Knowledge, attitudes and peer influences related to pregnancy, sexual and reproductive health among adolescents using maternal health services in Ugu, KwaZulu-Natal, South Africa

Adolescence is a complex stage in life that is characterised by conflicts among responsibilities, independence and experimentation [1], and health and social problems may be extensive during this phase [2]. According to the World Health Organization, the main health issues among adolescents include early pregnancy, childbirth, HIV/AIDS, depression, violence, alcohol and drug abuse, intentional injuries, malnutrition, obesity, and tobacco use [3]. Adolescents account for 1.2 billion people globally and 11% of all births worldwide are to girls aged 15–19 years [4]. South Africa is home to approximately 9.68 million adolescents [5] and the adolescent pregnancy rate here is 47 births per 1000 females aged 15–19 per annum [6]. Adolescent pregnancy and childbearing is increasingly recognised as a serious, worldwide public health concern. The maternal mortality rate associated with pregnant adolescents has been attributed to pregnancy induced hypertension, HIV/AIDS, Tuberculosis, obstetric haemorrhaging, and medical and surgical disorders [6, 7]. The HIV prevalence in South Africa is estimated at 13.1% [5].

Sexual and reproductive health (SRH) programs are often not prioritised due to a lack of funding and the emphasis that is placed on community-based HIV prevention programmes [8]. There are also restrictive laws and policies concerning adolescent sexual and reproductive health [9]. Access to SRH in the Asia Pacific Region is dependent on age and the regulation of marital status [10, 11]. Customary and religious laws require persons under the age of 18 years to seek consent from parents or spouses to access SRH [10]. Healthcare providers may also be prohibited from delivering contraceptive services to unmarried persons [11]. The age that an adolescent is allowed to consent for sex often conflicts with the age that the adolescent is allowed to consent for medical interventions [10]. Thus, the blatant disregard of adolescent SRH often results in a damaging transition to adulthood [9]. Education and clinical services, which are the cornerstones of SRH, are essential in promoting positive sexual development and decreasing adverse social, economic and health outcomes associated with sexual behaviour [12]. Parents, teachers, healthcare providers and community leaders are the gatekeepers of adolescent sexual and reproductive health because they are responsible sources of SRH information and services for adolescents [13].

The Safe Motherhood Initiative was a key outcome of the first international Safe Motherhood Conference in Nairobi, Kenya, in 1987 [14]. The pillars of the Safe Motherhood Initiative include family planning, antenatal care, obstetric care, postnatal care, post abortion care and STI/HIV/AIDS control. The Safe Motherhood Initiative is founded on the principle of sound knowledge and practices of reproductive health; however, only a few studies have investigated adolescent mothers’ knowledge of sexual and reproductive health [14]. Universal access to SRH services is one of the specific targets of the Sustainable Development Goals pertaining to health (SDG3) [15]. Thus knowledge, personal attitude and peer influences can influence adolescents’ decision to access maternal, sexual and reproductive health services or not. However, far too little attention has been paid to the knowledge, personal attitudes and peer influences related to pregnancy, sexual and reproductive health among adolescent girls accessing maternal health services.

A lack of pregnancy related knowledge among pregnant adolescent girls can adversely affect their lives as well as those of their unborn children [16]. Therefore, adolescent pregnant women should be equipped with knowledge so that they will be able to engage in good health practices during pregnancy. They should also identify danger signs during pregnancy and make prompt decisions about appropriate care and support. The age and maturity level of pregnant women may impact their susceptibility to antenatal education and their ability to identify danger signs associated with their pregnancy [17]. However, knowledge of SRH and pregnancy among adolescents has remained inadequate [4], and therefore adolescent pregnancy is considered a high health risk as poor nutrition, limited knowledge, and ignorance of danger signs during pregnancy can be devastating.

This paper is an excerpt from a larger doctoral study that aims to develop a community of practice model for a multidisciplinary and comprehensive approach towards caring for pregnant and parenting adolescent mothers. This doctoral study is being conducted in Ugu, KwaZulu-Natal, South Africa. The purpose of this paper is to report the knowledge, personal attitudes and peer influences related to pregnancy, sexual and reproductive health among adolescents who utilised maternal health services in a district hospital in Ugu, KwaZulu-Natal, South Africa.

Knowledge plays an important role in facilitating people’s access to healthcare [16]. The aim of this study was to determine the knowledge, personal attitudes and peer influences related to pregnancy, sexual and reproductive health among adolescents who attended maternal health services in a district hospital in Ugu, KwaZulu-Natal, South Africa. Although 43.9% of participants scored > 50% for the knowledge test on pregnancy, HIV/AIDS and STIs, there are serious gaps in their knowledge of danger signs of pregnancy, anaemia, alcohol and tobacco use during pregnancy and sexually transmitted infections.

In our study, 60.4% of the participants was able to identify vaginal bleeding as a sign of preterm labour. In reviewing the literature, this is low when compared to 86.0 and 82.2% who were able to identify vaginal bleeding as a danger sign during pregnancy in studies conducted in Malaysia and Tanzania respectively [16, 17]. The current study found that only 23.3% of the participants was able to identify blurred or spotted vision as an abnormal sign during pregnancy in comparison to 47.8 and 39.4% in studies conducted in Malaysia and Ethiopia respectively [16, 23]. Prior studies have noted the importance of pregnant women having adequate pregnancy related knowledge to identify the appropriate steps to decrease the risk of preterm labour. In this study, 44.2% of the participants was able to identify the appropriate steps to decrease the risk of preterm labour. This result is in concordance with the level of pregnancy related knowledge among pregnant women attending an antenatal clinic in Pune, Maharashstra [24]. The ability of pregnant women to identify the signs of preterm labour is critical if they are to counteract this emergency.

Anaemia is associated with adverse events in pregnancy and is common among pregnant adolescents. [25]. The participants in the current study demonstrated poor knowledge of the signs and symptoms of anaemia. More than half (63.2%) was not aware that iron deficiency can lead to anaemia. This is in contrast to the findings in Brosankro, Ghana, where only 3% of the participants in a study, was unaware of the link between iron deficiency and anaemia [26]. In the current study, 59.5% of the participants could identify only one out of thirteen signs and symptoms of anaemia. Less than half of the participants in this study identified pale lips (31.3%) and pale finger nails (29.8%) as symptoms of anaemia. This is low in comparison to 87% of participants who was aware of this fact in a study in Dahalik, Baghdad [27]. In the current study, 43.3% of the participants identified preterm delivery and low birth weight as complications of anaemia, in comparison to 25.0 and 11.0% who respectively correctly identified preterm labour and low birth weight as complications of anaemia in a Ghanaian study [26]. Moreover, knowledge of the benefits of folic acid supplementation and neural tube defects is important, yet this study found that only 35.6% of the participants knew of the benefits of folic acid for brain and spine development. This was slightly better than the findings of a study conducted in Pakistan, in which only 18.4% of the participants knew of the importance of folic acid for the unborn foetus [28]. A study conducted in Sudan found that only 8.9% of 1000 pregnant women knew that folic acid prevented birth defects [25].

Alcohol and tobacco use during pregnancy is detrimental to the health of the unborn child [29]. Persistent tobacco inhalation can cause preterm labour, low birth weight, intra-uterine growth retardation, and spontaneous abortion [30]. It is also related to foetal alcohol syndrome [31]. The prevalence of foetal alcohol spectrum disorder (FASD) in South Africa ranges from 29 to 290 per 1000 live births [32]. Many research studies have focused on the population’s knowledge of the harmful effects of smoking and alcohol use among adult women of reproductive age. However, research data of knowledge of this threat among pregnant and parenting adolescent women are limited. This is a matter of grave concern, as this study found that only 19.6% of the participants knew that alcohol consumption results in low birth weight. A national survey among Australian women aged 18 to 45 years revealed that only 28.5% knew that drinking alcohol during pregnancy could result in low birth weight [31]. Furthermore, the participants’ knowledge of the negative effects of tobacco during pregnancy on the unborn child was poor, as only 22.4, 16.6 and 6.7% identified that smoking tobacco during pregnancy can result in low birth weight, spontaneous abortion and preterm labour respectively. These findings are low compared to those of a US study among pregnant adolescents and adolescent mothers that found that 79.6, 85.3 and 89.0% were able to correctly identify that smoking during pregnancy results in low birth weight, spontaneous abortion and preterm labour respectively [33].

In our study, 42.9% of the participants knew that pesticides should be avoided, compared to 96.0% who knew this in a survey conducted in Northern Thailand [34]. However, regardless of their high knowledge of the harmful effects of pesticides to the unborn child, 37.0% of participants in Thailand admitted that they still used pesticides in their homes during pregnancy [34]. The knowledge of the harmful effects of pesticides to the unborn child is of public health importance due to neurodevelopmental toxicity [34]. Cats harbour the protozoan parasite Toxoplasma Gandii in their intestinal tract [35] that causes Toxoplasmosis. Toxoplasmosis infection during pregnancy can cause spontaneous abortion, preterm labour, cerebrospinal fluid abnormalities, retinochoroiditis scarring, and intra-uterine growth retardation [35]. Respectively, only 41.1 and 37.0% of the participants in this study agreed that playing with cats and cleaning a cat’s litter box should be avoided. This rate is low compared to the 77.9% of participants who correctly indicated that a pregnant woman should avoid cleaning a cat’s litter box in a study conducted in the Netherlands [36]. The contrast in these findings could be due to a higher literacy rate and access to antenatal education in the Netherlands.

The World Health Organization recommends exclusive breastfeeding for the first 6 months as a global strategy for infant and young child feeding [37]. Breastfeeding has numerous health benefits for the mother and child. The benefits for the child include reduction of dental cavities, improved immunity, and protection against the risk of diabetes and obesity later in life [38]. Most studies to date have investigated knowledge of breast feeding practices rather than knowledge of the health benefits of breastfeeding. In this study, 71.8% correctly identified that the recommended period for exclusive breast feeding is 6 months. Similarly, 70.13% of participants in a study conducted in Croatia identified that exclusive breast feeding is recommended for 6 months [39]. Most of the participants (78.8%) in this study agreed that breastfeeding improves the immunity of babies. Although somewhat lower, this finding was high enough to support the 92.9% of a Croatian study [39].

STIs increase the risk of HIV infection, pelvic inflammatory diseases, life threatening pregnancies, and infertility [40]. Adolescents have a higher risk of STIs than adults [41]. In this study, the participants were unable to identify common STIs as only 24.5, 15.0 and 15.6% were able to identify Gonorrhoea, Syphilis, and Genital Herpes as STIs respectively. These findings are consistent with those of a study conducted in Nigeria where 23.0% identified Gonorrhoea, 2.8% identified Syphilis, and 6.5% identified Genital Herpes as STIs [42]. However, the ability to identify signs and symptoms of STIs was better as most participants were able to correctly identify genital sores (57.1%, n = 186), burning urination (54.9%, n = 179), discharge from the vagina (65.6%, n = 214), and discharge from the penis (59.8%, n = 195) as symptoms of STIs. These response rates were far better than those found by Sharma and Sherkane [40], in whose study only 22.8, 41.7 and 13.9% identified genital sores, genital discharge and burning urination respectively as signs and symptoms of STIs.

The prevalence of HIV amongst women of reproductive age is high in South Africa [43]. In this study, 70.2% of the participants was aware that a pregnant woman infected with HIV can transmit this disease to her unborn child, which was high in comparison to the 51.6% in a study conducted in India [44]. Most participants (92.6%) in the current study confirmed that condom use can prevent HIV and STIs, in comparison to 55.6% who had this knowledge during a study conducted in Nepal [45]. With regards to HIV prevention, 7.7% thought that birth control pills would prevent HIV infection. This is low compared to the 41% in a study conducted in South Delhi, India, who incorrectly believed that birth control pills would prevent HIV infection [46].

A recent study by Amod et al. explored adolescent mothers’ perceptions of the Life Orientation curriculum in Gauteng, South Africa [47]. The participants felt that although sexual health was included in Life Orientation, their teachers were not comfortable to teach them about sex education. Furthermore, the participants reported that learners would laugh during the lesson and this annoyed the teacher. Under these circumstances, the lessons on sexual health would be dismissed. Similarly, a study on learners’ experiences of Life Orientation in the North-West Province reported that 33.3% of learners mentioned that sex education was covered in Life Orientation [48]. In this study, 87.7% mentioned that adolescent pregnancy was covered in Life Orientation, while 77.9% mentioned that HIV/AIDS was covered in Life Orientation. Contrary to the findings of our study, 33.8% of the North-West study stated that HIV/AIDS was covered and 22% stated that adolescent pregnancy was covered in Life Orientation.

On face value, the Life Orientation programme appears encouraging, but the practical implementation of this programme has been plagued by many problems, and thus the limited research that has been done on its efficacy in terms of SRH education should be augmented as a matter of urgency.

Personal attitudes towards sexuality and reproductive health is often under-researched. In this study, only 26.7% agreed that abstaining from sex is difficult during adolescent years. This suggests that most participants had a positive attitude towards abstinence. Similarly, a study by Masters et al. [49] found that more females than males reported positive attitudes towards abstinence (means 3.6 vs 4.0 on the five-point Likert scale, where a score of 3 was neutral). In the current study, only 16.3% believed that condoms reduce sexual pleasure during sexual intercourse. During a literature review regarding decision making and condom use among South African women, Mash et al. [50] found that men were more likely to believe that condoms reduce sexual pleasure than women. In a patriarchal society, South African women are disempowered and more likely to please their partners by agreeing not to use condoms during sexual intercourse [50]. Thus gender based power inequalities were clearly voiced when 66.3% of the participants in this study agreed that it is females who are responsible for protection during sexual intercourse. Furthermore, 23.9% indicated that they would be too embarrassed to buy or find condoms, which suggests that they were not in a situation to negotiate protective sexual intercourse.

Peer influence is related to sexual risk behaviour and adolescent contraceptive behaviour is also influenced by peer norms. Govender et al. [51] conducted a scoping review and found that adolescents who associated with friends who were adolescent parents were more likely to become adolescent parents themselves. In the current study, 66.8% of the participants had friends who were adolescent mothers which, based on the former study, may suggest that they might be at risk of engaging in unprotected sexual behaviour as well.

The participants limited knowledge of preterm labour, anaemia, alcohol and tobacco use, and sexually transmitted infections may hamper the Safe Motherhood Initiative. The misconceptions harboured by these adolescents about oral contraception and protection against HIV and STIs also suggest the threat of unsafe sexual practices among young people in the Ugu community. Health education on SRH is an integral part of the Safe Motherhood Initiative that is aimed at educating societies about safe sexual conduct.

The study has several limitations. Firstly, our study was conducted in only one district in KwaZulu-Natal and therefore the findings may only be generalised to the Ugu and similar districts. Moreover, the study did not investigate the participants’ sources of pregnancy or information regarding their sexual and reproductive health. Recall bias was likely to have occurred when participants are asked about their past exposures. The use of convenience sampling could have also lead to under-representation or over-representation of particular groups within a sample. Although our inclusion criteria stipulated that adolescent girls under the age of 18 years had to obtain parental/legal guardian permission prior to consenting to participate in this study, we report that there were no participants under 18 years who were excluded in the study because parents and legal guardians were available to provide written permission.

The adolescent participants’ knowledge of pregnancy, sexual and reproductive health was deficient in many respects. Our research has shown that, regardless of repeat pregnancies, adolescents were not necessarily better informed about pregnancy, sexual and reproductive health. Thus we conclude that social determinants, modes and platforms regarding the delivery of adolescent sexual and reproductive health education have become more important than ever before. Moving forward, an innovative mode to the delivery of sexual and reproductive health education includes the emerging digital platform [1, 52]. The digital platform encompasses social media, multimedia and mobile phones which is growing popular among young people. Previous studies in Sub-Saharan Africa have demonstrated the feasibility of using mobile phones to deliver SRH information [53, 54].

Schools can play a role in reducing high risk sexual behaviour, transforming the future and improving the well-being of all adolescents. The role of the education sector is therefore crucial as schools can offer skills based SRH education. Schools are also an ideal social environment that can target the individual, families and societies [15]. The role of the healthcare sector is equally important. Health facilities need to be adolescent or youth friendly with convenient service hours. Healthcare providers also need to provide non-judgemental adolescent SRH education and services. Universal access to SRH as echoed in SDG 3 can only be achieved through intersectoral collaboration. Knowledge through education is likely to ensure that adolescent women are better informed to make appropriate decisions about their health during pregnancy and childbirth.