Experiences of pregnancy among Iranian adolescents: A qualitative study

Abstract

Background:

Pregnancy rate among Iranian adolescents below 20 years of age is increasing. Pregnancy during adolescence is considered a social issue associated with medical, emotional, and social outcomes for the mother, child, and family. The current research examines the experience of pregnancy among Iranian adolescents.

Materials and Methods:

The qualitative content analysis method was used. A purposive sample of 14 pregnant adolescents was enrolled in the study. Deep interviews were carried out with them.

Results:

Three themes were came up after analyzing the interviews: 1. Psychological reactions including three subthemes of feelings, concerns, and fears; 2. physical reactions including the subthemes of symptoms and feelings; and 3. spiritual reactions including religious beliefs and faith.

Conclusions:

The present study showed that for the purpose of assessing pregnancy in adolescents, one should consider the context and culture in which the adolescent lives. This is because factors such as preplanned or unwanted pregnancy and imposed or consensual marriage within or outside the family may draw different reactions from adolescents. Hence, all those factors need to be considered in order to plan health education during pregnancy for this age group.

INTRODUCTION

Pregnancy rate among Iranian adolescents below 20 years of age is increasing. According to the World Health Organization (WHO), 10% of the girls from low- and medium-income countries become pregnant at the age of 16 and mothers aged between 10 and 19 years account for 11% of all births worldwide. The WHO figures also show that nearly 23% of childbirth-related diseases in the world occur in adolescent mothers.[1] Given the characteristics of adolescence, pregnancy during the period is basically different from other age groups and creates different feelings in women. Pregnancy during adolescence is considered a social issue associated with medical, emotional, and social outcomes for the mother, child, and family.[2] Studies have shown that childbirth during adolescence is associated with the risk of negative outcomes for the mother and child. Pregnant adolescents are exposed to unique challenges. Adolescent mothers are more likely to have poor prenatal health behaviors and poorer health status.[3]

Over the past decades, many studies have been conducted on pregnancy among women below 20 years of age. Most of the studies were quantitative, while a few assessed the experience of women below 20 years of age.[4] The researches usually address the physiological results of pregnancy during this period, the risks of pregnancy, and ways to control them. So, what adolescents experience during the period has been studied to a lesser extent.[5,6,7,8,9,10,11,12] Furthermore, the studies have been conducted mainly in countries where adolescent pregnancies occur outside marriage and their culture is totally different from that of Iran. In Iran, most adolescent pregnancies occur within legal marriages. This can lead to a different experience during pregnancy. It is necessary to assess the adolescent pregnancy under such circumstances to see if it is different from pregnancy at a higher age. Furthermore, nurses, particularly those working at the health and prenatal department for women below 20 years of age, play a key role in this regard. The healthcare services cannot be provided without considering the emotional and psychological aspects.[13]

Gaining an insight into pregnancy of women below 20 years of age, particularly the experience of pregnant women, can boost the knowledge of nurses who give healthcare services to the women. Perception of adolescent pregnancy may provide basic knowledge for healthcare workers, so that they can take care of the mothers below 20 years of age at this transitional stage. This can help the service providers develop their special interventions so that they would satisfy the needs of young women in the best possible way and correct the childbirth outcomes for them.[14] Considering the significance of the matter and lack of any information about the experience of pregnant women below 20 years of age, the present study was conducted to gain an insight into that experience.

MATERIALS AND METHODS

In the present study, qualitative content analysis technique was used. The healthcare centers of Karaj formed the research setting. Purposive sampling method with maximum variation sampling was used. Sampling continued until the data saturation. The interviews conducted with 14 participants yielded no new categories or subcategories in addition to the previous ones. Deep and semi-structured interviews with open-ended questions were used to collect data. This type of interview is suitable for qualitative research because it is flexible and deep.[15]

The interview began with open-ended questions like: How did you feel when you realized that you were pregnant? What was your experience like? What created this experience? Was your pregnancy preplanned? The interview lasted between 30 and 45 min. All the interviews were recorded and then typed verbatim for analysis. In qualitative studies, the researcher needs to immerse himself in the data.[16] Hence, the researcher listened to the interviews several times and reviewed the transcriptions many times. Conventional content analysis was used. In this approach, the researcher usually avoids using predetermined categories. Instead, he allows the categories and their titles to be extracted.[17] In the present study, the analysis of data involved three stages: Encoding, re-creating the categories, and abstracting.[15]

To assess the validity and reliability of the data, Lincoln and Guba criteria were used. One of the best techniques to validate the data is to have a long engagement with the subject. In the present study, the researcher was involved in the topic of the research, the data collected, and the pregnant women for a year. Since the author worked as an instructor at healthcare centers before starting the study, she established a good relationship with the subjects before and throughout the research. The findings were checked out with the participants. Thus, a summary of the researcher's interpretation of the key points was given as feedback to the participants so as to ensure their validity. The supervisors cross-examined them. For this purpose, some parts of the interview along with the related codes and categories were sent to the supervisors so that they would examine the process of analysis and express their opinion on their validity. To determine transferability of the data, a diverse sample was used so as to help transfer the findings. To this end, expecting women below 20 years of age who had planned or unplanned the pregnancies were studied at different gestational ages. For confirmability and dependability of the research, the author accurately recorded and reported all stages of the study so as to make it possible for others to check out the research.

Ethical considerations

The Ethics Committee of Tehran University of Medical Sciences approved this study. The participants signed written consent. Authors had no conflict of interest.

RESULTS

The participants in the study consisted of 14 adolescents. All the participants said their mothers and sisters or both had a history of becoming pregnant under the age of 18. Most of them had got married because they were not interested in higher education [Table 1]. The author came up with three themes after analyzing the interviews: 1. Psychological reactions including three subthemes of feelings, concerns, and fears; 2. physical reactions including the subthemes of symptoms and feelings; and 3. spiritual reactions including religious beliefs and faith.

Table 1.

Characteristics of participants (n=14)

Psychological reactions

The theme involved the subthemes of feelings, concerns, and fears. The subtheme of feelings included those about pregnancy, spouse, and child. As for the good feelings about pregnancy, the participants whose marriage and pregnancy were consensual referred to such feelings as life, happiness and feeling great, leaving behind childhood, sense of responsibility, enthusiastic for early pregnancy, sense of being a mother, a beautiful feeling, increased happiness, enthusiasm for a growing belly, waiting anxiously for the end of the pregnancy, and sweetness of pregnancy despite difficulties. One of the participants said about her pregnancy thus:

“One feels like leaving behind childhood. I mean first you only care about yourself. After marriage, you still care about yourself. But when you are pregnant, you feel that there is someone else in your abdomen; you feel that someone else is growing; you try to be careful much more; and you care about that someone. Now, I’m like that. I care more about my child than myself. I try hard to learn how moms behave so I will be the same.”

Some participants who considered their age to be low for pregnancy had different feelings compared to other mothers. Their feelings ranged from feeling unthankful for pregnancy, lazy, and heavy. They also said they had bad feelings when they were alone, or they felt frightened or thought they were in danger, or felt that pregnancy was difficult and they were suffering or worried. One of them said:

“I said I don’t want this child at all; I mean it was sort of being unthankful, you know; I said I want abortion and stuff. I was pissed off. I was feeling terrible.”

As for the child, most participants who had consensual marriage or preplanned pregnancy expressed good feelings. The feelings included life being sweet with a child, being in a hurry to give birth, feeling that someone else exists within oneself, speaking to the fetus out of happiness, and loving the child. One participant said:

“I feel great; the sense of becoming a mother and that I should shoulder the responsibility; someone else is within me. What a nice feeling!”

The participants who had got married non-consensually or become pregnant in a unplanned way had bad feelings about the child. The feelings included inability to shoulder the responsibilities, lack of confidence about the ability of a mom who is a child to raise another child, the difficulty of thinking about how to raise the child, and not being interested in having a baby immediately after marriage. One of the participants said:

“I’m too young. I could wait. But more because of ovary cyst (doctors said I mustn’t become pregnant) I was afraid. Otherwise, I didn’t want to have a baby. It was too early for me. I was a still a student.”

Most participants had good feelings about their husbands such as the feeling that their spouses understood them well and that their husbands cared more about them during pregnancy. A participant said:

“My husband goes the whole hog during my pregnancy. He says ‘hopefully both you and the child will be all right.’”

One of the participants whose marriage was not consensual expressed feelings such as hatred for her husband, and also the feeling that her husband was not treating her well, the feeling that she disliked her husband from the bottom of her heart, the feeling that her husband was cheating on her, and the feeling that the father of the child was bad. She said:

“My husband is a very bad guy. I’ve seen no kindness in him.”

Elsewhere, she said:

“I don’t trust my husband so I can have a baby. I thought that he is unfaithful.”

The subthemes of worries were worry about labor, premature childbirth, baby's health, its condition, and abortion. One participant said:

“You see other children. Then, you think that because there is a history (of such cases) in your family, God forbid, your child may not be healthy. However, this may not be genetic. It is God's will.”

As for the subtheme of fears, the participants mentioned things such as being afraid of pregnancy due to young age, being afraid of childbirth, fearing people's jinx because of pregnancy at young age, being concerned about how to raise the child alone, being worried of not having menstruations, being afraid of what the doctors would say about baby's health, fearing that the baby may be strangled to death, and fear of harming the child by lying on their side. One participant said:

“I was worried that the child in my stomach might be strangled if I put my hand on it; I feared that I would deal a blow to the child when I was sleeping on my side. And now I’m worried about giving birth.”

Physical reactions

As for the physical reactions, participants reported symptoms such as dropping of the blood pressure, nausea, backache, headache, feeling pain in legs, edema, and feelings such as piercing spasm in the stomach, feeling that one's belly is being torn apart, feeling flatulence after eating something, and feeling that something was moving in the belly. One participant said:

“I feel that my stomach is being torn apart.”

Spiritual reactions

As for the religious beliefs, participants spoke of cases like the child in the stomach being a miracle, reading the Quran for the child's health, and believing that having a baby at a young age was providence. Regarding the subtheme of faith, they referred to things such as supplicating God for a healthy pregnancy, praying God for a healthy child, husband's prayers for the health of the mother and the child, supplicating God and being satisfied with what God ordains no matter what it is. A participant whose pregnancy was preplanned and whose marriage was consensual said:

“I can’t get any sleep at nights. I wasn’t feeling well. I feared that my blood pressure might drop. But gradually, I would say ‘I trust in God. Whatever He wills will be ok.’”

DISCUSSION

The findings of the study showed that some reactions of the adolescents to pregnancy were different compared to other age groups. Pregnancy is a multi-dimensional phenomenon in which the expecting adolescent, her husband, relatives, and fetus must be monitored. The findings of the study also showed that the expecting adolescent reacts psychologically, physically, and spiritually to the phenomenon and its dimensions. Most participants who had married consensually and become pregnant in a preplanned way had good feelings about pregnancy and having a baby. The findings of Ebanks showed that expecting adolescents who had planned pregnancy described it as a positive experience in their lives.[18] Rosengard et al. found that having a positive view of becoming a mother during adolescence causes the adolescents view having a baby a motive for setting their targets in life and loving someone who reciprocates their love and a sign of maturity.[19] Montgomery's study on preplanned pregnancy of adolescents referred to themes such as being good for further growing up along with a sense of responsibility, independence, maturity, a long history of the usefulness of pregnancy, and being a mother and pregnancy being the next natural step in one's life.[20]

In the present study, one participant who had got married non-consensually had bad feelings about pregnancy and her husband. She said that the feelings had led to worries and anxieties during her pregnancy. Other studies in different countries have shown that anxiety and stress during unwanted pregnancy is associated with few positive feelings about being a mother and much difficulty in becoming a mother, as well as with symptoms of depression.[21,22] Paskiewicz found that the experience of pregnancy among adolescents was associated with things such as conflict, role change, and social isolation.[23] Also, Meadows-Oliver found that participants with unwanted pregnancies considered it as fast aging and a loss of their adolescent period. The results showed that becoming a mother means transition from adolescence to adulthood faster than peers. Under such circumstances, adolescents cannot do activities that they enjoy doing.[24]

In the present study, as for the feelings toward husband, the participants spoke of things ranging from ability and making plans to look after the infant with the help of the husband, succeeding in adapting oneself with pregnancy with the help of the husband, feeling that one is understood by her husband, and feeling that husband cares more about his wife during pregnancy. A phenomenological study by Spear showed that eight expecting adolescents had a good feeling about becoming a mother alone, completing one's educational goals and maintaining the protective relationship with the child's father.[25] Some other findings of the study are compatible with the results of the present research. Most participants referred to their husband's consent besides their willingness regarding their planning for pregnancy. Siegel (2001) showed that pregnant adolescent's husband and community are the most important factors in decision-making for planning pregnancy.[26]

The physical reactions of adolescents were similar to those of other age groups. However, it is necessary that the inexperienced pregnant adolescent's relatives and husband support her and inform her of how to deal with these reactions. In the study titled, “Nursing for expecting adolescents,” Montgomery reported that looking after the pregnant adolescents physically is similar to that of adults, but the adolescents have unique needs.[20] Adolescents often need care and extensive instruction during pregnancy and after giving birth. They are less experienced than adults. This reduces their ability to adapt themselves to life changes they experience during pregnancy and labor.

The theme of spiritual reactions involves two subthemes: Religious beliefs and faith. The participants said, “it was God's providence that we had a baby so early” and “trusting in God for the health of the child.” Some studies referred to the role of faith and religious belief in shaping one's attitude toward pregnancy. Tanner et al. showed that resorting to religious messages by participants often provides the logic for conception. As the adolescents participating in their study said, unwanted pregnancy can be God's will.[27] One of the minor findings of the present study was that most pregnancies occurred among those adolescents who conceived just for the sake of avoiding continuing their studies to higher levels. Haldre et al. also said one of the factors concerning pregnancy during adolescence was attitude toward school (reluctance to go to school any more).[28] In the present study, all the expecting adolescents, including those who had married consensually and non-consensually and those who had planned or unplanned pregnancies, reported a history of their relatives (mother or sister) marrying and giving birth while they were too young. Gokce et al. reported that factors such as marriage during the period of adolescent, high school, or lower education and having sisters with a history of conception during adolescence had a relationship with pregnancy among adolescents.[29] East et al. also showed that there was a relationship between pregnancy during adolescence and the history of conception during the period among family members. According to the study, adolescents whose mothers or sisters or both had experienced pregnancy during adolescence had most probably experienced the same thing.[30]

CONCLUSION

The present study showed that for the purpose of assessing pregnancy in adolescents, one should consider the context and culture in which the adolescent lives. This is because factors such as preplanned or unwanted pregnancy and imposed or consensual marriage within or outside the family may draw different reactions from adolescents. Hence, all those factors need to be considered in order to plan health education during pregnancy for this age group.

Limitations

This study is a qualitative research. Therefore, one of the basic limitations is inability to generalize the findings to a target population.