Abstract
A study of the opinions, attitudes, behaviors, experiences and socio-economic profile of three groups of teenagers (currently pregnant, mothers and FP clients who had never been pregnant) was conducted using self-administered questionnaires. The objective of the study was to obtain information on the reproductive health needs of Seychellois teenagers in order to facilitate provision of user-friendly services. This study, based on teenagers attending reproductive-health-related clinics confirms findings in other similar societies that contraceptive awareness does not guarantee use. The partners of those who are the youngest, and thereby most at risk, are often adult men. Respondents clearly felt that parents should be primarily responsible for sexuality education. The behavior of the teenagers who became pregnant was significantly closer to their perceived behavior of their peers, while the FP clients' behavior was significantly closer to what they thought was right. (SMDJ, 1999;6;11-15.)
Introduction
It has been estimated that worldwide, over half of all teenage girls have their first sexual experience before they reach the age of 20 (1). Patterns and trends in teenage sexual behavior vary between and within regions and countries but households headed by young single mothers have increased even in countries, such as those in Latin America and the Caribbean, where sexual activity among girls under 20 appears to have fallen or remained stable (2). Over the past 15 years in Seychelles, there has been a clear fall in fertility among women in all age groups between 20 and 45. However, between 1982 and 1996, the age specific fertility rate (ASFR, the number of births per year per 1000 women in a specific age group) for young women aged 15 to 19 did not fall convincingly, fluctuating between 59 and 78 per 1000 (3,4).
This study was conducted in order to obtain a profile of teenage mothers and those who were currently pregnant at the time of the study, including information regarding their reproductive health-related attitudes and behavior and their experiences of education, health, social and pastoral care. This profile is compared with that of teenage FP clients who have not experienced a pregnancy. It was hoped that this study would provide some of the required information on the reproductive health needs of teenagers in Seychelles to enable government and its partner agencies to provide more effective services for them. In this article, the terms teenage, adolescent and young person, are used in accordance with the accepted WHO definitions.
Background
The teaching of Family Life Education (FLE) as a specific time-tabled subject began in 1980. The implementation of the curriculum has not been totally satisfactory largely due to a shortage of trained teachers and a lack of commitment on the part of the schools to make full use of the recommended programs. The FLE curriculum, and the training offered to those who teach it, has recently been reviewed with a view to improving the quality and appropriateness of the materials used and the capacity of teachers responsible for this area of the curriculum (5). FLE has now been incorporated into the broader Personal and Social Education (PSE) program in primary and secondary schools.
Health care
Family planning (FP) services are available at every district health center. Clients may seek FP services at the health center of their choice, not necessarily the one where they live. However, anecdotal evidence suggests that many of the staff at the health centers are not comfortable about providing contraception to young women under 18 because of perceived legal constraints, lack of clear Ministry of Health guidelines and/or personal beliefs. If the young woman has experienced a pregnancy, there is much less discomfort about providing contraception. The Youth Health Center, near the capital, can provide young people with professional counseling, referral to other professionals and condoms but not other methods of contraception.
Teenage fertility
In 1996, it was estimated that there were 3643 young women aged 15 to 19 in the country. In that year, the ASFR for this age group was 63/1000.Mothers under 20 had 14.5% of all births and 33% of first births. Of the 1611 births registered in 1996, only 5 births (0.3%) were to mothers aged under 15 while 228 (14.2%) were to mothers aged between 15 and 19.Of the 228 births, 206 (90.4%) were first births and 22 (9.6%) were second births (4). No teenagers had a third baby in 1996 but in 1995, 7 teenagers did so. In that year 79% of all births occurred out of formal wedlock and 29% were not legally acknowledged by the father, while for teenagers, the figures were 95% and 44% respectively. (3).
The sharp decline in the ASFR for young women aged 15-19, from 119/1000 in 1980 to 76/1000 in1982 (6) was probably related to the introduction of the National Youth Service and the expansion of the Seychelles Polytechnic. There has not been a further sustained fall in teenage fertility since then. Using figures supplied by the relevant government offices (3), the author has calculated that at least 4% of girls aged 16 in 1995 dropped out of school because of pregnancy.
Figures from the hospital show that 75 teenagers were admitted for some sort of abortion in 1996, of which 33 were therapeutic and the remaining 42 spontaneous or illegally induced. The latter were induced outside the hospital and then required hospital treatment. Therefore 24% of all recorded pregnancies among teenagers ended in induced or spontaneous abortion. There is no record of how many teenagers had abortions that did not require hospital admission.
The number of teenagers registered as FP clients at the health centers in 1996 was 433 (7), while about another 34 were registered with the 3 private practices in the country (8), altogether accounting for 13% of young women aged 15-19.FP nurses supported the author's estimate that about half their teenage FP clients had already experienced a pregnancy. In addition there was an unknown number of teenagers who used condoms which they, or their partners, obtained without having to register as FP clients.
Study design
The 3 categories of participants in the study were:
Mothers aged 13 to 19 attending district child health clinics with their children: 45 respondents were included in this category. Thirty-four of the young women had babies under 1 year old, accounting for 15% of all teenage mothers with infants. Pregnant 13- to 19-year-olds attending antenatal clinics: There were 40 of these (17 attending the 7 district health centers providing antenatal care and 23 the main hospital antenatal clinic), representing 17% of teenagers delivering in one year.
FP clients aged 12 to 19 who have never been pregnant: 46 girls/young women attending district FP clinics in September and October 1996 agreed to participate in the study but one had had an abortion so only 45 were included in the study, representing over 20% of girls/young women in this category.
A convenience sampling method was used: starting in September 1996, the nurses working at the above clinics were supposed to ask each teenage woman/girl attending their clinic if they would participate in the study until they had obtained the prescribed number of participants from their clinic. The number required from each clinic depended on the size of the clinic. Most clinics recruited the required number of participants within 3 months. However, one clinic took 6 months because the staff only recruited participants when they were not busy.
Participants were asked to fill in a self-administered anonymous questionnaire on the spot, which took between 30 minutes and an hour to complete. There was a different questionnaire for each of the 3 categories. Each question was asked in both Creole and English and answers could be given in either language. Development of the questionnaires was guided by a review of questions used in studies covering similar topics in Seychelles, Mauritius and the UK (9,10,11,12) and by the findings of focus group discussions conducted in March 1996 with a group of 5 teenage mothers and a group of 7 pregnant teenagers. These girls/young women, and 5 other teenage mothers, also filled in trial questionnaires. While all those who were invited to participate in the study agreed to do so, there was potential for bias with regard to which girls/young women were invited to participate.
The data were coded and then computerized on FoxPro. Epi Info was used for the analysis. Results included simple percentages, mean values and chi-square tests. The sample size did not allow for meaningful multivariate analysis, so only univariate analyses were carried out and the existence of the most obvious confounding variables is pointed out.
Results
Where there is no significant difference between the responses of the pregnant teenagers and mothers and the responses of the FP clients who had never been pregnant, the findings are given for the participants as a whole. Almost all the girls said they found the questionnaire interesting and/or useful and 80% said they would be interested in participating in a follow-up activity.
Socio-economic characteristics
The mean age of the pregnant teenagers, teenage mothers and teenage FP clients was 17.4, 17.5 and 17.8 years respectively. However, the majority were over 18: 47(55%) of the mothers and mothers-to-be and 28(62%) of the FP clients. FP clients were somewhat more likely to have been brought up by both parents than the mothers and expectant mothers but the difference was not statistically significant. Overall, 49% of all the study participants were brought up by both their natural parents, 34% by their mother alone, 8% by their mother and a relative or stepfather and 8% by a relative or other person. The mothers and mothers-to-be were significantly more likely than the FP clients to have a sister who had had a teenage pregnancy.
Only 4 (3%) of all the respondents were married: 2 of them pregnant, one a mother and one a FP client. While 87% of FP clients lived with their family and 16% with their partner, the mothers and mothers-to-be were equally divided between their biological families and their partners.
All the respondents had completed primary school and had at least started secondary school. Among the pregnant teenagers and mothers, 41% had completed secondary school and 9% had completed polytechnic or vocational training, while 86% of the FP clients had finished secondary school and 46% had gone on to complete a polytechnic course. Table 1 shows the mutually exclusive categories of "employment" are ‘student’, ‘employed’ and ‘unemployed’.
| Table 1. Percentage distribution of "employment" status of participants | |||||
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| Mothers/pregnant teens (N=85) |
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| FP clients (N=45) |
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Girls in Seychelles who become pregnant while still studying and are then unable or unwilling to return to school are at a distinct disadvantage when it comes to seeking employment because most of their compatriots have completed secondary school and obtained some further qualification. Also, any job they get is unlikely to pay more than the amount they would have to pay for a child-minder, travel, work clothes, etc. Hence it is not surprising that three quarters of them are unemployed. Over a third of them said they would like more education and training.
Sources of information and education on sexuality and FP services
The response to the question, ‘Where and from whom did you get information on sex?’ is summarized in Table 2. With 2 notable exceptions, the answers given by the pregnant teens and mothers were similar to those of the FP clients. The exceptions were for teachers and books and the differences are indicated in Table 2. This may reflect the longer period in school of those in the FP group. Of the 10 who ticked the ‘other’ option, 6 specified that the ‘other’ referred to a nurse or nurses.
| Table 2. Percent of study participants who received information on sex from different sources (N=130) | |
| Information source | Percent who received information from the source |
| Boyfriend | 47 |
| Teachers | 46 [FP: 67/others: 35*] |
| Books | 42 [FP: 58/others: 34**] |
| Parents | 36 |
| Friends | 30 |
| TV | 28 |
| Magazines | 26 |
| Radio | 20 |
| Church | 5 |
| Other | 8 (nurses: 5) |
| No answer | 4 |
| * Difference significant at p<0.001.
**Difference significant at p<0.05. |
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Only 35% said they thought the information was adequate. In answer to questions about how much information they would have liked before starting a sexual relationship, 60% or more of the respondents said they would have liked more information than they were given on contraception, sexual intercourse and making decisions, as well as on STDs, HIV/AIDS, pregnancy and standing up for their rights.
When it came to the question of who should be responsible for sexuality education in general, it was clearly felt that parents should be primarily responsible, although most respondents also believed that teachers, the media, church and friends should also contribute to some degree.
Most respondents said they would prefer to receive information about sex and contraceptives from nurses or doctors, but parents were also a preferred source for over a third of them and FLE teachers for over one in five. These responses fit with the responses to the question about activities that might help young people learn about contraception. The most popular choice of activity was one-to-one counseling, followed by videos/pamphlets and then group discussions.
When the study participants were asked where they would like to receive contraceptive advice and counseling from, the most popular choice was ‘family planning clinic’ (72%), followed by ‘health center’ (38%), ‘hospital’ (19%) and ‘Youth Health Center’ (17%). Fewer than 10% chose ‘school’, ‘student welfare unit’ and ‘private doctor’, while fewer than 5% chose ‘private pharmacist’ and ‘community center’.
First sexual intercourse and first pregnancy
All the participants were asked at what age they thought most girls start having sex and what they think is the right age to start. Further on in the questionnaire they were asked at what age they started themselves. The mean age at first sexual intercourse for the pregnant teens and mothers was 15.5 years, while for the FP clients it was 16.8 years. This difference was not significant for the sample sizes in this study. However, the behavior of the teenagers who became pregnant was significantly closer to their perceived behavior of their peers, while the FP clients' behavior was significantly closer to what they thought was right (Table 3).
| Table 3. Responses to questions about perceived age at which most girls start having sexual intercourse, respondents' age at first intercourse and 'right' age for first sex | |||
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| Mothers/pregnant teens |
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| FP clients |
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The younger the respondent was at first sexual intercourse, the greater the age difference between her and her partner was likely to be. Analysis for all the respondents together showed that the mean age difference with the first sexual partner was 6.5 years for girls who were aged 15 or under at first sex, whereas for young women aged 16 or over at first sex, the mean age difference was 4.4 years (difference significant at p<0.01).
Although 71% of the pregnant teens and mothers said they had wanted to have sex with the baby-father (the biological father of their baby), 67% of them said that they did not think they were ready for their first sexual intercourse and only 19% wanted a pregnancy. Almost half of them (47%) said they started having sex because of pressure from their boyfriend, compared to 24% of FP clients (difference significant at p< 0.01). This difference between the FP clients and the teens who had had a pregnancy was probably partly related to the difference in age at first sex between the two groups (47% of teens who were aged under 17 at first sex said they started having sex because of pressure from their boyfriend, compared to 28% of the young women who were older at first sex (difference significant at p<0.05)).
The mean age of the respondents at first pregnancy was 16.5 years, while 85% of the baby-fathers were in their twenties. Also, the younger the age at which the respondents became pregnant the greater the age difference with the baby-father was likely to be. For teens who became pregnant at age 16 or less, the mean age difference was 8 years, while for young women who became pregnant at age 17 or over, the mean age difference was 5.3 years (difference significant at p<0.01).
The above findings may be a reflection of the relative ease with which a young teenager can be persuaded to act against her better judgement when there is an imbalance of power in the relationship as a result of differences in age, experience, emotional maturity and economic status.
Responses to pregnancy and parenthood
As can be seen from Table 4, although 69% of the teenage mothers said they felt emotionally negative towards their pregnancy initially, by the time of the study only 9% said they still felt emotionally low about it. However, almost half of them said they faced financial difficulties. The change from a predominance of negative feelings on first discovering they were pregnant to a predominance of positive feelings at the time of the study was also observed among the young women who were still pregnant.
Almost 80% of the teen mothers and mothers-to-be were still with the baby-father at the time of the study. While 89% of the mothers said they wanted the baby-father's support, 84% of them said the baby-father was supporting his child in one or more ways: 60% said he provided money, 53% said he played with the baby, 51% said he provided food and clothes, 42% said he helped with feeding and bathing, etc. and 20% said he provided other support e.g. ‘phones daily’, ‘gives love’, ‘cares for us’. Seven of the baby-fathers (almost 16%) were married to, or in consensual union with, another woman. However, 4 of these were providing some support to their child.
| Table 4. How the respondents (in percent) felt about their pregnancies: initially and at the time of the study (N=40 for pregnant girls and 45 for teenage mothers) | |||||
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| Initial feelings | |||||
| Pregnant girls |
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| Teenage mothers |
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| Current feelings | |||||
| Pregnant girls |
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| Teenage mothers |
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The responses of the pregnant teens and mothers indicated that their own mothers, their baby-fathers, nurses, doctors and other family members were usually the most supportive, while their own fathers, social workers, teachers and the church had been the least supportive.
The mothers and expectant mothers were asked to select which services from a given list they would like to have for teenage mums. ‘Counseling’ was chosen by 65%, ‘more information’, ‘childcare’, ‘parenting skills’ and ‘more financial aid’ by 40%-50%.
Only 19% of the pregnant teens and mothers had used any contraception at first sexual intercourse, compared to 58% of the FP clients. Nearly three quarters of the mothers and mothers-to-be (and 87% of those who were under 18 when they became pregnant) had never used any contraception before the first pregnancy. Most of those who had, had used the pill. Among those who did not use contraception at first intercourse, the reasons selected most often were ‘I didn’t think about it’ (42%), ‘I did not expect to have sex’ (34%), and ‘I was too embarrassed/shy to get/use contraception’ (34%). However, among the respondents who were 16 or younger at first intercourse, almost 40% said they had not known they could get pregnant. A large majority of the respondents believed the right age to have a baby was 20 to 24 years.
Although almost all the respondents said they worried about HIV/AIDS and most of them knew condoms could help protect against transmission of HIV, only one of the 29 mothers and FP clients who said they had had more than one partner was using condoms consistently. Overall, only 9% of all the respondents were using condoms. It is possible that most of them felt they were protected because they had only one partner at the time of the study. It is also possible that many of them felt vulnerable but were unable to negotiate condom use with the partner.
The ability to relate to young people, trust, confidentiality and listening were rated as important qualities in family planning (FP) workers. In answer to a question asking if they had noticed specific qualities in FP personnel, 87% of FP clients said the staff were able to relate to young people and 75% said they were helpful and listened to them. However, only 56% thought they were confidential. Somewhat fewer young mothers had noticed the above qualities, with only 40% believing that service providers were confidential. The lowest ratings came from the pregnant respondents but many of them would not have had any direct contact with FP services. One in four of the mothers and pregnant respondents said they had not confided in anyone concerning their problems or queries related to sex and they appeared less able to confide in their peers (siblings and friends) than the FP clients.
Discussion
This study confirms findings in other, similar societies that contraceptive awareness does not guarantee use (13). The findings illustrate the need for an improvement in the quality of health education, counseling and other support offered to teenagers who come into contact with FP and midwifery services and to those who are best reached through other services. Helping these girls is complicated by the fact that the partners of those who are most at risk are often adult men who are 5 to 10 years older. As a result the girls are often the more vulnerable partners in the relationship, both psychologically and economically, and the men may not be amenable to seeing a health worker.
A study carried out in 1991 at the National Youth Service and a more recent one (10,14), indicate that a substantial number of girls are starting to have sexual intercourse during the first 2 years in secondary school. The need for access to information and services for girls this age cannot be ignored but must be addressed in a sensitive manner, bearing in mind legal issues and public opinion.
In a 1980 study of girls who became pregnant before the age of 18 (9), only 13% of the girls said they had heard about sex from their parents, compared to 31% of the girls aged under 18 in the current study. This is an encouraging sign that parents are becoming more willing and able to communicate with their children about sexual matters. Even if their attempts are not always very effective, their willingness to try is a beginning on which to build.
The Convention on the Rights of the Child, ratified by nearly all nations, recognizes the primacy of children’s interests in decisions by families, legal systems and other state action (2). When it comes to reproductive health, the difficulty lies in obtaining a consensus on what children’s/adolescents’ best interests are, how they should be met and who is best qualified to decide, at both general policy levels and at the level of individual case management.
A large proportion of teenage girls who become pregnant are not psychologically prepared for their first sexual relationship, even if in many cases they feel at the time that it is something they want. Thus it is important to find ways of cultivating/teaching the knowledge, beliefs and attitudes required to help the girls recognize when they are not prepared for a sexual relationship and ways of imparting the skills needed to postpone their first sexual relationship. This includes providing girls with clear personally relevant information about contraception and pregnancy, before they start to have sex.
References