Postnatal experiences of teenage mothers in selected communities in Central Region, Ghana: a phenomenological study

Abstract

Background

Teenage childbirth is an issue of social and public health concern in Ghana, with high prevalence in some regions, including the Central Region. There is a dire need to understand the experiences of teenagers beyond pregnancies to facilitate comprehensive sexual and reproductive health information and service provision. We explored the postnatal experiences of teenage mothers in five communities in the Central Region of Ghana.

Methods

We adopted a descriptive phenomenological design. Using in-depth interview guides and pictorial diaries/guides, 30 teenage mothers who had given birth less than two years before our study, were recruited. Data were analysed thematically using a systematic qualitative-oriented text analysis with QSR NVivo 12 Pro software.

Results

Teenage mothers experienced pregnancy and childbirth related complications such as postpartum haemorrhage, preterm births, and low birth weight of their babies. Socio-cultural, psychological, and economic-related experiences were also observed. Teenage mothers were inexperienced and lacked financial support after childbirth. They often depended on the microsystem consisting of the family, friends, and the children’s fathers as major source of support to enable them and their babies to survive, develop, and become healthy and happy in life.

Conclusions

Teenage mothers are confronted with challenges that require the assistance of actors within the microsystem to address. We recommend that stakeholders including healthcare professionals, traditional birth attendants (TBAs), and parents be sensitive to the postnatal challenges faced by teenage mothers so that they can work at providing the necessary skills and support to enable them to cope better with motherhood.

Introduction

Teenage mother’s health and development remain an issue of public health concern globally. The need to prevent early pregnancy and childbirth among teenage girls has been given prominence in recent years [1, 2]. Teenage childbirth has significant implications at individual, societal, national, and global levels [3]. Globally, about 16 million teenage girls (aged 13–19) give birth every year [4], with almost 95% of these births occurring in low- and middle-income countries (LMICs) [2, 5]. According to UNFPA, sub-Saharan Africa (SSA) has the highest prevalence of teenage pregnancy, compared to other regions of the world [6]. The average birth rate of teenage mothers aged 15 to 19 in sub-Saharan Africa is 143, higher than the world’s average of 65. This affirms that teenage pregnancy and childbearing, along with maternal and child mortality, are major challenges facing young females in African countries [2]. Without a concerted effort to deal with these challenges, the achievement of Sustainable Development Goal 3.2 which seeks to end preventable death of newborns and children under -five years of age by the year 2030, would be difficult [1, 4].

Childbirth among teenagers is associated with adverse outcomes such as preterm delivery, pre-eclampsia, puerperal endometritis, postpartum haemorrhage, neonatal deaths, anaemia, and gestational hypertension [6, 7]. Also, teenage girls who give birth before age 15 are five times more likely to experience complications or die during delivery, compared with women in their twenties, due to physical immaturity [7]. Teenage mothers have been identified to have an increased risk of infant and child mortality, with associated negative demographic and social consequences [8–11]. Other studies have observed that teenage pregnancy and childbirth have a strong association with low levels of educational achievement for young women, which, in turn, may have a negative impact on their position and potential contribution to the family, society, and the nation at large [10, 12]. Teenage motherhood requires support, attention from the family, and community involvement, irrespective of the mother’s cultural and psychological background and socio-economic position [13, 14]. Teenage mothers and their babies are at a social and health disadvantage because of unpreparedness and the maturity required for motherhood or parenthood [10]. Teenage childbirth brings negative consequences, including school dropout, helplessness, low self-esteem, depression, and suicidal attempts than married adults [10, 12]. Negative behaviours such as not accessing health services (ante and postnatal care) may cause higher rates of postpartum haemorrhage, dysfunctional labour, premature rupture of membrane, preterm babies, or low birth weight babies. Previous studies have also examined socio-cultural factors and the economic outcomes for teenage mothers—poverty, unemployment, and others—which may result in poor childbirth and child-rearing [2, 15, 16].

At the end of 2011, 12 per cent of teenage girls aged 13 to 19 years were either pregnant or had already given birth in Ghana [17]. The teenage birth rate in Ghana has been increasing over time [18, 19]. Evidence shows that adolescents were responsible for 30 percent of all births registered and 14 percent of teenagers aged 15 to 19 had begun childbearing [8, 19]. In terms of regional prevalence, the Central Region has consistently increased teenage pregnancy and childbirth and the number of teenage mothers with one child in the region was estimated at 7% which is higher than the other regions [2, 20]. However, the Western, Brong Ahafo, and Volta regions also account for the high teenage pregnancy rate in the country [20, 21]. Despite the effectiveness of efforts aimed at promoting family planning and improving access to adolescent sexual reproductive health and comprehensive sexuality education in Ghana [9, 22].

A recent growing body of literature has examined attitude, sexual health knowledge, behaviour, health services use, and risk factors for pregnancy among teenagers [2, 21], as well as correlates of unintended teenage pregnancy [23]. Other studies have delved into teenage pregnancy and motherhood [8, 12], unsafe abortion and contraceptive use, and adolescent sexual and reproductive health [9]. In addition, previous studies conducted in the Komenda-Edina-Eguafo-Abrem municipality showed that with the existence of negative socio-cultural norms, teenage girls are exposed to the risk of pregnancy and childbirth [2, 16, 24]. Whereas these studies have contributed immensely to the field of interest, particularly with older mothers (> 20 years), there is a paucity of empirical literature on teenage mothers’ experiences with childbirth. Our study contributes to the discourse by exploring teenage mothers’ postnatal experiences with childbirth in the five selected communities (Komenda, Elmina, Eguafo, Abrem, and Ankaful) in the Central Region of Ghana. Our findings could be useful for policy and implementation decision-making regarding maternal and child health in Ghana, SSA, and beyond. The study interrogates the following research questions: What are postpartum experiences of teenage mothers? How do teenage mothers adjust to motherhood and what support available to them?

Conceptual framework

Our study is underpinned by the Ecological Systems Theory (EST) developed by Urie Bronfenbrenner [25]. The ecological systems theory is a study of the progressive, mutual accommodation between the developing person and the changing properties of the immediate and broader perspective in which the person lives [25]. The original model of EST (in Fig. 1) has been applied in studying teenage mothers’ experiences [14, 15]. This theory concentrates on the layers of the environment as identified by Bronfenbrenner as micro, meso, exo, macro, and chrono systems and focuses on the interaction between the individual, for instance, the teenage mother, and her environment based on the events and processes that occur in each of these systems [5, 25]. In our study, a microsystem would be the connection between the microsystem such as the relationship between members of the teenage mother’s own family and between her parent’s family and the family of the baby’s father, or the connection between the teenage mother and her parent’s home or her school (see Fig. 2, adapted EST model).

Fig. 1.

Conceptual framework original Ecological System Theory (EST). Source: Bronfenbrenner (1979)

Fig. 2.

Conceptual framework adapted Ecological System Theory (EST). Source: Bronfenbrenner (1979)

The exosystem contains the external environment settings and other social systems that indirectly affect the development of the individual. In this study, the exosystem of teenage mothers is the community, media, organisations, religious affiliation, health, and other social services. The macrosystem, which is seen as the broader layer, includes the culture, sub-culture in the form of societal beliefs or norms, and lifestyle of the people that directly or indirectly influence the teenage mother. In this study, it is somewhat understood that the culture and beliefs of the people in the communities influence teenage mothers’ behaviour and experiences. Chronosystem was later added by Bronfenbrenner outside the systems, which is made up of all the other levels. It accounts for the temporal changes in the individual or teenage mother’s environment or life and social–historical events that occur or happen over time. This also has some level of influence on the interactions between developing individuals (teenage mothers) and the micro, exo, and macrosystems in which they are embedded [14].

These factors or systems have been adapted to understand the scope and the impact of the health and social context on ‘childbirth’ experiences among teenage mothers. The perceived weakness of this conceptual framework is its inability to critique factors/systems that would have directly or indirectly influenced the teenage mother in the mesosystem in the third layer of the original framework. Again, the theoretical perspective did not provide the possible success of difficult situations or circumstances which means that ecological theory is lacking in the dimension of resilience. The basic contention of the ecological systems theory has often remained that the individual (teenage mother) develops within a context. However, the model focused on factors such as the technological, environmental, attitudes, and ideologies of culture that depend on each other and influence everyday life. These factors or systems have been modified to help to understand the scope and the impact of the health and social context on ‘childbirth’ experiences and where challenges, constraints, support or as well as coping mechanisms and a combination of both positive and negative experiences exist to make this framework (Figs. 1 and 2) suitable for this study.

In addition, teenage mother’s ability and capability to adapt to difficult situations, recover from physical and emotional challenges, risk-taking, despite their exposure to stressful experiences (childbirth complications) is referred to as resilience [26, 27]. Resilience is the capacity to overcome challenges, frustration, and unfortunate circumstances [28]. The literature suggests several characteristics that explain resilience. Positive self-esteem, hardiness, effective coping mechanisms, and a perception of a major threat to development's ability to adapt are some of these variables [26, 29]. According to Perry [27], resilience is the ability to deal with challenges without experiencing a major decline in one's ability to function. Protective psychological risk variables that promote the development of favourable outcomes and good personality characteristics are commonly used to describe resilience [28, 29].

A young first-time mother and her newborn/infant face numerous complications, challenges and difficulties while still in their adolescent years. Their extended families and the communities in which they reside are also affected. The difficulties come in juggling the demands of motherhood, such as meeting the infant's or kid's material, emotional, and medical needs while completing the typical teenage developmental chores, with the need to look after yourself and your child (child care). Some teen mothers exhibit tenacity in the face of these obstacles to meet their children's developmental needs. Some of these teen mothers manage to sustain themselves financially and get support to finish their education while others do not complete it. Consequently, teenage mothers might experience the challenges and constraints of being a first-time mother/parent and demonstrate indications of developmental distress, such as anxiety, despair, and low self-esteem [29].

Materials and methods

The consolidated criteria for reporting qualitative research (COREQ) was adopted in reporting this research (See Additional file 1).

Setting

Five communities (Komenda, Elmina, Eguafo, Abrem, and Ankaful) were purposively selected from the Komenda-Edian-Eguafo-Abrem (KEEA) municipality in the Central Region of Ghana. The study areas fall within the central coastal zone of Ghana and have in the recent past been experiencing a high prevalence of teenage pregnancy and childbirth due to inadequate sexuality education/interventions on reproductive health services in the region [2, 16, 20, 24, 30], coupled with fisherfolks and immigrants contributing to the subject matter/phenomenon in the study areas because young girls (15–19) engage in sexual activities resulting in unplanned pregnancies/childbirths and cervical cancer [30]. Unlike the greater Accra, Eastern, Western, Brong Ahafo, and Volta regions where adequate literature is available on this phenomenon, the same cannot be said about the risk/rate of teenage pregnancy in the Central Region of Ghana [2, 13, 20]. Also, regarding health profile: health institution, types, ownership, and status. Elmina which is the municipal capital has one poly-clinic. Komenda has one health centre. Abrem Agona has one health centre. Ankaful which falls between KEEA municipality and Cape Coast metropolis has one Leprosarium and psychiatric, contagious District prison which are government and functional without any surgical facility/theatre and cervical cancer screening services, [24, 30]. However, improvement in health facilities could provide a safe, supportive environment for teenage mothers, giving them the medical, psychological, and educational support needed to navigate postpartum challenges and recover successfully.

Study design

A qualitative exploratory descriptive phenomenology study design was adopted for this study. The study targeted mothers aged 13 to 19 who had given birth less than two years. Teenage mothers were purposively selected from five communities (Komenda, Elmina, Eguafo, Abrem, and Ankaful) in the Central Region. Some selection characteristics were age at first birth, geographical (e.g., rural, peri-urban, urban), etc.

Study population

The primary target population for this study was teenage mothers, who had experiences in childbirth. To acquire in-depth views and experiences of postnatal teenage mothers in light of the challenges they face. The teenage mother needed to have a child of age less than two years to abridge recall bias [31, 32]. This inclusion criterion was helpful since most of these young mothers might have forgotten some critical childbirth/postnatal experiences after two years. It has also been recommended that recruiting young mothers with less than five years of childbirth experience gives real, honest and pertinent information that helps to gain more meaningful, clearer, and multi-dimensional perspectives [31]. Based on this recommendation, the study ensured that teenage mothers who had given birth for the first time with considerable postnatal experiences were recruited and interviewed.

Sampling

A purposive sampling technique was used to recruit participants for the study. Homogeneous sampling was adopted to ensure that teenage mothers who had given birth less than two years and had considerable first-time postnatal experiences were considered for the interviews. This resulted in sampling 30 teen mothers from the communities.

The size of the sample included in the study was guided by the need to obtain pertinent information or rich data. More than 30 participants were approached but participants were made aware that their participation in the study was based on availability and voluntary participation. This resulted in 30 who voluntarily participated. A saturation was reached and informed a priori based on the recommendations made by Marshall et al. [33] who have shown that theoretical saturation mostly occurs between 10 and 30 interviews [33].

Research team

Data collection was done by the first author and three field assistants (all female nursing students) who were all in their final year at Cape Coast Nursing and Midwifery in the Central Region. Even though the field assistants had considerable experience in conducting qualitative interviews, the assistants had five hours of training each day for three days to acquaint them with the research instruments and ethical issues.

Data collection

The research instruments used for this study were an in-depth interview (IDI) guide and a pictorial diary/guide. The instruments were developed after a thorough literature review. The pictorial diary interview method [34], which combines photos and/or visual representations in support of in-depth interviews was used to draw evidence for the study. This enables us to adequately explore teenage mothers’ challenges during and after childbirth based mainly on participants’ narratives [35]. The pictorial diary was used and served the function of supplementing/complementing the interviews to ensure data quality, in that, they provide us with the opportunity to gain at least some modicum of access to naturally occurring events whose meaning can then be easily explored in the interview. For instance, after the participant had described her experiences based on the question asked, a pictorial diary/guide was shown to her to point at, and tell what actually happened during or after childbirth as a way of probing to reflect on her narration. It makes interviewing very easy and interesting because it reduces recall bias and/or serves as a memory aid and as a way of accessing past and current situations/experiences to enrich the data.

The data instrument had three broad sections; sections I, II, and III. The first section (I) focused on teenage mother’s background or socio-demographic characteristics (e.g., age, level of education, religion, marital status, occupation). The second section (II) explored postnatal experiences that teenage mothers encounter during and after childbirth while the last section (III) elicited information on teenage mother’s support/coping strategies in light of the challenges they face after childbirth.

Before the commencement of the data collection, all the necessary community entry protocols were followed. Individual meetings were organized for teenage mothers. This was done to brief them about the purpose of the study. The teenage mothers (participants) who met the criteria were screened and selected with the help of field assistants. Participants who were available and agreed to participate in the study were asked to propose a convenient place and time for the interview based on the data collection plan.

In-depth interviews were used in collecting data from the participants (teenage mothers) through face-to-face (one-on-one) interaction at their homes. All interviews were conducted in Fante/Mfantse dialect which is one of the principal Akan languages commonly spoken in the study areas. This helped the teen mothers to express themselves very well. To ensure that the use of the native or local language does not affect the quality of the data collected, the first author did all the recording (using audio recorders) to ensure that interviews were not halted should anything happen or any equipment break down during the interview process. All field notes and some important issues concerning the interviews and handwritten notes (with pen and notebook) were discussed (debriefed) with the field assistants before leaving the field this also contributed to easy transcription and interpretation of the data. Each interview lasted for about 40 min minimum and 70 min maximum depending on the participant's ability to respond to the questions. The data collection lasted from 6th April to 16th May 2019. Teenage mothers were informed that the research formed part of the first author's master’s requirements. The interviewer and the interviewee did not establish any relationship before and after the data collection. However, participants were informed that they may be re-visited if there is the need to respond to any important question that may appear to be missed during the transcription or interpretation of the data. The first author who is fluent in both Fante and English language did the translation. The first author transcribed in Fante and translated the transcribed Fante into English. Also, direct translation and meaning based translation was done because Fante may have expressions or saying that do not translate directly into English. However, double-check translation was done by other last author to ensure accuracy and consistency.

Trustworthiness

One of the criteria to determine the quality of qualitative research is trustworthiness. According to Korstjens and Moser [36], trustworthiness encompasses credibility, transferability, dependability, and confirmability. In this study, the potential threats to the trustworthiness of the study were necessary addressed and demonstrated to avoid research and participant biases. The researchers ensured that after each interview the main content of the issues was confirmed (member checking) by the participants to be sure that their responses were accurate. The study was conducted ethically, and fairly and ensured that the results gave a true reflection of the participant’s experiences. Credibility was well explicated and justified. Credibility was operationalised through the process of member checking to ensure what Lincoln and Guba [37] referred to as ‘fit’ between the participant's views and the researcher’s representation of them. Transferability was also considered in the study to provide a detailed description so that those who seek to transfer findings to their settings can judge transferability. The researchers ensured that the research process was logical, systematic, traceable, and documented [38]. The researcher had in mind to demonstrate the dependability of the study so that its process can be checked. This means that examiners and readers can also examine the research process and better judge the dependability of the study. In other words, the study and its findings were clear or auditable in the sense that another researcher with the same data, perspective, and situation could reach the same or comparable but not contradictory conclusions [38]. Lastly, confirmability was well-followed like other criteria ensuring that the reason for theoretical, methodological, and analytical choices throughout the entire study may be understood. This may help other researchers to understand how, why, and what decisions are to be made in the research process when conducting a similar study.

Reflexivity

To ensure reflexivity, another senior qualitative research fellow closely with the first author (RFT) did independent checks on codes to ensure data coding reliability. This was done to determine and increase the inter-rating reliability of the data. The rationale for this approach was situated on the Birks et al. [39] assumptions that reflexivity can be achieved through, prior assumptions and experiences, use of memos, reliability of coding, and comparison of the data within and across the data set. The initially identified codes/categories were modified to build a coherent scheme and used to substantiate the issues discussed. For example, economic challenges to financial challenges. This, however, did not alter the meaning of the subjective views expressed by the participants in any way. Apart from the reflexivity assumptions, some criteria also guided the first author to identify and acknowledge biases and data collection processes to ensure data quality or trustworthiness.

Data analysis

The data was managed following a systematic qualitative-oriented text analysis [35], with the help of NVivo 12 Pro software for qualitative data analysis. The issues were described, interpreted, summarized, and organized into themes (parent nodes) and sub-themes (child nodes) to demonstrate the key issues that were identified from the data for further analysis [35, 40, 41]. A numeric scheme of coding was employed to mark all parts of the written discourse that contained one category or another (classification) in line with the systematic-oriented text analysis. These categories were then reduced into much smaller groupings (similar and related) to arrive at new categories, which were many personally constructed typologies. In the process of analysing the data, a total of six major themes and eight sub-themes, and seventeen quotes were obtained and used for this study. Specific participant’s quotations were represented by the identity number (pseudonyms): PD1 to PD 30. The initial coding was done by RFT (principal investigator and analyst).

Results

Socio-demographic characteristics of participants

Table 1 presents the socio-demographic characteristics of participants. Of the 30 teenage mothers interviewed, the mean age of the participants was 17.5 years. Only three had completed Senior High School and were married, whereas 19 were never married (single). Nine in 10 of the participants were Christian. Half of the participants had no occupation. However, 6 of them engaged in petty trading while others were engaged in vocational and mobile banking services. Based on the socio-demographic characteristics of the participants, it is observed that 50 percent or half of the sample is 19 years old. The implication of this could be that younger teenage girls or mothers (below 17 years) might have a different risk profile or experience childbirth than older teenage mothers.

Table 1.

Socio-demographic characteristics of participants

Variable	Frequency (N) (N = 30)	Percentage (%) (100%)
Age (in completed years)
16	1	3.3
17	6	20.0
18	8	26.7
19	15	50.0
Level of Education
Primary	9	30.0
JHS	18	60.0
SHS	3	10.0
Marital Status
Never married	19	63.3
Married	3	10.0
Cohabiting	8	26.7
Religion
Christian	27	90.0
Islamic	3	10.0
Occupation
Not working	15	50.0
Petty trading	6	20.0
Seamstress	4	13.3
Hairdresser	3	10.0
Mobile banking/Transfer	2	6.7

Source; Fieldwork, 2019

Thematic results

With the aid of the systematic qualitative-oriented text analysis (SQOTA), Fig. 3 (thematic framework) was developed to systematically explain the main and sub-themes that emerged from the data. The main themes were childbirth experiences, psychological experiences, socio-cultural experiences, economic-related experiences, religious perspectives, and future aspirations. The sub-themes comprised postpartum haemorrhage, severe pain, tiredness and dizziness, preterm babies associated with psychological difficulties, faith and hope in childbirth, financial challenges, unmet needs, challenges with the baby fathers’ attitude, denial and irresponsibility, desire to return to school amidst fear of stigma. These issues have been subsequently described and discussed.

Fig. 3.

Thematic framework showing the summary of main themes and sub-themes

Child birth experiences

Postpartum haemorrhage

Teenage mothers indicated that they experienced a number of health complications, including postpartum haemorrhage (vagina bleeding following delivery), preterm births, and other neonatal problems. Some of the participants noted that they were frightened about experiencing such complications. However, they were very concerned about their own survival and that of their babies. For instance, these are some of the questions, we asked from the interview guide.

Interviewer: We are going to talk about some postnatal care (PNC) challenges that you faced(ing) during and after childbirth

• Please how would you describe your experiences the day you gave birth to your child? (Probe for postpartum haemorrhage/vagina bleeding, low birth weight child, and any complications? [show the pictorial guide])

• Further probe: What happened? Ask in relation to the complication mentioned

These were some of the views expressed by the participants:

‘‘… Yes, hmm! When I gave birth, I experienced similar things [reflecting on those in the pictorial guide: picture 9 …], I had a lot of blood coming from my vagina for some days. It was really bad because I could not deal with the pain at first, but when I came home the pain had gone down…’’ ¬PD3; 18 years with a female child.

Another participant who experienced bleeding from the vagina or haemorrhage had this to say:

‘‘… When I gave birth, hmm […], it was a tough condition for me at that time. I bled a lot [pointed at picture 9 in the pictorial guide] and had severe pains as well. This continues for some time; I am even scared to sleep [have sexual intercourse] with someone again …’’. ¬PD 6; 18 years with a female child.

Severe pain, tiredness, and dizziness

Even though childbirth generally is associated with pain, the teenagers shared the view that they have to cope with excruciating pain during the process of delivery. Most of the participants revealed that they experienced things such as severe pain, tiredness/dizziness, and hunger at the same time. It was evident from the narratives that these feelings were unexpected and most of the teenage mothers were shocked. In most cases, the participants were scared that something undesirable might happen to them. Some of the participants had this to say:

‘‘… I feel dizzy and also intermittently, I feel pain in my upper right belly…’’ ¬PD 23: 18 years.

Another participant with a similar experience had this to say:

‘‘…my baby took all my energy[strength], she was too big […] I got tired in the process and I become hungry, but I know it is because of the sudden loss of weight and energy...’’ ¬PD 16; 19 years with a female child

Psychological experiences: preterm babies with associated psychological difficulties

Whereas most of the mothers experienced complications to themselves in the form of postpartum haemorrhage, others experienced preterm babies. Participants shared the view that such experience often has attendant negative psychological effects after childbirth. A 19-year-old narrated his ordeal as:

‘‘…My baby was too small when I saw him, yes [participant pointed at picture 10 in the pictorial guide]. I felt disappointed and I was so scared. I delivered at 8^th months, and I was dissatisfied with this because I did not want them to retrieve my baby, until my full nine months but he could not have stayed in my womb. I even asked myself so many questions, was my child going to die in my stomach? Because I was surprised and concerned about my health and the well-being of my baby…’’ ¬PD 17; 19 years.

Religious perspective: the faith and hope in childbirth

Even though most of the study participants largely shared negative experiences with regard to childbirth, some participants indicated their experiences of giving birth as natural and painful, but ‘worth it’. They saw the benefits in terms of feeling more physically resilient and better able to give birth easily without any complications. Most of them were positive (self-confidence) and were determined to have a successful delivery. Most of the teenage mothers put all their faith and hope in God during labour even though some of them knew they were too young to give birth at that time. Some of the participants had this to say:

‘‘….Hm, it was very painful, especially my last push [she sighed], I know God did it because, before that, I was frightened anytime I went to the hospital, and there was a lady who died some time ago when she went to give birth […] I had a friend who had two children already and we stayed together so she was always telling me to have confidence and pray to have a successful delivery…’’ ¬PD 20; 18 years with 3 months child.

Aside from the negative experiences, some of the teenage mothers also expressed their positive experiences to show how determined they were during and after childbirth. They showed confidence in themselves (certainty about going through a successful labour or parturition).

Another participant narrated:

‘‘…oh! I thank God, initially, it was not easy for me, and I could not sleep for some days. I suffered a lot but I had confidence in myself that some of my friends passed through what I am going through [labour]. In the end, it was successful and it was worth happening…’’ ¬PD 27; 19 years with a female child.

Economic-related experiences: financial challenges

Teenage mothers have lower incomes and face difficulties in getting financial assistance from their family, and young fathers of their children. Financial challenge was one of the major challenges that emerged from the data analysis. Most of the participants shared a narrative of how they struggled financially after becoming pregnant. Most of them were not working before they became pregnant and so lost the financial support they used to receive from their families. The main family income was generally from fishing and farming activities. Any extra income comes mostly from the baby’s fathers, relatives, and friends. Having a baby not only increased the cost of living but also reduced the labour force within the family. Those who got pregnant when they were schooling were, therefore, assisted by their mothers who often had to reduce or quit entirely their own working hours and business travels just to help care for the babies, thus creating further financial strain. Financial support seemed crucial to teenage mothers being able to provide good care for their children. Some participants had this to say:

‘‘Hmm […] getting support is a big problem I am facing now. I need some help with my baby’s expenses. It really worries me […] since I had a baby, things have become very tough for me financially. No one in my family has a permanent job to earn a good income to take care of me [she sighed]’’. ¬PD8; 19 years with 10 months child.

Unmet needs

As part of the economic-related experiences, a number of teenage mothers indicated that they faced challenges with meeting the needs of their babies as well as seeking ways to satisfy their own needs as new mothers. Some of the teenage mothers indicated that they have to sell (petty trading) juggle with their multiple roles, and make strong decisions as responsible mothers. Some participants expressed the following;

…It is not easy for me at all ...hmm [she sighed], taking care of myself and that of my baby is hard. I have to leave my baby with some of the market women and take some of their second-hand clothing and sell it to get money to meet some basic needs of my child. Sometimes, I come home very late in the evening, prepare a meal before I eat…-PD 4; 18 years with a female child

I get so tired because I have to go and sell and wash for others to get little money like GHC 20 to take care of myself and provide some basic needs[pampers] for my baby because I am no more with my boyfriend support me and I cannot beg him to give me money either so I have to do other things to support myself…¬PD1; 17 years with a female child.

Socio-cultural related experiences: challenges with baby’s fathers’ attitude, denial and irresponsibility

Most of the participants (teenage mothers) mentioned that the negative attitudes of their baby’s fathers (boyfriends) toward them were major challenges they encountered. For most participants, the first person they told of their pregnancy was the father of their baby. However, some had been in a relationship with the father but had broken up before finding out they were pregnant. In such cases, the would-be fathers often denied responsibility for the pregnancy. In some instances, the teenage mothers even tried to protect the would-be fathers by refusing to reveal their identities to their families but they ended up getting disappointed. This brought shame and disrespect to their families in the community. Some of the participants had this to say:

‘‘My baby’s father was in SHS but after school, we broke up because of the issues concerning the pregnancy. Initially, I thought he was in school so I didn’t want to mention his name to the family to get disappointed because he told me not to tell the parents about it so I tried to mention somebody that nobody knew to cover him for some time. This caused a lot of problems for me because he also stood on it to deny me for mentioning the other person’s name. Hm! What he did really pains me and because of that I’m not even on good terms with him’’ ¬PD 12; 19 years.

This was further corroborated by a teenage mother aged 19 years.

‘‘…My baby’s father did not care. I asked him if he wanted me to keep the baby or wanted me to have an abortion and he chose the latter [abortion]. I was not happy to be with him anymore. Not long after that, we broke up. He is not a good guy…’’ ¬PD19; 19 years with 6 months child.

According to some teenage mothers, the fathers of their babies were in school studying and had no resources with which they (the babies’ fathers) could care for them and their babies. Most of the relationships were not approved by the parents of the baby’s father. Both teenage mothers and fathers also risked being expelled from school if the fact that they were in a sexual relationship was discovered by the school authorities. Unsurprisingly, many of these fathers just denied responsibility for the pregnancy because they are not resourceful enough to care for, support, and provide for the teenage mother and the baby. These were some of the experiences shared by some participants:

‘‘... He denied […] so we are no more ‘koraa’ [totally], he had already broken up with me…’’ ¬PD1; 17 years with a female child

However, few of the participants shared the view that they understood why their boyfriends denied responsibility because teenage pregnancy usually comes with enormous pressure for all those involved. In some instances, after giving birth, the boyfriends were welcomed after they started showing care and support for the young mother and the new-born baby. One of the participants had this to say:

‘‘…We were not on good terms when I got pregnant, he denied me, but I later welcomed him… he is my baby’s father. So, when he came back to me, I accepted him and forgot about what he did to me. Now he has been providing [for] my needs; he gives me money, and he buys me things that I asked for… ¬PD 8; 19 years with 10 months child.

Future aspirations: desire to return to school amidst fear of stigma

Even though participants’ pregnancies were untimely with associated challenges, almost all the participants had future aspirations. Nearly, all participants expressed interest in schooling. Being a pregnant/teenage mother was a challenge for most people we interviewed. Participants indicated that they would like to go back to school, but they realized that it would be very difficult and it would even take some time for them to go back because they have to wait for their babies to mature. However, a few of the study participants see motherhood as a state of maturity “grown up” so they cannot go back to school. The excerpts below highlight the views shared by the teenage mothers:

‘‘…Hmm! I wish [to return to school] but it is difficult [she sighed]. Who will look after my baby if I go back to school, I have to sit home and take care of my baby…’’ ¬PD16; 19 years.

In the same vein, some participants said that others judged them, gossiped about them, stared at them, and saw them as spoilt girls resulting in social stigmatisation. They reported that their lives have changed since they got pregnant and after giving birth others look down upon them. Some of the teenage mothers appear to have lost hope of ever returning to school since they don’t have anyone to support them. Some of the participants had this to say:

‘‘…The school authority asked me to leave the school when I got pregnant […] and I don’t have anybody to give me money, food or dress even if I say I want to go back to school again…’’ ¬PD 7; 18 years.

Another participant who felt disappointed because her friends gossiped about her and thought she was a spoilt girl had this to say:

‘‘…I was getting hate from some friends who gossiped when I got pregnant and now, I feel disappointed and regretful because my friends see me as spoilt because I got pregnant early. So, I don’t think I can go back to school. I will make sure I work to get money to take care of myself and have a good future like other friends who are going to school …’’ ¬PD 23; 18 years with 17 months child.

Discussion

Our study showed that teenage childbirth is associated with adverse health outcomes, especially for teenage mothers. With the aid of a pictorial diary (see, Fig. 4), a number of maternal risk factors and birth complications such as vagina bleeding or postpartum haemorrhage, waist pains, low birth weight, depression, loss of weight, and other neonatal problems were found to be common experiences among teenage mothers. These findings are congruent to those found by Kumar et al. [42], that childbirth among teenagers is associated with poor health outcomes (childbirth complications) such as preterm delivery, eclampsia, puerperal endometritis, postpartum haemorrhage, and neonatal deaths [7].

Fig. 4.

Pictorial dairy/guide

Results of the study point to financial challenges teenage mothers face after childbirth with many of them struggling to meet their basic needs, with the cost and resources for raising a baby and accessing quality health care. The main family income was generally from primary economic activities such as petty trading, fishing, and farming such as growing maize and cassava, vegetables, and fruits. Any extra income came mostly from the baby’s fathers, parents, and relatives. The findings of the present study affirm those found in the previous study by Ahorlu et al. [43] that the three most important sources of financial support were from parents, relatives, and partners (baby’s fathers) when they conducted a study to examine coping strategies with teenage pregnancy and childbirth in Ghana. Teenage mothers having a baby not only increased their cost of living but also reduced the labour force within the family and even created further financial strain [44].

Our study also revealed a mixed experience when it comes to teenage mothers’ relationships with the fathers of their children. While some of them revealed they had broken up before finding out they were pregnant or had given birth, others reported being in happy relationships with the fathers of their babies. Besides, most of these fathers, according to the teenage mothers, denied them and their babies which affected most of them emotionally and psychologically after childbirth. These findings corroborate findings from Ahorlu et al. [43]. They observed that partners may be a source of stress and conflict for teenage mothers. However, the findings in the present study appear to be in contrast with [10], who noted that pregnant and parenting teenagers most frequently cite their boyfriends as major sources of support emotional and psychological. However, few of the teenage mothers noted that little financial support was obtained from partners (fathers of their babies). This finding corroborates with those found in previous studies [11, 45, 46].

The findings of the present study support that of Ungar et al. [47] where social support facilitated access to material resources such as food, clothing, and shelter, and to educational, medical, and employment assistance which are important in overcoming adversity. The finding further corroborates with a previous study [46] where support offered by parents, peers, and teachers was recognized to have played an important role in the emotional and psychological well-being of teenage mothers.

Our study also revealed that teenage mothers faced challenges with meeting the needs of their babies as well as seeking ways to satisfy their own needs as new mothers. Some of the teenage mothers indicated that they have to sell (petty trading) juggle with their multiple roles, and make strong decisions as responsible mothers. However, the teenage mothers were able to identify the key challenging roles and develop coping strategies to overcome those challenges. This finding is consistent with the result of earlier study conducted in a suburb of Accra by [8], which shows that adolescent mothers face numerous challenges that place demands not only on the young mother’s stage of adolescent development but also on their ability to adapt to the obligations of parenthood and accepting responsibility as teen mothers. In a similar vein, support obtained from the fathers of their babies is equally found to be very useful in helping teenage mothers cope in light of the challenges regarding motherhood. Neamsakul [48] asserted that fathers who have much contact with their children, who are responsible for child care, and who encourage and support teen mothers in the transition to parenthood were likely to assist in releasing teen mothers’ stresses which otherwise would have resulted to emotional and psychological challenges.

We also found that bearing a child as a teenage mother in the communities is a challenge for these young mothers and their families. In this study, teenage mothers claimed to be good mothers and made efforts towards ensuring that they (teen mothers) together with their babies become successful in life course irrespective of the challenges they encounter. This is consistent with the finding from a previous study by Gyesaw and Ankomah [8], that adolescent/teen mothers face numerous challenges that place demands not only on the young mother’s stage of adolescent development but also on their ability to adapt to the obligations of parenthood and becoming successful in life.

The results from this study also revealed that almost all teenage mothers did not give up on life because they were having babies at such an early stage but had plans for their future. Their aspirations border on education, vocational training, and business. There was evidence of resilience and positive plans for their future and that of their babies. This is consistent with the findings from Alemayehu [49], that a person has the capacity to adapt, recover from, or remain strong in times of hardship to ensure successful outcomes. In addition, teenage mothers were confiding in themselves to hold on to their future plans and ensure that they achieve those future plans successfully. This finding corroborates that of Luthar and Cicchetti [29], where young mothers showed resilience and the ability to bounce back from adversity, frustration, and misfortune. The findings further support evidence put forward by Ledesma [50] that teenage mothers exhibit resilience and manage to satisfy their own developmental needs as well as those of their children.

Strengths and limitations

Only teenage mothers 13 to 19 years with a child aged two years or less were included in the study to reduce the risk of recall bias. The data were collected cross-sectionally but using a prospective or longitudinal approach could have revealed deeper insights about how teenage mothers' postnatal experiences change over time. However, our interest was mainly in unravelling the actual postnatal experiences of these mothers, a crucial aspect that seems to be missing in the current discourse. One of the strengths of the study could be associated with the high-quality interviews conducted because the first author (RFT) shares the same cultural background as the participants. The cultural background of the researcher helped to elicit detailed, rich interviews and descriptions from the participants. The fluency in the local language (Fante) allowed the investigator to understand the context of the issues. All the interviews or recordings and transcription (from Fante/Mfantse dialect to English) were done by the first author which is an essential requisite for rigorous qualitative research.

Conclusion

Childbirth complications such as postpartum haemorrhage, vagina bleeding, and other neonatal problems not only affect the health and well-being of teenage mothers but also have an adverse impact on their newborns and motherhood roles. Attention must be given to these teen mothers by Ghana Health Service (health professionals), and traditional birth attendants (TBAs) should have skill training on maternal and child health to facilitate childbirth. Mitigating childbirth complications is paramount in having less complicated and safe delivery. It requires concerted effort and a shared responsibility of teenage mothers (individuals), families, and healthcare professionals (nurses and midwives) to reduce maternal and infant mortality and contribute to achieving SDG 3. Also, Teenage mothers need to have a strong connection with the micro-system, including the family, parents, relatives, neighbourhood, and baby’s fathers to require social and financial support (welfare) from the exo-systems such as education (Ministry of Education), healthcare (Ghana Health Service/Ministry of Health), and social services (Domestic Violence and Victim Support Unit and Child Rights Promotion). The connection with these systems shall create a friendly environment to have equal access to antenatal care (ANC) and postnatal care (PNC) and discuss teenage pregnancy risk and other related adolescent sexual and reproductive health issues to help reduce the high prevalence of teenage childbirths.

Abbreviations

ANC

Antenatal Care

COREQ

Consolidated Criteria for Reporting Qualitative Research

EST

Ecological Systems Theory (EST)

IDI

In-Depth Interview

KEEA

Komenda-Edina-Eguafo-Abrem

LMICs

Low- and Middle-Income Countries

GSS

Ghana Statistical Service

GHS

Ghana Health Service

PNC

Postnatal Care

SSA

Sub-Saharan Africa

SDGs

Sustainable Development Goals

SQOTA

Systematic Qualitative-Oriented Text Analysis

TBAs

Traditional Birth Attendants

UN

United Nations

UNFPA

United Nations Population Fund

UNICEF

United Nations International Children's Fund

WHO

World Health Organization

Authors’ contributions

This was an MPhil Research by RFT who collected the data, did the analysis, and wrote the initial draft of the manuscript. EKMD supervised the dissertation. HA, VK, KKK, and KED critically reviewed the manuscript to improve its scientific quality. All authors contributed to a revision of the manuscript and gave consent for its publication.

Funding

The authors received no funding or financial support for the publication of this article.

Data availability

All relevant data are within the manuscript. The individual participant’s interview transcripts can not be openly accessible due to the privacy of participants. However, it can be made available upon request through the Department of Population and Health, University of Cape Coast. pop.health@ucc.edu.gh.

Declarations

Ethics approval and consent to participate

All ethical standards that guide the conduct of research involving humans were followed. First, copies of the research proposal were submitted to the University of Cape Coast Institutional Review Board (UCC-IRB) for assessment and ethical clearance. After obtaining the approval, an introductory letter from the Department of Population and Health and the UCC-IRB approval letter with ethical clearance -ID: (UCCIRB/CHLRB/2019/09) were given to the KEEA Municipal Health Directorate and permission was obtained from the public health officer who granted permission to carry out the study in the selected communities.

Also, consent was sought from the respondents/teenage mothers before interviewing them. Written and oral informed consents were obtained from their parents or guardians as well as the teenage mothers themselves before interviewing them. In addition to this, the investigators identified themselves to the participants to avoid false impressions. The investigators briefed them about the purpose of the study, the participation concept, the data collection approach, the informed consent form, and every item on the instrument (guide).

Again, before any interview took place, teenage mothers (the participants) who could read in English were given a written consent form to read and freely decide to participate in the study by signing. On the other hand, with those who could not read, the interviewer read the informed consent form to them in the language they best understood and made sure that the respondents agreed to participate and thumb-printed the consent form before interviews were conducted and tape-recorded. After every interview, the recorded voice and field notes were stored/kept safely to conform to the ethics of confidentiality. Further, participation in the study was not made compulsory. Participants were informed that their participation was completely voluntary; confidentiality and anonymity were fully assured and respected. No information could be revealed or identified about the participants. Pseudonyms were used instead of real names.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interest