Plain English summary
Background
Methods
Study design
Recruitment and procedures
Ethical considerations
Research questions
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What are the factors which increase vulnerability to teenage pregnancy?
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What are the vulnerabilities which increase the risk of death from pregnancy-related causes in adolescents?
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What could be done to mitigate the risks associated with teenage pregnancy in this part of Freetown?
Data analysis
Results
Major theme related to research question | Subthemes within major theme | Key informants on this subtheme |
Vulnerability to teenage pregnancy | Transactional sex • ‘not their own child’ • ‘water for water’ • ‘sex for school fees/grades’ • the criminal justice system Contraception and abortion | • young men’s focus group (YMFG) • women’s leaders (WL) • teachers’ focus group (T1 and T2) • Government of Sierra Leone participants (GI) • Senior NGO workers (NGO) |
Vulnerability to maternal death once pregnant | Abuse and abandonment • ‘just because she’s young it doesn’t mean she has to die’ Increased birth complications • Delayed care seeking Risk of death from anaemia and PPH | • young mothers’ focus groups (MFG) • hospital midwives’ focus group (HMFG) • community clinic health workers focus group (HWFG) • senior midwives (SM) • senior community leader (SCL) |
Possible interventions to reduce maternal death in adolescents | Mentoring Community-based blood donation • compensation • blood donation experience | • women’s leaders • young men’s focus group • midwives and other health workers |
Vulnerability to teenage pregnancy
Transactional sex
The other thing is the trade the girls do from house to house. When they are hawking their trade, some older men will call to them saying ‘Come! I want to see or buy what you are selling’. He will call her into the house and say, ‘I will buy everything you are selling if you have sex with me.’ (WLI3)
Some go to school in the afternoon so in the morning they will have to do their trade before school. At a certain time before noon they will come home and get ready for school … (it can) take the whole day to sell and when a man offers to buy everything she has for sex, that can be tempting. (WLI2)
Teenagers get pregnant a whole lot because of the water crisis – ‘if you give me water, I’ll give you sex’. ‘Water for water’. Especially in February, March, those two months. Oh! Very tedious – water! (WLI1)
It’s an agreement, as they are in love. It’s not a rape. The girls do not want to waste too much time at the stream or well. So, if the boy who controls the well or the water tap is the girl’s boyfriend... even if she has twenty or even fifty containers, he will make sure her containers are filled up first. So the girls get home a little bit earlier than normal. (WLI2)
Interviewer: what if a girl decides that she is not going to have sex?(WLI3): you will stand there for the rest of the day you would not be able to get the water.
The dam has got to be repaired or worked on. In days gone by here in Freetown there used to be taps at every street junction. Then we never used to have this problem of young girls getting pregnant due to water crises. (WLI3)
The man that impregnated me was helping me a lot for my schooling, so I fell in love with him, but I was so small at the age of fourteen. (MFG).
It’s just like bidding. The highest bidder has the highest grade. If you give 10 000 Leones, you will have your 10 000 Leones grade. If somebody comes with 20 000 Leones, that person will automatically have a higher grade than you! Let’s say for example Salimatu comes to school, and she does not have that money. Automatically she will have to repeat (the school year). No matter how brilliant Salimatu is, she will have to repeat that class simply because she does not have that money to satisfy the teacher. You have to satisfy your teacher both in writing and in the financial aspect. (T1)
Sex for grades
Children who are not able to read or write and find it difficult to, you know, understand questions and pass exams … some male teachers exploit that situation by offering, asking them to offer sex for grades. (T2)
The other day my daughter was telling me ‘Mama, even when I’m submitting my assignment, my teacher is asking me for money.’ If you don’t give your child enough money to pay for the assignment, what happens? ‘Ah Mr X, I don’t get money’. ‘OK, meet me at my house’ ... If the girl doesn’t get pregnant, its infection. STI, HIV. That’s why HIV is as high as it is. (NGO1)
Even in primary school, you see these girls have grown breasts, and maybe you are thinking ‘I don’t want to go to bed with this girl’, but your hands … you may want to like... touch her breasts, her buttocks, in that sexual way, after the class. (T1)
One time when I was at the teacher training college, they asked us to give our names and school of choice for our teaching practice. And some of our colleagues gave their names for a female school for one reason ... the reason is to have more girls you see. There are schools who are marked as ‘sex schools’. Sex schools! The other day someone was telling me ‘ah that school over there. If you go there, you can have women until your tire.’ (T1)
Some of these teachers, they use some of these boys to investigate these girls. Like for example they will say ‘Souri, I really want that girl. Go and look at the background of that girl. If they have any person that is strong in the family.’ And Souri will now go to the girl, and interview the girl. If he says they are poor, then automatically the teacher will take that as an advantage. (T1)
The criminal justice system
I think on one or two occasions, I’ve heard of the teacher being taken to the police. But … all the senior members of the society will come; ‘Oh, let this man go, he is a teacher. He’s actually doing very well in this community. Please don’t let this teacher go down to prison.’ (CBOI)
Even the government are unable to … interpret and implement the law properly. When someone has done something bad they should be in prison. If someone dies in pregnancy the person responsible should be charged with murder. If this is done to one, two or three persons as a sample, the others will be afraid. But most of those who commit such offense are freed one after the other. (SCLI)
In the past, there was lots of compromising on sexual abuse cases … but in the past three months, we have supported the prosecution of up to four or five sexual abuse cases of children between the ages of eleven and thirteen. All of them, when these cases are in court, the perpetrators have been remanded in prison. (CBOI)
In certain far remote communities, where you do not have magistrates court sittings … if a victim is staying in the community which is about 50 or 100 miles to where the court is, without all of this support, transportation, shelter, then she definitely will not come. (GI1)
Contraception and abortion
They listen to the people in the street that says it gives cancer, so they’re afraid. (HWFG)
And not only are many of them dying of childbirth, they are dying of abortion. Most of the mothers, because of the embarrassment and everything, take them for abortion. And they die, and they don’t talk about it. (MWI)
In the village, when I knew that I was pregnant, I drank a lot of herbs to destroy the pregnancy. (MFG1)
I drank loads of Seven-up with blue clothes dye in it. (MFG1)
Vulnerability to maternal death once pregnant
Abuse and abandonment
So my father came home … and said if he meets me in the home he is going to shoot me with a gun since he was a policeman. (MFG1)
My elder brother was so annoyed that I was beaten and I was wounded on my back and the sore was there for a long time on my back. (MFG2)
So I went to auntie Ami’s parlour, and I slept there on the hard tiles until nine months and was ready to have the baby. They didn’t feed me. Auntie Ami fed me once a day and let me sleep in her parlour because I did her washing and her dishes. (MFG2)
They threw her out of the home and she went and stayed with the boy who was an apprentice with a taxi cab driver, so they were sleeping in cars. She was cold, anaemic, not enough blood and was not eating well. She was sharing a plate of rice with her partner. She died. (WL2)
Increased birth complications
So it doesn’t mean she’s a teenager, she should die. (No, exactly!) If we know the risk, if she goes through the normal antenatal care, where they screen her, test the blood haemoglobin level, do head to toe assessment, palpation and all, she should receive care just as any woman who is pregnant, if we have proper, functioning systems in place. (HMFG)
And because of the inexperience, they don’t know when there is a raised pressure only because they refuse to come to the antenatal … and by the time they come to the hospital they come convulsing, fitting. You see them dying. (SMI1)
In the provinces, when the chief wants that young grownup girl, he convinces the relatives. After marrying her she becomes pregnant. Maybe she does not even attend antenatal clinic. When it comes to delivery, complication arise. To let them refer that case to the big hospital, it’s a problem. Maybe the husband is not around, then the relatives do not have money and they do not have a say over that woman so they delay to make decision. So after they have made the final decision to take the woman, transportation! Maybe the road is not good, there is no ambulance for the patient to come to the hospital. So after the patient has arrived now in the big hospital … maybe we need blood for this patient, there is no doctor to see this patient … if she comes in with bleeding, obviously she will lose her life. (HMFG)
Risk of death from Anaemia and PPH
When the mother attends ANC, and they tell her she will need blood … she will ask her family, saying ‘look here, I’ve been going to ANC and they say I will need blood, so what I want you to do, as a family is to be thinking who will give blood’... it’s all part of birth preparedness. (HMFG)
…well most of the time they tell them but they don’t comply, they don’t accept that there’s a problem, and then you see them running helter-skelter. (HMFG)
We don’t have much blood in the blood bank. They end up dying. We can help but we cannot give more than what we have. (SMI3)
Someone would have to pay for blood. I have been there on about seven occasions when young girls died there. They have that problem there. There is no free blood. People do not volunteer to give blood. Unless your relative volunteers to give blood on your behalf, if not so you would have to buy. (WL3)
Potential solutions
Mentoring
We the parents also, to some extent, we are to be blamed ... because we don’t make our children our friends. We have that communication barrier... some of us think that there is certain information that has to be hidden from these children, then they go astray as a result of that. You have to talk to your child! (HMFG)
What is most dangerous thing is this abortion, because some of them are so afraid of their parents and usually it’s the boyfriend who took them to non-qualified people. (MW1)
Now that I have given birth and decided to come for that training, I have joined the PPA so I will not give birth again. (MFG1)
But I bless this institution, training us. I wasn’t feeling good about myself, I just saw myself as a drop-out, I really felt it! (MFG1)
That (the Institute’s graduation) was very good. Some might want to learn but are not able to pay for the education. The parents might not be rich enough to pay. But if they learn a trade they will be able to provide for themselves and their children. (SCLI))
I had this urge, feeling and burden for children who are thirteen, fourteen, fifteen, in schools. This was bubbling inside me so … I started working with the girls that have been expelled from their family homes. I usually accompany them to talk to their parent, saying things like ‘it’s like a loaded gun - once the trigger is pulled it cannot be recalled. The only thing we can do is to take care of the girl’. I am thankful to God I have never had a victim or death... I will take the pregnant girl for check-up with a nurse making sure that everything about the pregnancy is alright then I will approach the parents. I do pray before I go to speak to the parents as some of them can be very bitter saying I would not accept the girl as she has chosen to be sexually active. Let her go and get married. I will say to them ‘this child is yours, a marriage can end but the girl will be the one who look after you when you are old.’ I will gather other people to help with the negotiation. Most times this is successful. (WL3)
Community-based blood donation
Yes, because for example if I was pregnant, my sister would be more willing to give blood for me, or my brother, so that nothing will happen to me. Rather than my husband. (NGOI1)
Whereas if a child needs blood, this will invariably be donated by the child’s father:It is the dads that give blood more than the husbands. (SMI1)
For children, most times the father does it. The fathers are willing. But they will not give for their wife. I don’t know what the issue is. (NGOI1)
Just because when people meet me and they explain to me ‘you need to help us in this situation’, I just need to do it, because that is my only way to help them. (YMFG)
Yes, I think people will be afraid to be tested, in case at the end of the day the doctor says, ‘you have HIV’ (YMFG)
People are afraid. People don’t want to be tested because of hepatitis and HIV. So, they dodge. Some husbands they prefer to give money to donors to getting them tested, or maybe some of them know their status, they hide it from the wife, and they don’t want to expose it. (NGO1)
In this country, when I say this person has HIV, they will just run away from you, it will just turn like Ebola. (YMFG)
People say when you give blood you die. When you give blood, you become sick. (WLI2)
Some people think if they come and take one pint of blood from them they will die tomorrow. It is just fear. (YMFG)
Even for someone to be able to give blood they should be able to have food to eat. If not so they will be anaemic. (YMFG)
The one I remember was (name). I was thinking that at the end of the day, I paid my transport to go there … I was thinking that when he got well, he would say ‘hey man thank you’, but … he couldn’t even look at me, but I had already done it, so I just let him forget about it. All the (other) four people, I’ve been happy to keep them alive, but for him, I was so angry about it, because he’s my brother (non-relative), so I was thinking he would say something like ‘thank you’. (YMFG)
There was an NGO who was paying people to donate blood. The donors were fed well. But the problem with our country we have so many groups which have been set up by so many NGOs who would come and start something, but it is for short time it does not last. (HWFG)
They would have to eat to replace that. We would not be able to keep this service going. It is not easy to get people to donate blood. Some people will do it once but they would make excuses the second time. They will say that they have not eaten since the morning. (MWI)
If you donate your blood, they will take care of you, explain to you how it’s supposed to be, during the blood donation, or after the blood donation. They will explain to you ‘sit down first and take a little bit of bread’. (YMFG)
Discussion
Vulnerability to teenage pregnancy
Transactional sex
‘More targeted work is also required, for example, with regard to girls involved in sexually exploitative relationships, who need practical and personal support to exit these relationships and re-engage at school’. (page 7) [19]
Findings reveal that girls are also engaging in transactional sex to access a range of other amenities and merits including, for example, school grades – in the aptly termed “sexually transmitted grades” [20](page 18).
Prevention of adolescent maternal death
Abandonment
Delayed care seeking
I’m not going to go and give my money and somebody will yell at me. I will pay money where I am respected. I don’t care if I don’t eat for the day, but I will pay my money, as long as I’m respected and somebody speaks nicely to me. (NGO)
Well in the private hospitals, people go there for the respectful care, but also they should know that though respectful is important, the skill also is very important. Because it’s the skill that will save your life. (SM)
And even for the TBAs, right, the TBAs will never never, in as much as they have their own issues, they will never yell at a woman when they go to see them in their house. As soon as they see them, they are ‘how are you?’, even when they don’t have all the skills. (NGO)