage pregnancy.

Table I.

Demographic characteristics of relatives (PRO).

Relatives	n (%)
Types of relatives
Partners	3 (17.65)
Mothers	10 (58.82)
Sisters	2 (11.76)
Tutors	2 (11.76)
Marital status
Single	6 (35.29)
Cohabitation	1 (5.88)
Common-law partner	5 (29.41)
Married	1 (5.88)
Widow/widower	4 (23.53)
Occupational status
Informal shopkeeper	3 (17,65)
Unemployed	7 (41.78)
Housekeeper	5 (29.41)
Industrial worker	1 (5.88)
Motorcycle taxi driver	1 (5.88)
Place of residence
Rural	5 (29.41)
Urban	12 (70.59)

Teenage pregnancy. A problem with multiple determinants

The participants' speeches identified numerous determinants that can cause this type of pregnancy. First of all, there are individual determinants that depend more or less on pregnant teenagers. More than half of the relatives (n=9) believed that juvenile delinquency is a major determinant of teenage pregnancy in Haiti. These verbatim excerpts testify to this: ‘Adolescents these days do not respect the norms. They are involved in delinquency and prostitution, so they get pregnant’ (PRO004). One mother said, ‘Young girls lead a promiscuous life. They consume alcohol and drugs. That is why they get pregnant’ (PRO008). Lack of sex education was seen as a factor in this type of pregnancy. One tutor expressed, ‘...I think lack of sex education is a cause. Teenagers have sex without a condom, and then they get pregnant’ (PRO015). Next, interpersonal determinants did not necessarily come from the teens but from those around them. Eleven participants revealed that Haitian parents' irresponsibility leads to increased fertility during adolescence. One partner said, ‘In my neighborhood, there are many cases of teenage pregnancy because parents have quit and abandoned their daughters on the streets without any training. The girls are left to their own devices’ (PRO008). Others believe that pairs influence the occurrence of pregnancy. One partner noted, ‘Sometimes a teenage girl gets pregnant in my neighborhood, and in a short time, her friends do the same thing. One influences the other’ (PRO007). Finally, the community determinants are related to the teenagers' living environment. Most participants (n=14) highlighted the poverty that affects Haitian society as the country's primary cause of teenage childbearing. One partner revealed, ‘Because of the poverty that rages in society, adolescent girls engage in transactional sex, so they get pregnant easily’ (PRO002). One mother said, ‘In my experience, girls see that their parents are unhappy, they will look for a partner to help them economically, but their bad luck, they got pregnant’ (PRO013).

Teenage pregnancy a social problem in Haiti

Based on the extent of teenage pregnancy in Haitian society, some relatives described it as a scourge that ravages the lives of teenage girls. One mother said, ‘I think teenage pregnancy is a scourge that is ravaging the lives of young women in the country. A lot of young girls are pregnant, and a lot of young girls are aborting, too’ (PRO001). Participants viewed teenage childbearing as a social problem. Another mother said, ‘This kind of pregnancy is a social problem because young girls leave society too early. It is a social deviation’ (PRO017). All relatives believed that teenage childbearing could negatively affect many layers of Haitian society. One mother said, ‘It's a problem that affects churches, families, and schools too. I think teenage pregnancy it's a disaster for Haitian society’ (PRO009). A tutor said, ‘Teenage pregnancy creates more misery and delinquency in the declining country. Young mothers live in poverty and have no means to educate their children. These children often become a danger to society’ (PRO015).

Different consequences of teenage pregnancy

Loved ones of the teens pointed out several negative consequences associated with teen pregnancy. Most relatives think that teenage pregnancy negatively impacts teenagers' future. One mother stated, ‘Teenage pregnancy prevents young girls from getting a good job tomorrow’ (PRO001). Another said, ‘Pregnancy ruins the future of teenage girls’ (PRO005). Dropping out of school was cited as one of the consequences of teenage pregnancy. One partner said, ‘the consequence I can say of teenage pregnancy is dropping out of school’ (PRO007). Relatives' discourses revealed that teenage mothers are vulnerable to repeat pregnancy. One mother expressed, ‘single teenage mothers are vulnerable to repeat pregnancies while looking for food for her first child’ (PRO005). Teenage pregnancy causes health and physiological problems. One mother stated, ‘pregnant teens' bodies are immature. They can develop diseases. They can be prematurely aged’ (PRO004).

The data showed that the negative consequences of early pregnancy also affect children and parents. For this mother, ‘ the children of teenage mothers suffer a lot because these girls do not have the means and capacity to take care of their babies’ (PRO014). Parents of pregnant teens are not immune to the harmful effects of this type of pregnancy. ‘The consequences affect the parents (...) household expenses are increased, and misery also increases’ (PRO003). Several relatives saw teenage pregnancy as a loss for the parents of teenagers. It sometimes has consequences for the parents' old age. One sister said, ‘It's a loss for the parents, they've lost their money, and in their old age, they won't have anyone to help them’ (PRO014).

Difficulties encountered by relatives during their Teenager's pregnancy

The difficulties relatives encountered following their teenage daughter's pregnancy are discussed in the next sub-themes.

Reactions of relatives to the news of the pregnancy

Often, teenage pregnancy comes about unintentionally and unexpectedly. All the relatives were surprised by the news of their teenager's pregnancy. This situation elicits different reactions. The majority of the parents were upset by the news. One mother said, ‘...my reaction. I was furious when I heard the news of my daughter's pregnancy. My daughter has no father. Imagine that I pay for her school fees and feeding her, and the result is a pregnancy’ (PRO001). One guardian said, ‘Many people in the family were angry, and so was I. But the baby has to be born, we have to do it. But the baby has to be born, we have no choice’ (PRO015). The news shook other participants. One mother said, ‘It was a total shock. I almost died after hearing the news because I didn't believe my daughter was sexually active’ (PRO013). One partner said, ‘When my girlfriend told me she didn't have her period, I was in torment’ (PRO002).

Other relatives took drastic action toward their pregnant teen. One mother said, ‘When I heard the news of the pregnancy, I kicked my daughter out of the house (...). Now where she is, I help her’ (PRO012). Other relatives forced their teenage daughter to bring their partner home. One mother said, ‘I asked my daughter to bring home her child's father, which was done. I asked the partner to take responsibility, and the guy accepted the fatherhood’ (PRO011). In contrast, other relatives made the same request; the partners denied paternity. One guardian said, ‘We asked my niece to come home with her partner. But the partner refused to come back, and he also refused paternity of the baby’ (PRO003).

Economic difficulties for relatives

Participants experienced severe economic hardship during their teen pregnancy. Often, the pregnant teen is their responsibility. As a result, they experienced financial difficulties in meeting their commitment. One mother said, ‘the only difficulty is that sometimes I don't have money to send my daughter even to the hospital during her pregnancy’ (PRO001). A partner said, ‘I work, but I have to save the money I earn during the day. Sometimes, I have gone whole days without eating. I do this just to save some money to prepare for my wife's delivery’ (PRO008). Due to their economic precariousness, most relatives stated that they were unable to feed the pregnant teenager. One mother said, ‘I have no money. I can't give food to my pregnant daughter; she goes hungry sometimes’ (PRO001). Another partner revealed, ‘the difficulty I encounter more often is when I go to work, I don't leave anything for my wife to eat because I don't have any money, and she goes days without eating anything’ (PRO007).

Humiliation and shame experienced by relatives during their teenage pregnancy

Pregnancy outside marriage is culturally frowned upon in Haiti. It is a source of criticism and contempt for the pregnant teenager and her family. As a result, several participants received humiliation during their teen pregnancy. One partner stated, ‘When my girlfriend got pregnant, her parents humiliated me. They think I am too poor to be their daughter's husband because I am an orphan’ (PRO008). One mother said, ‘I have received a lot of humiliation since my daughter's pregnancy. Even my brother, who was my main financial supporter, no longer talks to me. He makes several disappointments to me on the phone’ (PRO017). Other relatives have experienced this situation of shame and social isolation. One mother said, ‘Since my daughter's pregnancy, people in my neighborhood have criticized me. I am ashamed to leave my house. I lead a hidden life’ (PRO013). Another mother said, ‘I am ashamed to go to church. Imagine that I am a deaconess and here my daughter is pregnant in such a condition. She couldn't identify the father of her child. The shame is killing me’ (PRO005).

Periods of stress and anxiety

Due to their socioeconomic difficulty, most participants experienced the period of their teenage pregnancy with great worry. Some participants worried about preparing for the delivery of the pregnant teen. One partner stated, ‘I was wondering where I'm going to get money to pay for the delivery. That's a problem’ (PRO008). Others feared their living conditions would deteriorate since their teen pregnancy. One mother said, ‘I fear for the future because, since my daughter's pregnancy, our socioeconomic conditions are deteriorating daily. I live in anxiety’ (PRO005). It is also a stressful period for the relatives, some of whom have experienced it in anguish. One mother stated: ‘Since the news of the pregnancy, I live with a lot of stress. I can't sleep. I spend my nights thinking about the situation’ (PRO006).

Relatives' support for their teen during the transition to motherhood and planned support after the delivery

All participants provided support to their pregnant teens and planned to accompany them after they gave birth. The supports are described in the subsequent subtopics.

Economic and material support from relatives during pregnancy

Often, teen pregnancy occurs when teens are unemployed or in school. As a result, more than three-quarters (14) of the relatives said the pregnant teenager depended on them. According to their testimony, they did not receive any help from a third party. These quotes are taken from the interviews with the relatives: ‘after God, everything about the pregnant teenager depends on me, like housing, food, consultation fees and preparation for delivery’ (PRO007) or ‘I have no other support, my pregnant daughter is my responsibility. I can't take care of her properly, she sometimes suffers’ (PRO009). Beyond material support, several participants highlighted other services rendered. One guardian noted, ‘during the pregnancy, I let my niece rest a little. I do the laundry and prepare food for her’ (PRO003). One mother said, ‘I always accompany my daughter on her prenatal clinic visits’ (PRO014).

Planned accompaniment after delivery

All participants reported that they planned to support pregnant teens after delivery. Caring for the teen mother and her baby remained a priority for the relatives. One partner said, ‘After delivery, I want to take care of my wife and child. I want to be a good husband and father’ (PRO002). A sister stated, ‘I will take care of the unborn child as I did for his mother during the pregnancy’ (PRO016). In Haiti, no school will tolerate a pregnant teenager on its staff. As a result, teenage pregnancy automatically leads to dropping out of n school, either temporarily or permanently, given the importance of education for the future well-being of teenage mothers. Seven relatives confirmed that they would help young mothers return to school after the birth of their baby. One mother stated, ‘my daughter is admitted to rheumatology class after giving birth. She needs to go back to school to finish her high school education’ (PRO011). Another mother said, ‘After delivery, I will take care of the baby and return my daughter to school’ (PRO013). Finally, the mothers in this study emphasized that they would serve as mentors for teenage mothers. Examples of these verbatim excerpts include, ‘Since she is young, I will mentor her in her maternal role’ (PRO006) or ‘I will help her with the baby, and I plan to take the little one to the hospital for vaccination’ (PRO009).

Discussion

This study used a qualitative approach, and therefore the aim was to analyze the perception and experience of the relatives of pregnant adolescents in Haiti. Relatives live at the intersection of several social inequalities that make them vulnerable. The arrival of their adolescent pregnancy further complicates their living conditions. The results revealed that several determinants are at the origin of early fertility, including juvenile delinquency, lack of sexual education, irresponsible parents, peer influence, and poverty. A study in Tanzania found juvenile delinquency and adolescent prostitution as determinants of early pregnancy (31). Other work in several other countries identified a lack of sex education, irresponsible parents, peer influence, and poverty as facilitators of teen pregnancy (32,33).

Data analyses identified multiple negative perceptions of participants from pregnancy to adolescence. Due to the magnitude and negative consequences that are associated with this type of pregnancy, participants viewed it as a disaster or social problem. Previous studies have had similar findings (34,35). Due to the broad fields of negative consequences of this type of pregnancy, some relatives consider it a social scourge that affects pregnant adolescents, their children, their parents, and their community. These findings are consistent with the work of several authors (2,13).

Relatives face many challenges as a result of their teen pregnancy. Economically, all of the costs associated with the pregnancy depending on the relatives. Yet, these relatives experience the denial of redistribution or, in other words, economic injustice. Unlike some studies that have emphasized that pregnant adolescents benefit from state and social support (14,15), in Haiti, the family bears all costs. The onset of teenage pregnancy further complicates the situation for parents and partners of adolescent girls. It has increased the financial and social misery of Haitian families. It burdens the already precarious family economy (16).

Culturally, pregnancy outside marriage is frowned upon in Haitian society. It is seen as a socially deviant act. This symbolic or cultural recognition of pregnancy outside of marriage has social and psychological consequences for the family. A recent study showed that in Haiti, teenage pregnancy is a denigrating situation (16). The results of this study revealed that the participants experienced this period of anxiety, stress, and social isolation. As a result, parents and partners are not immune to negative criticism. Often, they are blamed for being irresponsible or negligent. This is an uncomfortable situation for them, and to this is added their anxiety about their uncertain family responsibility. Christian parents are written off from church activities because their home is a house of sin due to their daughter's pregnancy. Only an early marriage of their daughter could rehabilitate them (36).

Relatives have provided cash and in-kind support to pregnant teens during the transition to motherhood and plan to accompany them after they give birth. Their economic and material supports are important for adolescents who lack other support during their pregnancy. Several previous studies have found that significant others are important sources of support for pregnant adolescents during the transition to motherhood (11,37). The partners of the pregnant teens in this study made sacrifices to fulfill their role as fathers to provide for their wives during pregnancy. They plan to take care of their wives during pregnancy and after delivery. Several studies have argued that most partners of pregnant adolescents make efforts to meet their marital and paternal duties during pregnancy (11,38). Relatives in this study provided tangible support to their pregnant daughters in the form of money, goods (food, clothing), services (accompaniment to the hospital), counseling, and parenting education. This is consistent with the literature. One study found that relatives offer support such as caregiving, material support, and mentoring during this transition to motherhood and after delivery (39).

Importance for practice and research

Given the perceptions and experiences of pregnant adolescents' significant others described in this study, economic and psychosocial guidance should be offered to this group of individuals. Decision-makers should implement specific programs to support the families of pregnant teenagers. Indeed, they are also vulnerable to the adverse consequences of teen pregnancy. Further studies should explore the actual involvement of significant others with adolescent mothers and their children. In addition, future research is needed to explore the experiential experiences of partners of pregnant adolescents.

Strengths and limitations

The study contains several strengths. First, it is the first study of its kind in the country. In addition, this study sheds light on the different experiences of relatives of pregnant adolescents. Despite the relevance of the above findings, this study had limitations. First, the study was conducted in two departments of the country, so the results may not reflect the reality on a national scale. In addition, the population in this study had only three partners. Thus, the findings could be contrary if the population contained more partners.

Conclusion

In conclusion, the results of this research tested the working hypothesis. This study sheds light on the perception and experiential experience of relatives. They saw teenage pregnancy as a disaster and a social problem. Moreover, they are at the intersection of multiple inequalities that increase their social, economic, and psychological vulnerability following their teenage pregnancy. Indeed, policies and interventions aimed at reducing the adverse consequences of adolescent childbearing should develop psychosocial and economic service components for the relatives of pregnant adolescents. This will be an asset in addressing the social, cultural, and economic inequities experienced by the relatives of pregnant adolescents. Finally, the results showed that the negative consequences of teenage childbearing have a vast sphere. This social and health phenomenon must be a collective concern, and each community member has a role to play.

Funding Statement

Funding: This study received financial support from the International Development Research Centre (IDRC) and the Centre for Research on Social Innovations (CRISES).