Introduction

Adolescent pregnancy is a global concern, with an estimated 21 million girls aged 15–19 years becoming pregnant in low- and middle-income countries (LMICs), resulting in 12 million births1. Younger adolescents, under 15 years, account for an estimated 777,000 of these births1. Sub-Saharan Africa has the highest global fertility rate, with 101 births per 1000 adolescents aged 15–19, compared with 12 births per 1000 in high-income countries (HICs)2. This study was conducted in Zambia, a country with a high adolescent fertility rate (118 births per 1000), and the highest adolescent pregnancy prevalence rate in sub-Saharan Africa according to the latest Demographic Health Survey3. Furthermore, 29% of young women aged 15–19 are already mothers or pregnant with their first child. Young women from rural settings are twice as likely to have begun childbearing than those residing in urban areas (37% versus 19%). In addition, adolescent pregnancy rates vary by province, from 15% in Lusaka to 43% in Southern, with a combination of intended and unintended pregnancies.

Adolescents are a known vulnerable group, with pregnancy at a young age impacting on lifelong health and wellbeing. Poorer birth outcomes are reported, with increased maternal and perinatal mortality and morbidity4. Stillbirths and neonatal deaths are reported to be up to 50% higher for infants of adolescent mothers than for infants of women aged 20–29 years4, and their babies are more likely to experience physical5 and developmental issues6 adding additional challenges. Immaturity of adolescents also places them at risk, socially and medically7. Those living in rural areas, who are less educated, and poor are more likely to become pregnant, but are also the most ‘powerless’, making them more vulnerable than their peers8,9,10. Adolescents often experience profound psychological distress when pregnant, with some considering or attempting suicide11,12,13.

Much attention has been given to preventing or reducing adolescent pregnancy, but there has been less focus on improving experiences and outcomes. Engagement in care is important in reducing poor outcomes, yet this is likely to be influenced by the care being offered. In previous research, barriers to adolescents accessing antenatal health care in Zambia, have included poor staff attitudes and behaviours; being stigmatised by older pregnant women, and inflexible health facilities [opening hours, privacy, lack of adolescent-only clinics]14. A systematic review of care utilisation highlighted that adolescents are less likely to engage in care than older women; and emphasised the lack of high-quality research in this area15. A later meta-synthesis of qualitative studies exploring adolescent’s pregnancy experiences in LMICs16 suggested that care utilisation and experiences were greatly influenced by interactions with others and the perception of respectful care that they received. Others have highlighted the challenges adolescents have in accessing and continuing care17,18,19,20, some of which are related to social18,19,20,21 and economic difficulties22. Adolescent pregnancy rates are higher in rural than urban communities, compounded by early/child marriage, poverty leading to sex in exchange for money, limited availability of youth-friendly services (including contraceptives), and the celebration of early sexual debut23.

Many programmes have aimed at reducing pregnancy rates, yet less attention has been paid to supporting those adolescents who become pregnant16. Moreover, challenges with recruitment and consent processes have meant that adolescents24 have often been excluded from studies involving the wider maternity population. Even within studies focussing on adolescents, the younger age groups are rarely represented; this is partly due to researchers needing to navigate additional ethical review board processes and concerns regarding inclusion of minors25. However, the younger adolescents are likely to be the most vulnerable making it more imperative that their views are sought on experiences and care provision. Previous qualitative studies in Zambia have tended to focus on specific aspects of adolescents’ experiences, such as unintended pregnancy influences26, abortion27, impact on schooling28 and care-seeking behaviours29. Furthermore, the inclusion of fewer younger adolescents has been recognised as a limitation14. Thus, this study fills an important gap in the literature by developing a holistic understanding of the social processes that influence pregnancy experiences, drawing on multiple perspectives and age groups (females aged 13–16 and 17–19 years, male partners aged 13–16 and 17–19 years, health workers, key stakeholders and family members). Thus, the adolescent age range in our study was 13-19 years. The study objectives are (a) to understand adolescent care utilisation and experiences during pregnancy; (b) to understand the key influencers on adolescent experiences, and (c) to develop an explanatory theory that illuminates the experiences of adolescents during pregnancy.

Results

Demographic details

Of the 63 prospective participants approached, 10 declined. Demographic details of female and male adolescent participants can be seen in Table 1. Thirty-four adolescents participated, of which 18 were younger adolescent mothers (13–16 years), eight were adolescent mothers (17–19 years), four were younger adolescent fathers (13–16 years), and four were adolescent fathers (17–19 years). All participants stated that it was their first baby, and the pregnancy was unplanned. All delayed attending for care until the second or third trimester of pregnancy. The babies of participants were all birthed at ≥36 weeks gestation. Three of the partners had girlfriends less than 16 years. Ages presented relate to the age at interview. Additionally, eight female parents/legal guardians (median age 40 years, range 25–71 years), six health workers (one obstetrician, one medical doctor, one nursing assistant and three nurse-midwives), and five stakeholders (pastor, teacher, trader, mechanic and ward councillor) participated.

Table 1 Demographic details of adolescent females and males
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Categories

The core category Support me like a child, respect me like an adult demonstrates a stark juxtaposition, whereby female and male adolescents wanted their opinions to be valued and feel respected as prospective parents, but also sought supportive care and direction from others that acknowledged their youth and limited life experience. Health workers, parents and stakeholders, whilst acknowledging the susceptibility of adolescents, often accentuated their vulnerability through their communication and actions. Resilience was required from the adolescents to navigate their pregnancy journeys. The core category is supported by three themes, feeling vulnerable, lack of agency and autonomy and age discrimination (Fig. 1).

Fig. 1: Core category and main themes.
figure 1

illustrates the core category and main themes, with the arrows showing the relationship between them.

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Feeling vulnerable

All the female and male adolescents stated that they felt vulnerable on discovering the pregnancy and revealing it to others. They repeatedly used words like ‘sad’, ‘rejected’, and ‘alone’ during interviews and demonstrated disappointment at not receiving the assistance they needed. Their experience was presented in two ways; adolescents felt rejected by family, community and peers from whom they wanted to receive support, as a ‘child’; and were fearful of pregnancy consequences because of the disrespect and abuse that they anticipated they would receive.

Rejected by family, community and peers

Within the study setting, community views were paramount in shaping the actions of individual families. Being pregnant at a young age was considered taboo, and those that revealed their pregnancy received cruel treatment, regardless of their circumstances. Blame was usually directed towards the female, who was generally disrespected, particularly if she was of school age. One health worker summed up the views:

It does not matter whether this adolescent was raped. As long as it is an adolescent who is pregnant and not married, all they think of is promiscuity….. According to the community, these young women are supposed to be in school. When they get pregnant at this age they receive all negative attitudes from the community. [Chris]

Strong community values influenced how adolescents were treated by community members, family and friends. Many of the adolescents were removed from their homes to conceal their pregnancy creating disruption and instability and denying them the opportunity to complete their schooling. Instead of being protected by parents and supported to continue with pre-pregnancy activities, adolescents were often hidden away. Others were told they ‘brought bad luck to the family’. Happiness (age 15 yrs) said:

She [Mother] said she was embarrassed to stay with me and did not want her church mates to know she has an adolescent who was pregnant. Even the few times I have been at my mother’s place, she did not allow me to go outside. She could only allow me to go in the night and come back in the night for fear of her neighbours seeing me…I felt like an outcast.

One of the stakeholders, a pastor, confirmed the community punishment of individuals, who were ‘suspended’ from church engagement activities once the pregnancy was known. Varying periods of suspension were enforced, depending on the behaviour of the adolescent and any prior respect for community roles was negated:

That individual [adolescent female or male] is restricted from performing certain duties in the church. The individual is not allowed to give offerings, not allowed to offer a prayer in church, not allowed to sing in a choir. [Frank]

The narratives demonstrated the shame which was placed on the female adolescent’s family. It was suggested by health workers and stakeholders that the mother of the daughter was partly to blame for the pregnancy. Family hierarchy’s dictated that mothers should influence their daughters decisions and not to do so was an indication of poor parenting. As a consequence, a mother may also be treated badly by the wider community:

Adolescent pregnancy bring differences in homes. Fathers or husband in most cases pushes the blame on mothers or women. “You did not advise your daughter properly”, that is what they say. [Vicky, Midwife]

Not all parents wanted to abandon their daughters. Some mothers stated that they were disempowered to provide the support they wanted to give to their child, due to cultural constraints and power coercion. Being financially dependent was a particular constraint:

She stays with her boyfriend’s parents (looks down). Her uncle decided it, but I was not for the idea… I feel sad but there is little I can do. My Husband is the head of the house. All his decisions stand. Moreover, He is the one that buys food and everything I’m just a housewife. [Charity, Aunty, Legal guardian - 14 yr old]

Male adolescents were also displaced from their homes and endured devastating consequences for impregnating a young woman. Adolescents, like Elijah, recognised their own immaturity and need for emotional and finanacial support, but this was not always received:

I was chased from home by my parents after my girlfriend’s family reported that she was pregnant…I felt sad, desperate and disappointed with myself.…. My father said “If you can start impregnating women then you are a full grown man ready to fend for your own family”. I had nowhere to go so decided to go into the streets. I found a gang of street kids and I joined them. After two days, I became so hungry that I went to beg from the motorists. One of the motorists was my uncles’ friend…He got me in his car and brought me here [Uncle’s house]. [Elijah 16 yrs]

Whilst some adolescents left their schooling, others continued. Nevertheless, they experienced harassment and were often bullied by classmates. Some of the friends were under instructions from their parents not to liaise with pregnant adolescents, using fear tactics to enforce their rules. Unice, for example, wanted to ‘play’ with friends, whilst pregnant, but instead she was verbally abused:

My friends deserted me… One of my friends told me that her parents told her to stop playing with me because I was carrying a bad spell of pregnancy that could easily be transmitted to her and that should get pregnant as well soon. [Unice 13]

Although the teachers interviewed stated that their interest was ‘in the welfare of the girl child’, and aimed to be inclusive, their advice to ‘push on even when they face mockery’ [Charlotte], suggested a passive approach, which neither supported the adolescent or respected her feelings.

Fearful of pregnancy consequences

Being aware of the potential consequences of being pregnant led some adolescents to remove themselves from their homes, believing that they would receive punishment from their parents. Delaying revealing the truth about the pregnancy was a common ploy, and adolescents used various tactics to conceal their pregnancy, including wearing larger clothes, avoiding parents and staying at family members’ homes outside of the region. Marion (15 yrs), stated:

I decided to run away from home. I went to stay with my elder sister…. I was scared. I did not know how my parents would react when they discovered that I was pregnant. I did not know whether they would beat me or chase me from home.

Jane (13 yrs) went to her ‘aunties place because she is blind’. Like many of the adolescents, these delay tactics contributed to late booking into antenatal clinic (second or third trimester).

Male adolescents feared being prosecuted for impregnating a young girl under the legal age of consent to sexual activity, which is 16 years in Zambia. This fear prevented some of the partners from accompanying the woman to the clinic:

I wanted to accompany my partner [to clinic]. I even prepared myself but one of my neighbours told me that I will be taken to police for defilement because my partner was only 14 years. I got scared and stayed away. [Paschal 17 yrs]

The older male adolescents also feared their roles and responsibilities of being the partner of a pregnant woman:

The fact that we are young without any experience of pregnancy made me worried. I was wondering how I was going to handle a pregnant woman in my hands… [Fred 19 yrs]

Whilst the adolescents were fearful of their immediate future, their parents and guardians were equally concerned about their long-term plans:

I was so disappointed with her because we had so many plans for her, she was the only one who would have completed school, gone to college and also changed our lives. Blessed [grandmother of 11 yr-old]

Lack of agency and autonomy

Family and community hierarchy’s prevented adolescents from being respected as pregnant parents, as power dynamics dictated that they conformed to the wishes of others. Being pregnant removed adolescents’ control over many aspects of their lives. Adolescents were unable to decide whether or not they remained at school, where they lived or how they managed their pregnancy. For the latter, the lack of information and subsequent understanding was a real barrier to making decisions, meaning that they had to rely heavily on the knowledge and experience of others.

Lack of information

Most adolescents craved the support of their parents and those that received it were generally grateful, particularly for the information they received:

I didn’t know at what point one books for antenatal, my mother is the one who told me to start as early as possible to avoid been shouted at by health workers. [Angela 18 yrs]

However, they also wanted to be included in discussions regarding their pregnancy. When adolescents attended antenatal clinic, they often found that information was provided through others. For example, Rose (15 yrs) stated:

Some information was given to my aunt to tell me, like on how to take the drugs.

Some health workers were openly unsympathetic towards adolescents’ lack of knowledge or experience and would humiliate them for their lack of understanding. Jane, a 13-year-old, recounts her experience of attending antenatal clinic, demonstrating how her young age was used as a weapon for issuing abuse:

I did not know what was expected of me when I go for antenatal. So, when it was time for me to be examined, I did not know that I have to expose my abdomen and lie on the couch. When my name was called, I went in and stood waiting to be told what to do. The nurse said “do not waste your time and our time. If you do not know what you have come here for”….one health care worker said “I do not have time to waste by explaining things to someone who is not supposed to be here. Her place is school, and I am tired of these small girls getting pregnant”.

Some participants, who wanted to learn more about pregnancy and birth, were concerned that the information was not tailored to their level of experience, meaning they were left with a superficial understanding. Adolescents never referred to themselves as adults but wanted to receive equitable respectful care:

When the midwives were teaching us, they just picked the main points. To adults who had knowledge already, it was well for them. To us young ones, it was not okay. We needed to learn in detail so that we have the knowledge and understanding. [Fred 19 yrs]

Others had a better experience stating ‘The nurses would answer all my queries. They had time for us. [Sarah 14 yrs].

Reliance on others for direction and support

Attending the antenatal clinic was a significant milestone for adolescents, but, in the main, they wanted advice and support to do so. Most adolescents were happy to defer to others regarding decision-making, partly because they did not have the information on which to make the decision, but also, they wanted an advocate who would support them:

I was happy when my guardian told me, “Tomorrow you have to wake up very early in the morning. We need to be at the health facility on time”. I then asked her if she was going to escort me, she said yes! I was very happy…. When we went for antenatal, my guardian was with me all the time. She explained everything to the nurse including the anti-retroviral. I was so glad that it was not me doing all the explanations. [Catherine 13 yrs]

Many of the adolescents were too afraid to ask questions of health workers, thus relied on the person accompanying them to do so, such as Rose (15 yrs) who said she ‘was too shy to ask questions and I did not know what to ask’. Some relatives took control of the situation, to ensure that they actually went to the facility and also took the advice given to them, stressing that they ‘needed an elderly person to escort her’ [Dorcas, sister of 16 yr-old]. Amie, a mother of a 15-year-old stated:

She may not take the lessons and advice given at antenatal seriously. When I am there with her, I would be able to emphasize to her and encourage her to follow the advice given. Sometimes with that childish mind these girls may not reach the healthy facility when they leave home alone. They will just go to their friend’s place and start chatting.

Health workers generally related the need for support at appointments to be a legal requirement in case of consent issues:

They need to be accompanied by a parent or guardian as they seek health services…. certain procedures that need to be done should be done in the presence of a parent or guardian because some of them are not of age to give consent for themselves. [Chris]

Age-discriminating behaviours

Evidence of age discrimination was prevalent throughout the narratives of participants, presenting itself as humiliation and abuse, and resulting in age-discriminating care. Adolescents were cogniscent of being regarded as children, and often defined themselves this way; this was not an issue to them. However, instead of receiving the compassionate and supportive treatment one would expect, as a child, they were often victimised. The fact that they were pregnant and considered a child gave others unspoken and unchallenged permission to be disrespectful.

Humiliation and abuse

The humiliation of adolescents commenced as soon as it was revealed that they were pregnant. In the classroom, adolescents often experienced significant and persistent bullying that they were not prepared for. Some stated that they hoped the teachers would intervene, but this did not happen; they received no protection, as a child. Some adolescents did not have any environment in which they felt safe and supported:

One day a boy in my class drew a girl with a big tummy on the board and everyone laughed. I felt like crying and stopping school but then being home was equally horrible. [Happiness 15]

Although there were some instances of physical abuse from parents, reported in the form of ‘hitting’ and ‘slapping’, much of the abuse was verbal. Angela, an 18-year-old stated:

My mother and grandmother took turns in shouting at me. Children from our neighbourhood came and started laughing at me. it was the most embarrassing and humiliating day of my life.

Males also experienced verbal abuse from the wider community, particularly in the antenatal clinic:

I was so humiliated…we were a lot of men at the antenatal, but no one was treated the way I was treated. I went with my school uniform, and they [pregnant women] started laughing at me. [Elijah 16]

A few adolescents had positive experiences of antenatal clinic attendance, but this tended to be those from the older age group:

We looked a young couple, but they did not take advantage of us to demean us in any way. They actually welcomed us and made us feel at home. We interacted well with nurses and doctors. [Fred 19 yrs]

For many, antenatal attendance was a traumatic experience, with adolescents observing the inequity of care provided to them by health workers compared to older women:

The health care workers were smiling to other women. They were gentle when speaking to them too. why was I not treated like other older women? It is because I was young, and I could not do anything. [Grace 14]

This was also witnessed by the accompanying parents and guardians:

when we just arrived for the first visit, the women we found murmured, one health worker said “this small girl is pregnant?” I feel that was verbal abuse. I could see that my niece was uncomfortable… [Charity, Aunty – 14 yr old]

Some adolescents referred to themselves as ‘girls’ or ‘children’ and wanted this to be acknowledged by the health workers and treated accordingly:

Two midwives came and greeted everyone. “Women, how are you?” But I was not a woman. That group comprised of women and girls. How can they just greet women? (looking away). [Jane 13 yrs]

Adolescents wanted to be treated by someone who they could relate to, who was empathetic and acknowledged their young age but also treated them kindly and with respect. Evidence for compassionate and supportive care was often lacking in the narratives, although it was possible, as evidenced by Edith (17 yrs):

The nurse I found looked young. She was good to me. She encouraged me to go back to school and continue with my education after giving birth. She said she also had two girl children. She used to handle me well. She did not shout at me or use any bad words.

However, infantilising adolescents as a way to admonish them, was also considered unacceptable:

When I told the nurse in the waiting room my age, she began to treat me like a young girl. She was talking to me like an 8-year-old girl.…The nurse told me that I was too young to get pregnant. [Cheryl 15 yrs]

Participants from all sample groups urged organisations to reorganise their services to provide specialist care for adolescents. This is summed up by Rose:

I would want to be treated with respect, I also want to live in a society where people accept that an adolescent is also a human being who can fall pregnant. I am tired of walking in shame at the clinic. If space is not enough for adolescents, I suggest they a put a day when adolescents can go for antenatal reviews. [Rose 15 yrs]

Others also requested this, as a way of protecting the older women from ridicule, when the health workers shout at them in the presence of the younger women. Angela (18 yrs) stated it felt ‘so weird when a health worker is shouting at an elderly woman in our presence’.

Age-influencing care

Being pregnant as an adolescent influenced the care received by most of the participants. As the majority of adolescents did not have a partner with them, they were often seen last by the health worker. Discrimination, based on whether or not a partner was present, was a source of frustration for participants, who were angry that individual circumstances were not considered when ordering patients to be seen:

I feel that is not good because circumstances in which we get pregnant are different. There are young girls who got pregnant after being raped. Others were impregnated by other women’s husbands. For others, their partner died and others they refused to be responsible. Where do these women manufacture partners to escort them to the hospital? [Livuka 18 yrs]

Others stated that health workers should adapt their language in the presence of a mixed age group of women, to comply with cultural expectations and norms. In particular, adolescents were not happy discussing reproductive health issues in the company of women they considered to be their elders:

When they were teaching about danger signs in pregnancy, they mentioned the vagina. You know, mentioning such parts in our local languages is an insult and sounds heavy. I felt shy as though I could just open the ground and get buried.… [putting her hands together]. I was just too young to be found in that discussion together with older people the age of my grandmother. It is a taboo to talk about sexual issues in an open space like that and in a group of people of a mixed age group…. In African culture, it is a taboo as I said. In our communities, discussions of sexual nature are very sensitive and are handled by elderly women who should be a very close relative. That is our culture, and we follow it as a way of life. [Cheryl 15 yrs]

Amie, the mother of a 15-year-old, reinforced the need to tailor language for younger women:

They [adolescents] think like a child. Some messages and topics are not for their ears. They would feel shy to express themselves in the presence of adults.… We are Africans and we live and follow African tradition. I cannot discuss sexuality topics with my daughter.

It was suggested that older woman were also uncomfortable in the presence as adolescents in clinic. Sally (15 yrs) recounted a situation whereby an ‘elderly woman’ got a question wrong during a health education session and the young women laughed at her.

Some adolescents believed that they were treated differently because pregnancy at their age was considered related to promiscuity:

People in the world today think that any youth who becomes pregnant is promiscuous. It was for this reason that they took us to that room and started asking us about HIV and syphilis. I do not think they would ask such questions to an elderly couple. [Christina 15 yrs]

Health workers acknowledged the need for ‘social and psychological support’ in addition to ‘close monitoring’, but some blamed adolescents for the treatment they received, as they were ‘un-cooperative’. Health workers all recognised that care was insufficient for adolescents and there was a need for specialist antenatal services. Age-appropriate forums were suggested by Rhona (Midwife) such as ‘radio and community drama groups’, and a dedicated ‘adolescent contact person’. Other health workers suggested that the provision of tailored support for adolescents was not practical within a resource-stretched health system.

Discussion

This study aimed to explore the social processes that impact on adolescent pregnancy journeys, in Zambia. The narratives demonstrated a complex interplay of social behaviours that influenced their experiences, illuminating the challenges they faced when trying to navigate unfamiliar systems and hostile communities, whilst adapting to their pregnancy. Adolescents wanted their age to be acknowledged, as a catalyst to receiving the information, engagement and support that they craved, recognising their own vulnerability. However, for most adolescents this did not happen. Instead, their age was used against them, presented through rejection, humiliation and abuse, exclusion from decision-making, discrimination and the need for reliance on others.

Although we generated themes iteratively and grounded in the data, we realised during the analysis, when transitioning from axial to selective coding, that the findings were aligning with Bronfenbrenner’s socio-ecological framework30. This framework became a useful theoretical lens in which the core category could be viewed, assisting understanding of the factors impacting on the social interactions that took place (Fig. 2). The core category ‘Support me like a child’ which reflects a desire to belong, be nurtured, and guided, and ‘Respect me like an adult’ which reflects a desire to receive equitable care which is free from humiliation and abuse, is evident at each level of the sociological framework.

Fig. 2: Model of influences and experiences.
figure 2

Figure 2 illustrates the multi-layered factors (Bronfenbrenner’s socio-ecological framework32 shown in circles) impacting on the social interactions adolescents encountered during their pregnancy journey. Whilst they sought a supportive environment, their age resulted in them being discriminated against, making them feel vulnerable and lacking any agency and autonomy. Adolescents craved caring support and guidance and acknowledgement of their young age (like a child), but also wanted to receive information and be involved in decision-making (respect me like an adult). Resilience was needed for adolescents to navigate their pregnancy.

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The micro system level involves those individuals that adolescents closely interacted with, including parents, families, friends, health workers and teachers. Whilst a few of the adolescents were supported by family and received empathic care in the health facility, these were a minority, with dominant socio-cultural influences, and gendered power imbalances contributing to a feeling of being alone and disconnected from prior social environments. The ‘actors’ within this study behaved in a way that was expected of them within their social circles, even if this went against their personal desires, resulting in a lack of respect for the adolescent. Stigma was a particular driving force, a factor identified in a study conducted in a similar setting, Uganda, which called for stigma-reducing actions31.

At the mesosystem level, the environments of school, hospital and home should have been places where adolescents felt secure; however, this was not the case, hence the core category ‘support me like a child’. From the narratives, it appeared that there was little interaction between the three systems, which, during pregnancy, were experienced as unpleasant environments. Most female and male adolescents lacked agency, resulting in decisions being made for them, such as being made to leave their family home either temporarily or permanently; this created instability and distress. By exploring the views of those in contact with adolescents, we were able to highlight the patriarchal and socio-cultural drivers of these actions. The hospital environment was particularly hostile, and provided inequitable and disrespectful care to adolescents; a factor regularly reported16. Previous work suggests that more specialist services, that are tailored to individual adolescent’s needs, are more likely to result in positive experiences32,33,34. However, as noted in our study, the lack of resources and staff shortages make this challenging to operationalise. Schools also failed to offer adolescents the security they needed, which was a source of disappointment to those who attended and wanted to maintain their childhood identity.

At the exosystem level, peer groups, the church, and wider community undermined the adolescents who were denied a sense of belonging, making them feel vulnerable. Belonging is fundamental to social wellbeing35, but was not initially afforded to many adolescents. The open and direct criticism directed at adolescents tended to be cruel and unanticipated, showing a lack of respect not afforded to adults. The adolescents knew that being pregnant at a young age was outside socially accepted boundaries, and believed there would be some negative consequences, but some thought that being a child (which many referred to themselves as) would result in them also being nurtured.

At the macro layer, cultural values, social norms, societal beliefs and national policies had the greatest influence on the individuals, organisations and environments in which the adolescents existed. Participants were highly influenced by societal expectations and often referred to the ‘African culture’ in justifying their behaviours. In our study, socio-cultural drivers resulted in abandonment of daughters and sons, rejection from the church, mistreatment of the adolescent and non-acceptance of open reproductive health communications. This latter point has been well described in other qualitative studies that highlight the taboo nature of parents discussing reproductive health issues with their children36,37. The core category sums up the situation as adolescents were viewed as a child but not supported like one, and were not afforded the same respect those considered pregnant ‘adults’ would receive.

Importantly, Bronfenbrenner’s later addition to the framework38, the chronosystem, was relevant to these findings. The chronosystem refers to the influence of timing of an event during a person’s development, with potential for profound impact. This was true of all pregnant participants; none had planned the pregnancy, and all believed they were too young to experience childbirth. The findings of others39 who explored risks to poor perinatal resilience, resonated with the adolescents; these included poor relationships, social isolation, disengagement from the community, fear of being judged, and low self-esteem. However, over the duration of the pregnancy, our participants demonstrated signs of resilience. This arose mainly due to greater social connectedness, once they had become established in an environment in which they could safely move forward with their pregnancy. It is well known that inadequate support and social isolation is associated with lower resilience40, and all adolescents experienced this to some degree. Nevertheless, they demonstrated a degree of resilience in different ways, including maintaining the pregnancy (only one considered abortion but did not go through with it), attending school despite being bullied, attending four or more antenatal visits (despite having to endure humiliation and disrespect) and navigating health service processes.

The strengths of this work lie in the exploration of experiences from different vantage points, the richness of the data and the inclusion of adolescent females and males of different age groups, residing in rural and urban settings. The study created a community engagement and involvement group of adolescents who were able to access those who would ordinarily not opt into research; we were therefore fortunate to include the younger age group of participants, and male adolescents, adding to our understanding. Male adolescent views were particularly important, as much of the previous literature has focused on female perspective; within the study context, the notion of pregnancy being ‘woman’s business’41 makes this sample group particularly challenging to recruit.

Although we only explored views from one region in Zambia, we were able to determine potential transferability of findings when disseminating them to women and health workers from other parts of sub-Saharan Africa. We were not able to confirm the actions described by adolescents, for example, in observations, but believe that their views, as expressed, represent their own positionality based on how they experienced their pregnancies.

There are several recommendations that can be made from these findings. Firstly, there is a need to dispel myths around unintended adolescent pregnancies. As highlighted in the findings, individual circumstances led to the pregnancies, some of which were out of the control of the individual (e.g., rape). Nevertheless, adolescent pregnancy was viewed as synonymous with promiscuity, evil spells and bringing bad luck to the family, by peers, friends, family and communities. These responses encourage pregnancy concealment and prevent access to care and contraceptive use. Secondly, adolescents need to receive appropriate information in accessible formats and language, which consider their immaturity, to be able to better engage in decisions regarding their pregnancy. Some adolescents, who were abandoned by families, had to assume responsibility for their health and were not equipped to do so due to lower levels of health literacy. This is important as lower health literacy levels are associated with heath inequalities that may lead to poor outcomes42, and are likely to contribute to delays in accessing antenatal services. Thirdly, as suggested by all sample groups, there is a need for tailored ‘adolescent-friendly’ health services. Many of the adolescents were anticipating disrespectful care from health workers because of their young age; sometimes their expectations were met. As suggested by participants, services could include adolescent support groups, peer-peer support networks, separate clinics, tailored communications and dedicated health personnel. Fourthly, families may also benefit from external support. Mothers often wanted to support their child but felt powerless to do so due to pressures from their husband, wider family or community. Support services for these women may have been helpful. Finally, training and clinical mentoring of health workers on how to support adolescents in a respectful away that is equitable to that given to adults is imperative. This should include how to be welcoming, engaging with them as independent individuals (rather than talking through a guardian), using appropriate language, and not chastising them for being pregnant. Health workers need to acknowledge the adolescent’s age and associated needs, whilst providing an inclusive and supportive environment in which they feel cared for whilst also being respected for their own positionality and decisions. However, any interventions to improve the experiences of pregnant adolescents need to be subjected to rigorous evaluations, informed by appropriate theory. Exploring ways of reducing vulnerability, using resilience theory may provide a meaningful framework to underpin such work. Individual interventions may have limited impact. Therefore, development of interventions that connect the environments of school, home and hospital, may be a way of improving adolescent support. There is limited evidence, from LMICs, on the most effective and culturally acceptable interventions to enhance experiences and improve outcomes for pregnant adolescents; this is a critical area for future research.

Methods

Research design

We drew on grounded theory techniques, informed by symbolic interactionism43, to enable understanding of the impact of social interactions on participants’ views and experiences. Grounded theory is an approach aimed at developing a theory directly from data that has been systematically collected, as opposed to a priori assumptions, and analysed using a comparative technique44. Using these techniques enabled a deeper understanding of adolescent experiences from multiple perspectives, moving beyond simple descriptive accounts towards the development of theory45. The Straussian approach was used45 to enable an iterative and inductive process, that rejects a fully objective stance and encourages researcher reflexivity. This is important as all researchers on the team were health care providers, unable to fully ‘bracket’ their prior knowledge and understanding; this was revealed to the participants.

All data involving human participants in this study were approved by Liverpool School of Tropical Medicine (LSTM) Research Ethics Committee reference 22-007 and the University of Zambia Biomedical Research Ethics Committee reference 2958–2022 and were conducted in accordance with the ethical standards and regulations outlined in the Declaration of Helsinki.

The study took place in two university teaching and referral hospitals in Lusaka, and five level one facilities in surrounding rural areas in Zambia.

Participants included female adolescents (primigravida and multigravida, those experiencing live birth, stillbirth or neonatal death), male adolescents, health care workers and relevant stakeholders and family members or legal guardians. None of the participants were known to the researchers. Although female adolescents were the primary focus of the research, it was important to understand wider support mechanisms, relationships and interactions associated with their pregnancy. Thus, an initial purposive sample of three participants were recruited in the following groups:

  • Female adolescents aged 17–19 years, who experienced maternity care.

  • Female adolescents 13–17 years, who experienced maternity care.

  • Male adolescents 19 years and under who experienced maternity care.

  • Health care workers [midwives/nurses, obstetricians, support workers] who actively engage with adolescents.

  • Key stakeholders [teachers, community leaders].

  • Family members or legal guardians of adolescents who experienced maternity care.

Following purposive sampling, theoretical sampling commenced. Analysis of the initial data resulted in a number of ideas, concepts and patterns such as those related to age discrimination, community influences, and decision-making which needed confirming or refuting. These concepts directed the recruitment strategy towards participants in the younger and older age range, those with higher levels of education (secondary) and adolescents with partners. The external influences on pregnant adolescents’ experiences directed sampling of a wider range of stakeholders and an additional five parents/guardians. Data saturation was confirmed when there was a lack of new information and replication of existing data was observed.

Recruitment and consent

Two trained research assistants (both registered midwives), who had worked with the team previously and were working towards a master’s qualification, carried out the recruitment. The process was informed by a Community Engagement and Involvement group (CEI), comprising 12 young women aged 20–23 years who had experienced pregnancy as an adolescent. The CEI group reviewed the information sheets and suggested amendments to wording to improve understanding. They also provided guidance on how to approach younger adolescents and their parents, including the use of sensitive language. The CEI group also suggested that a male researcher would be more acceptable to male adolescents; a male researcher was identified. Postnatal adolescent women with a live birth, stillbirth or neonatal death and male partners were recruited in the hospital postnatal ward or follow up clinic by a researcher after initial contact was made by a clinician. Written and verbal information (in local language) was supplied, and potential participants were given up to 4 weeks to consider participation. Written or witnessed thumb print consent was obtained for those who agreed to participate. For adolescents less than 18 years, parental consent and written adolescent assent were required.

Family members were recruited through the female adolescents. Health workers were recruited from the local health facilities via posters in the clinical area which displayed contact details to enable opting in. Stakeholders were recruited verbally, through known sources, and contact information provided (using a consent to contact form) to allow individuals to opt into the study.

Methods of data collection

Data were collected in the form of structured demographic details and in-depth, semi-structured interviews, between one and six weeks post birth. Field notes and memos enabled understandings to be contextually grounded. Given that the researchers were midwives, an open stance was sought, and reflexivity maintained throughout, to ensure theoretical sensitivity46. Women, partners, and family members were interviewed in local language. Health workers and stakeholders were given a choice of local language or English. Demographic details were collected at the beginning of the interview, to contextualise findings. Interview topic guides were informed by previous literature and CEI members, resulting in broad areas of inquiry. In keeping with grounded theory45, the interview topic guide contained minimal questions to promote respondent-led direction. Each interview commenced with an opening question, such as: ‘What has been your experience of pregnancy?’. Additional, individualised questions were then introduced to explore further the unique accounts provided by participants47. New insights were then followed up in subsequent interviews for confirmability. Participants were encouraged to provide their own narratives, in their own way, without the influence of others. Interviews were audio-recorded, lasted between 30 and 90 min, and took place at a location chosen by the participant (home, community location, hospital facility or clinic). The interviewers kept field notes to capture nuances within the interview process and to document non-verbal communications. Recapping took place at the end of each interview as a form of member-checking. Data collection and analysis occurred simultaneously, using an iterative approach.

Data analysis

The grounded theory approach32 informed data management and analysis, and included three stages of coding: open, axial and selective. An example of coding can be seen in Table 2.

Table 2 Example of coding
Full size table

Open coding

KT, and MDH conducted the open coding. Prior to open coding, individual interviews were transcribed verbatim and read in their entirety for familiarisation. Interviews conducted in local language were translated into English and back translated for confirmability. Line-by-line coding was conducted manually on the actual transcripts, by writing codes in the margins. Properties (e.g., age discrimination) and dimensions (e.g., discriminatory behaviours, prejudice) were explored by systematically examining the whole transcript and its parts, ensuring authenticity. Open codes were then entered onto an excel spread sheet for review by the whole team during fortnightly meetings. Findings discussed in these meetings directed the theoretical sampling.

Axial coding

KT, CB, and TL began the process of axial coding, which was then discussed with the remaining authors. Memos were used to capture a decision-trail. The axial coding involved constant comparison48, starting with the female transcripts, then working between different transcripts and sample groups, to identify any relationships within and between them. In a systematic and cyclical process, codes were clustered into initial sub-categories, according to their commonalities, following team discussions. Highlighter pens, sticky note pads and an excel spread sheet, enabled visualisation of the relationships between codes and confirmation of final sub-categories. During the constant comparison process, it became clear that the emergent theory was aligning with Bronfennbrenner’s socio-ecological model30,38, which asserts that there are multiple layers of interconnected influences, and has been used by others in similar contexts49,50. Thus, this model was used as a theoretical lens through which the sub-categories and categories could be explained in a way that acknowledges the multiplicity of influencing factors on adolescents’ experiences, thus enhancing theoretical sensitivity. This was not an a priori decision, but one that enabled a theoretically informed analysis whilst using grounded theory techniques.

Selective coding

Selective coding was conducted by KT, CB and TL through a cyclical process of reviewing and refining the open and axial coding and establishing the most meaningful central concept related to the research aim and observed coding patterns44. Through review and team discussions, a core category was identified which was consistent with the data and offered an authentic story line to provide understanding of the phenomenon.

Rigour was maintained through member-checking, a transparent decision-trail, multiple analysts, external confirmability (through CEI members) and presentation of quotational evidence. Pseudonyms, assigned by the researchers, are used in the presentation of findings.