Annually, over one million adolescent girls in Nigeria become pregnant. With active participation in decision making by their caregivers and peers, more than 60% of them end up in induced abortions. Generally, peers exert major social influence on adolescent sexual behavior by playing "role model" for others in their close contact. These "role models" are the first to be contacted when any problem such as unintended pregnancy occurs and most times they are involved in counseling as well as contributing ideas to solving such a problem. This qualitative study explores peer's experiences and feelings about pregnancy termination by their adolescent peers in a typical Nigerian setting.
This was a descriptive study that utilized qualitative method for data collection from adolescent secondary school participants. Participants were recruited from four public secondary schools selected from the eleven administrative wards that make up Uyo using multistage random sampling design.
Many adolescents express support for their peers who terminated pregnancy. Reasons for their support include; avoidance of being sent out of school or home if pregnancy is discovered, avoidance of complications of childbirth including delivery through operation, consenting to mother's wish etc while those against mentioned religious sanctity of life. Some blamed the Government for not doing enough.
The ways in which adolescent students in our study express their experiences and feelings about their peers who terminated pregnancy suggests that they could play an important role in curbing this menace if properly informed and guided.
Perspectives, Experiences, Feelings, Pregnancy Termination, Adolescents
Adolescents constitute about 20% of Nigeria's population of over 170million people. This population group is largely forgotten in term of Health Care planning and implementation. Nigeria has a low contraceptive prevalence which is virtually unavailable for this age group. This vulnerable group becomes disproportionately more exposed to a broad range of Reproductive Maternal Newborn Adolescent and Child health (RMNCAH) challenges including unintended pregnancies. Adolescents are frequently exposed to sexual materials on television, movies, magazines, music videos and books. The potential negative consequence may include early initiation and experimentation on romantic relationship and sexual activities. Peers are presumed to exert a major social influence on adolescent sexual behavior. For instance, peers who are sexually active may serve as role models for others in close contact to initiate sexual activity. These "role models" are the first to be contacted when problems arise and most times are involved in contributing ideas to solving such problems which may include sourcing for solution on how to deal with an unintended pregnancy. It is right to assume therefore that long before the adolescent actually engage in sexual intercourse, he/she would have developed a complex set of ideas about sexuality and sexual encounter. Many eventually see sexual intimacy as being permissible in the context of affection.
It is estimated that about 25% of Nigerian adolescents are sexually active with age of sexual debut ranging from 10 to 15 years [1,2]. Every year, over one million teenage girls become pregnant in Nigeria due to indiscriminate and unprotected sexual adventures [3]
Unsafe sex is a common practice among adolescents including inconsistent and incorrect condom use resulting in unintended pregnancy that ends in unsafe abortion and its complications [4,5]. It has been shown that over 60% of unintended pregnancies among adolescents in secondary school will invariably end up in induced abortion [6]. Due to the fact that abortion is illegal in Nigeria (unless medically recommended to save the mother's life), a number of these abortions are clandestine and most times are carried out in unsafe environment by unskilled providers [7].
Abortion is generally associated with negative stigmatization in many African countries including Nigeria. This on its own discourages qualified and trained professionals from offering such services, a situation typically exploited by the untrained to perpetrate their unskilled services to unsuspecting adolescents. This situation unfortunately poses a great danger to the lives of these adolescents and also contribute to the overall maternal mortality rate in this sub-Saharan country [8]. For the small percentages that will not end up in unsafe abortion, it is imperative to note that serious negative effect may occur resulting in worse pregnancy outcome for the adolescent. These include; anemia, obstructed labor and its sequelae; genital fistulae, low birth weight and perinatal mortality [9,10].
It is worthy of note that in most cases adolescent pregnancy interferes with their education since in most instances the adolescent has to make a choice between terminating such pregnancy to remain in school or keep the pregnancy and risk dropping out of school.
Unsafe abortion imposes a heavy financial burden on both women and Nigeria's fragile health care system. For example, one study estimated that post-abortion care cost US$103 per patient in Nigeria in 2005, amounting to US$19 million; the average per-case cost for hospital care was US$132, of which 72% (US$95) was borne by women and their households [11].
Generally speaking, Nigerian society is judgmental when it comes to issues of adolescent's pregnancy. Because of this a pregnant adolescent girl will want to do everything it takes in cost and risk to carry out abortion in order to remain "blameless" in the eye of many including their peers. This study assessed the experiences and feelings of adolescents whose peers had attempted or carried out termination of pregnancy. The findings are hoped to add to knowledge on this important adolescent health matter.
The minimum sample size was determined using the formula:
n = Z2P(1-P)/d2
where, Z = 1.96, corresponding to 95% confidence interval, at d = 5% acceptable margin of error = 0.472(corresponding to 47.2% prevalence of abortion from previous study [12].
Using the above formula, the minimum sample size was approximately 383.By addition of 10% attrition rate (i.e. 38), we arrived at a final sample size of 421.
Four public day schools were randomly selected from the eleven administrative wards that make up Uyo in the first stage. Public schools were purposively selected in that due to free education program of the State Government, most of these schools have admixture of older students and the younger ones age wise interacting together at school. Another rationale is the supposition that being a day student allows for the likelihood of higher frequency of contact and interaction with adults and peers from other schools in the larger society. This kind of interaction could allow for sexual coercion and increased sexual activities that may result in unintended pregnancy with attendant likelihood of wanting to terminate such pregnancy.
For each selected school, one hundred and five students were randomly selected from the senior classes (SS1–SS3). Each student was given a structured self administered questionnaire to complete. The first section of the questionnaire contained information on the participant's biodata while in the second section the students were required to answer "yes" or "No" to the question: Has any of your friends ever attempted or successfully terminated pregnancy?. Without disclosure to the participants, those who answered "Yes" were recruited into focus group discussions while for the purpose of blinding those who answered "No" were grouped into another unrelated discussion group.
A total of 157 out of the 421 participants (made up of 39, 46, 32 and 40 students from the four respective schools) answered "Yes" and therefore formed our study population. For convenience, in each school, the participants were randomly allotted into groups of 8 to 13 with the authors as facilitators. The groups were of mixed gender. Focus group discussions were held in the school compound during break time so as not to disrupt academic activities.
The focus group discussion was moderated by the authors and two trained assistants. Before the commencement of each session, the first author introduced the topic and explained the purpose of the focus group. The opening question was "How often do you think about your peer who had attempted or successfully terminated pregnancy?" To guide the discussions, interview guide was used. The topics addressed included participants experience and feelings about induced abortion practices in their peers. The length of discussion was between 45 to 60 minutes and was recorded on paper and in tape recorder with consent of the participants. Each participant was encouraged to freely give his/her point of view. The same interview schedule was used for all the groups with some flexibility in the protocol. Focus group discussions were done in English language in the school compound at agreed time and place. Participants were assured of "no consequence" if they decide to withdraw from the study at any time. Snacks were provided to the participants at the end of the session. No other incentives or financial reward were given to the participants.
Exploratory and qualitative study design was used to obtain information about experiences and feelings of adolescents whose peers have either attempted or completed termination of pregnancy. In all, a total of twelve focus groups of adolescent secondary students whose peers have attempted or completed abortion in the past were conducted. The authors facilitated all the focus discussion. Prior to the group discussion, the peers were met and aim of the study was explained to them and asked if they were willing to participate in the study.
Ethical approval was obtained from the research and statistics unit of Akwa Ibom Ministry of Education. Informed consent was obtained from the parents through the Chairman of the Parents-Teachers Association of all the schools selected for the Study. The participants were assured that their responses would not be linked to their identities and hence the reason that their names were not required for documentation.
One hundred and fiftyseven adolescent school students participated in the focus group discussion. The participants were aged 13 – 19 years made up of 88 and 69 male and female adolescent students respectively. All of them were of Christian religion and senior secondary day students of the sampled schools
In all the Focus Group Discussion (FGD), participants mentioned that abortion is a common practice among adolescent girls. However most of them assert that their peers on their own would not have opted for abortion but for the situation they would find themselves in the family and even the community. Discussants indicated that the problem usually arise when the parents or people around discover that the adolescent girl is pregnant.
The problem we face is being driven away from home by our parents when pregnancy is discovered.......under such a situation the girl will become a laughing stock. At the larger society she may not be accepted hence leaving her to roam the streets. So I did not blame my friend when she had to abort the child after she realized that she was pregnant (18 years old adolescent)
My friend when she discovered the pregnancy had to tell a lie to the parents that she was chosen by the school to be among those to undertake excursion to French village in Badagry. The parents then gave her some money which she used to pay for the abortion because she did not even want the boy to know that she was pregnant. (19 years old adolescent)
She was living with the aunty who brought her up after she lost both of her parents at very young age. .If the aunty had known she would have been sent away and I don't think anybody would have accepted her or took care of her and the baby( 15 years old adolescent).
My friend was a victim of deceit in that she only got to know that the man who impregnated her was married with children when she went to tell him about the pregnancy. The man only told her that there was nothing he could do since he was already married. He however gave her some money to abort the baby. So she quickly went to abort the baby before people could know that she was pregnant for a married man. She would have kept the pregnancy if the man had accepted to take care of her and own the child (18 years old adolescent).
Some of the participants agreed that their peers decided to terminate the pregnancy because they were afraid of operative delivery or some complication because of their young age since they were not sure they could deliver the baby safely by themselves.
My friend was afraid of being asked to deliver by operation because she was not mature enough to be able to deliver by herself. I think she took that decision because sometime after the operation, you find a woman with very ugly mark on her tummy. Imagine if a young girl could carry such a mark (16 years old adolescent)
My friend knew that young girl may begin to leak urine involuntarily following difficult delivery, so she did not want hers' to be like that ( 17 years old adolescent).
She was afraid of dying during labour. She mentioned to me that one of her cousins developed swelling of the whole body when she was pregnant, became unconscious after delivering the baby and died few days after delivery. She believed that there may be a problem in the family that can kill a young girl who becomes pregnant without proper marriage(19 years old adolescent)
I got to know about the abortion because complication set in. She started bleeding seriously. Myself I was afraid that she was going to die. Thank God her parents quickly carried her to the hospital for treatment (16 years old adolescent)
Some participants agreed that poverty could sometimes be responsible for wanting to terminate pregnancy. In their opinion, if the pregnancy resulted from a relationship for financial or material gain, the option to terminate the pregnancy is the wisest decision because it would be more difficult to cater for the baby.
My friend was sent out of school for nonpayment of school fees and the man who lived in the same compound deceived her that he will be paying school fees for her since the parents are unable to do so. She accepted the relationship thinking that the man was doing her good. She later became pregnant and her mother had to arrange for her to abort the pregnancy. So since it was her mother who arranged for the D&C I supported it(14 years old adolescent).
In my own case the mother did not like the guy because he was from a poor family background so she asked her (my friend) to urgently go and terminatethe pregnancy before people get to know(18 years old adolescent).
The majority of the participants equally agreed that the parents especially the mother sometimes play very important role in taking a decision as to whether to keep the pregnancy of their adolescent daughter or not.
I think it was the influence of the mother that made her to abort it because she had expressed her readiness to have the child as she had always desired to have onemuch early in her life. This is because she always admired seeing a child who looks like a junior sister to the mother and always wishes she was the one (19 years old adolescent). .
There was divergence of feelings among the participants about induced termination of pregnancy. Majority felt that the induced abortion should not be condemned since in most cases it has taken away shame from the girl and her family by allowing the girl to continue her education. In the other hand some see induced abortion as wickedness and murder despite its perceived benefits to the girl and her family.
I feel abortion has its merits. For instance in most cases, those responsible for the pregnancy would want to deny responsibility. In such cases instead of giving birth to a bastard child who would have to struggle through life with the problem of identity, discrimination, social neglect and hardship especially if the child is a male. In such a situation, abortion is a good option.(19 years old adolescent)
"...the boy friend denied being responsible for the pregnancy and warned her not to ever mention his name. He also told her that his parents will not want to take the unborn child for any reason so she had no option than to abort the baby. He even threatened to beat her up. In fact he did not contribute any money for the abortion. For me it really shows how irresponsible some of these guys could be. Who would like to have a child for such a person? (16 years old adolescent)"
You know in this our society if they know that you delivered a child while in school, no one may be willing to marry you. This will bring shame to the parents of the girl and the family. Even if it happens, you will be treated like second hand wife without respect. So I feel my friend did well to save the family's name (18 years old adolescent).
I did not see anything wrong with that, after all everybody is doing it (19 years old adolescent)
Some participants felt that induced abortion should be condemned irrespective of who is committing it or under what condition it is being committed.
I made it clear to my friend that it was murder and blamed her seriously. I asked her to pray for forgiveness of the sin of murdering the innocent child (15 years old adolescent)
I feel that the Government should make law to punish both the person committing it and the one aiding or performing it. Don't they know that life is sacred? If any of my friends commits it, I will cut off my friendship with her(14 years old adolescent).
I feel very sad each time I hear that somebody had committed abortion. Why should someone even subject herself to such inhumane treatment?. Almost 2 years ago when my cousin committed abortion I still find it difficult to be close to her because I feel if she could do that it means she can kill. Who knows what that child could become in future?(17 years adolescent)
Nigeria has a growing population of young people, with adolescents constituting an important proportion of the population. About 28% of adolescents in Nigeria are said to be sexually active [1]. Expectedly unwanted pregnancy and abortion tend to be most rampant in them especially school girls [13]. Induced abortion is no doubt a huge problem among adolescents. This is because of the crude and very risky ways of procuring same that majority of adolescents often resorted to. There are overwhelming negative effects that may be associated with these practices. Several factors are involved in determining what an adolescent would do to an unintended pregnancy. These include support from the peers, parents, family tradition and culture.
Most of the participants did not express any blame for their peers who opted for induced abortion because this was deemed to be an easy way out of personal shame and social stigmatization. This is because premarital pregnancy is viewed by parents as a disgrace to the family by spoiling the good family's moral and name [14,15]. On the other hand, opting for abortion will ensure that the adolescent will continue to be in school. Studies have shown that adolescents who become pregnant while in school either have to drop out from school or be dismissed [1,16]. It is a known fact that any school girl who becomes pregnant will most likely be socio economically disadvantaged. This is because they are likely to have fewer opportunities to complete their education after childbirth and have fewer opportunities for socioeconomic advancement. In such a situation the adolescent girl may be pressured to marry the father of the child. Whether the girl eventually married the person who was responsible for the pregnancy or not, her new position will likely put her under intense financial strain. This is because she is likely to lose some support from her parents and relatives.
Participants also reported that the peers could not be blamed because they opted for induced abortion to prevent some complications which they were aware of. These included; Caesarean delivery due to their immature pelvis, development of vesico-vaginal fistula, pre- eclampsia/eclampsia etc. It appears that the participants are more aware and worried about the complications of teenage delivery and possibly lack information about the complications of abortion. This is not surprising because adolescents in developing countries like Nigeria are faced with barriers to both sexual and reproductive health care that would have allowed them to access services necessary to secure and protect their health, In most cultures in Nigeria for instance, the adolescents are denied sexual and reproductive health information as it is perceived or seen to breech their long standing cultural traditions that prohibit frank parent-child discussions about sex. To fill in this gap, some adolescents receive some informal instructions about sexual and reproductive health from their peers in school and those out of school. However, this instruction is often incomplete and inadequate from the adolescents' perspective.
There are many reasons why adolescent girls initiate and maintain sexual activities which may result in unintended pregnancy. One of the participants described how her peer was coerced into undesired sexual activities by an older partner who offered to pay her school fees when she was sent out of school for nonpayment of fees.In some communities accepting such an offer is seen as a means of making up for what their parents could not provide and should otherwise be encouraged. Here the adolescent student's inability to cope with the school demand was thought to have justified her action of sustaining sexual activities that eventually resulted in unintended pregnancy and equally a justifiable reason to want to terminate the pregnancy possibly in order not to drop out of school. Poverty and non-availability of funds to meet basic needs has been reported to be associated with initiation of sexual activity among adolescents [17]. Apart from making the adolescent at risk of contracting sexually transmitted infections including HIV, unintended pregnancy still remains a major consequence of sustained sexual activities.
Poverty does not only push the adolescent girl into sustained 'gratifying' sexual activities but sometimes if pregnancy occurs becomes an important issue to consider in order to determine the possible way forward of the pregnancy. A mother's hope and expectation in marriage for their daughter are usually high. This is more so in Africa and indeed Nigeria where extended family system and bonding remains high virtually through ages. In different Nigerian cultures, various items and money (Bride price) are presented to the family of the bride by the groom in a highly orchestrated ceremony which is seen by many as symbolizing a "presumed" status. The ability to be able to present all that are required is dependent upon the socioeconomic status of the groom. This probably was the reason the mother of the adolescent girl opposed to the daughter keeping the pregnancy for a person considered to be financially incapable.
A number of people generally play vital role in deciding for abortion by an adolescent girl. In some cases the mother of the adolescent girl takes the decision to have the pregnancy aborted. This was the case of a number of the participants that the decision to abort the fetus was taken by the mother of her peer even against her will. This probably may be prompted by the desire to maintain social approval since in most cultures adolescent pregnancy is regarded as a failure of the adolescent's girl mother [18]. Apart from this; it is also possible that the mother of the pregnant adolescent may have equally considered the potential economic burden to their family before deciding for the abortion. Another relevant issue is the possibility of an early pregnancy interrupting the adolescent's educational process, forcing her to leave school and hindering her inclusion in the job market [4]. It appears that adolescent abortion is a phenomenon permeated by personal, social, cultural, religious and family conflicts. This may have to do with response to lack of support or a decision imposed by those who are of necessity the primary caregivers.
Among the participants, there were diverse opinions about illegal abortion practice among adolescents' girls. Somewere in support while others were against their peer's decision to termination pregnancy. Some participants blame the government for not making and enforcing appropriate laws to reprimand the offenders and those aiding it. Those supporting it believed that their peer's decision was the best option for the prevailing situation while others feel that their peers had committed sacrilegious act. Some see abortion as murder and would rebuke their peers. Without argument, the opinions and reactions to the act of terminating pregnancy among the peers could encourage or discourage future abortion attempts thereby increasing or reducing the burdens of induced abortion and its effect on the adolescent population.
This study had shown that adolescents communicate passionately among themselves on matters concerning their reproductive health and sexuality. Their support for one another could encourage or discourage risky behaviors and practices such as unprotected sex with consequence of pregnancy and pregnancy termination among them. There is need for proper education and counseling of this group as they can form a veritable source of information for one another in addressing their reproductive health issues. Primary care physicians should use every available opportunity to educate the adolescents on their reproductive health matters as well as strategies to adopt in curbing with practices that are inimical to their attainment of intellectual capacity.
Since most of these schools have qualified nurses in charge of their school clinics, their role could be expanded to include provision of information on pregnancy and its risks, abortion and its complications, early childbirth and its consequences etc.
There is also a need for health educators to focus on adolescent groups and high-risk behaviors among them. Special programs should be initiated by government and the various bodies to address ignorance concerning adolescent sexual matters, and the challenges and risks associated with pregnancy and parenting by adolescents.