Live Experiences of Adolescent Mothers Attending Mbale Regional Referral Hospital: A Phenomenological Study

Background Adolescence is a period of transition from childhood to adulthood, and is a critical stage in ones' development. It is characterized by immense opportunities and risks. By 2016, 16% of the world's population was of adolescents, with 82% residing in developing countries. About 12 million births were in 15–19 year olds. Sub-Saharan Africa, particularly East Africa, has high adolescent pregnancy rates, as high as 35.8% in eastern Uganda. Maternal mortality ratio (MMR) attributable to 15–19 years olds is significant with 17.1% of Uganda's MMR 336/100.000 live births being in this age group. Whereas research is awash with contributing factors to such pregnancies, little is known about lived experiences during early motherhood. This study reports the lived experiences of adolescent mothers attending Mbale Hospital. Materials and Methods A phenomenological study design was used in which adolescent mothers that were attending Young Child Clinic were identified from the register and simple random sampling was used to select participants. We called these mothers by way of phone numbers and asked them to come for focus group discussions that were limited to 9 mothers per group and lasting about 45 minutes–1 hour. Ethical approval was sought and informed written consent obtained from participants. At every focus group discussion, the data which had largely been taken in local languages was transcribed and translated verbatim into English. Results The research revealed that adolescent mothers go through hard times especially with the changes of pregnancy and fear of unknown during intrapartum and immediate postpartum period and are largely treated negatively by family and other community members in addition to experiencing extreme hardships during parenting. However, these early mothers' stress is alleviated by the joy of seeing their own babies. Conclusion Adolescent motherhood presents a high risk group and efforts to support them during antenatal care with special adolescent ANC clinics and continuous counseling together with their household should be emphasized to optimize outcome not only during pregnancy but also thereafter. Involving these mothers in technical courses to equip them with skills that can foster self-employment and providing support to enable them pursue further education should be explored.

As of 2016, adolescents made up about 16% of the World's population with 86% of them living in the developing World. Approximately 21 million girls aged [15][16][17][18][19] years become pregnant in the developing world and about 12 million gave birth. At least 777,000 births occur to girls below 15 years of age in the developing world [2][3][4].
Adolescent pregnancy is very prevalent in Africa especially Sub-Saharan Africa. In a systematic review and metaanalysis of published and unpublished studies in Africa by Getachew et al., the overall prevalence of adolescent pregnancy in Africa was 18.8% and highest at 19.3% in Sub-Saharan African (SSA). East Africa registered the highest prevalence at 21.5%, while the North African region registered the lowest rate at 9.2% [5]. Moreover, a multilevel analysis of risk and protective factors of pregnancy and early motherhood among adolescents in five East African countries, in which the researchers focused on weighted subsample of adolescents aged 15-19 years pregnancy and early motherhood, was common in the five countries, ranging from 18% among adolescents in Kenya (2014) to 29% in Malawi (2016) and Zambia (2014) [6].
Adolescent pregnancy is associated with increased odds of maternal and perinatal adverse outcomes. Neonatal mortality increases as the age of the mother decreases; teenagers who give birth before the age of 15 years are five times more likely to die during pregnancy or delivery as women in their 20s, partly as a result of physical immaturity [7][8][9]. However, adolescent pregnancy and motherhood not only negatively affect the teenage mother in terms of health but also have far reaching physiological, psychosocial, economic, and cultural consequences such as dropping out of school, failure to reach ones potential, siblings likely to get pregnant, and 'doorway' to poverty [7,8,[10][11][12][13]. Some studies have held that it is a catastrophic period that literally prescribes one's 'life script' [14]. e 2016 Uganda Demographic and Health Survey reported one of the highest maternal mortality ratios of the World at 336 per 100.000 live births and 17.1% of these were contributed by adolescents aged 15-19 years [15]. Although overall estimated prevalence of teenage/adolescent pregnancy in rural Uganda is at 27%, other regions especially Eastern Uganda continue to register rates higher than the national average, such as 35.8% in Kibuku [7,15].
Factors associated with adolescent pregnancy including rural residence, ever married, being out of school, no maternal education, no father's education, lack of parent to adolescent communication on sexual and reproductive health (SRH) issues, divorce, contraceptive nonuse, multiple sexual partners, frequent sex, peer pressure, sexual abuse, and lack of control over sex were observed to increase the likelihood of teenage pregnancy [5,16,17].
Several studies have in fact urged that some adolescents have benefitted from early motherhood and become more responsive to positive living. It has further been urged that, once supported, these adolescent mothers can attain potential as much as their peers that postponed child bearing. Moreover debate has raged on that the undesirable lifestyles are not a consequence of adolescent pregnancies and motherhood but rather an extension of the predisposing factors [18][19][20].
However although studies have been done in different parts of the country to ascertain the factors associated with teenage pregnancies, there is a dearth of research concerning phenomenological studies to hear the adolescents' lived experiences.

Selection Criteria.
Using the clinic's register, we selected the participants by purposive sampling among those that had recently visited the facility with efforts taken to create diversity by inviting mothers from different parishes. e mothers were traced through their telephone contacts. If the availed number did not go through, the next coupon was picked till one was approached. e numbers used were either their own or ones of their relatives/friends as had been registered during the clinic day. We used the register since those mothers are at least 6 weeks postpartum and are thus more relaxed and likely to hold a discussion. e nature of the research was explained to the adolescent mothers and their voluntary participation was sought.

Sample Size.
ere was no sample size but FGDs were halted on realizing that saturation level had been reached.

Ethical Considerations.
Ethical approval for this study was obtained from Cure Children's Uganda-Research and Ethics Committee (CCHU-REC/19/019) and administrative clearance sought from Mbale Regional Referral and Teaching Hospital (MRRTH). Informed consent was obtained from the research participants and participation was voluntary and efforts were taken to observe confidentiality. e participants were informed of voluntary nature of participation and ability to withdraw from the study at any time without undue explanations and that this would never jeopardize their ability to seek services from any department of MRRTH.

Data Collection and Management.
Each focus group discussion was made up of 9 adolescent mothers and lasted for approximately one hour. In order to maximize openness and confidentiality, the research assistant used was not an employee in the clinic and had training in qualitative data collection. e research assistant had training prior to embarking on data collection. ere were 10 guiding questions we used during the interview. ese questions were developed for this research (supplement). e data collection tool was pretested on other adolescent girls in the adolescent clinic. e focus group discussions were held in venues that were convenient for participants, such as open spaces at the health facility (after close of clinic hours). Lunch and transport refund were provided to the participants.
At every focus group discussion, the notes and recordings taken were largely in the local languages of Lumasaba, Lugwere, Luganda, and Ateso. Some participants communicated in English. After every focus group discussion, the recorded discussions were fully transcribed and translated verbatim into English [22]. Each transcript was analyzed by two researchers working independently to reduce bias using NVIVO software version 13. Coding was done manually based on the key words and phrases developed from the data. e codes were then grouped together into higher order headings. Accordingly, on a higher logical level of abstractions codes, subcategories, categories, and themes were formed. e themes were categorized according to the experiences in relation to pregnancy, child bearing, child care, parental views, and reactions. e data was sorted out thematically by clustering material with similar content. At this stage, we used a creative and analytical reasoning to determine categories of the meaning.

Results
Forty-five of the sixty-five adolescent mothers that were approached participated in the study. 20 were unable to come since they had relocated to places far away from Mbale. In each FGD, some of the study participants reported that there was shame to have a baby at an early age and some expressed regret.
"I feel ashamed because people will laugh at me," 18-yearold participant.
"I feel ashamed because my school mates will laugh at me," 19-year-old participant.
"I feel ashamed in the community because of pregnancy though I have hope of getting the baby," 19-year-old participant.

Subtheme: It Feels Bad.
In each of the discussion groups, participants mentioned they felt bad because people in the community went on talking about how they left school after conceiving their babies.

"I feel bad because people talk about me because I left school when still young" (19 years old).
"I feel bad because I left school and lost friends" (19 years old).

eme 3: Fear of Reactions from Parents, Community, and
Colleagues.
e majority of the participants reported that their parents and guardians were not happy upon hearing the girl was pregnant; to many parents, pregnancies came as a surprise and they were upset and shocked. Participants had fear on how their parents would react upon hearing that they were pregnant. "Some parents sent me away from their homes to avoid spoiling their daughters" (17 years old).
" ey felt bad and sorry for her while other people were happy because she has also been brought down like others" (17 years old).
In one of the discussion groups, a participant reported that some of her community members felt so good upon her pregnancy because she had joined the group of drop-outs.
"Some of the community members felt good because I have joined them" (19 years old).

Subtheme: Teachers'
Reactions. Some of the participants reported that they felt bad and most especially the teachers.

" ey felt very bad especially my teachers" (19 years old).
" ey felt so sorry for me" (17 years old).
" e teachers and the community members started to talk against me when I got married" (18 year old).

"I and my teachers felt unhappy when I got pregnant at school" (19 years old).
" e teachers, parents and the community were not happy when I went to get married" (17 years and 19 years old).
"My teachers, guardians and friends were not happy and went police to report the case, my boyfriend was put in jail" (18 years old).

Subtheme:
In-Laws Reaction. Some of the participants mentioned that their in-laws and their parents were happy when they got pregnant. e in-laws expected them to take care of them, while some parents expected to receive dowry as it is a custom in the area.
"My in laws were happy that I was going to take care of them" (19 years old).

eme 6: Reaction Based on Marital Status.
Most participants reported that the unmarried teenage mothers are not given due respect by the community.
" ey are not given any respect because they delivered while at their parent's home" (18 years old).
" ey are being under looked, not loved and even friends have neglected them" (19 years old).
" ey are being laughed at by the friends, that they will never marry" (17 years old).
" ey are being abused and harassed because they expected a lot from them" (19 years old).
" ey feel bad because they have dropped out of school" (19 years old).
All participants reported a negative feeling of being called a mother out of marriage as it was associated with shame and embarrassment to parents and the family at large. A few of the participants mentioned that they had no support from their partners; they showed no love, no attention, and no support towards the caring of the child.
"I wanted to eat after delivery but I had nothing" (18 years old).
"I lack a source of income for supporting the baby, medication, feeding and clothing" (19 years old).
"I have no assistance from the man, he is very rude to me" (16 years old).

Subtheme: Stress.
Two of the participants report that there was stress in caring for the baby.

"I feel a lot of stress in caring for the baby like who to feed, clothing the child and medication of the baby" (19-year-old participant). "It's hard and stressing to have a child at this age because I was not prepared for the child" (19-year-old participant).
3.7. eme 7: Abortion 3.7.1. Subtheme: Option of Abortion. One of the participants mentioned that she had opted to carry out an abortion although she failed to procure one. She narrated that this would have been a better option taken to dodge community embarrassment. Most young girls do abortion without knowledge of their parents or guardians.
"As teenage girl I had fear and opted to abortion the baby to avoid being away from home to the boy's home" (19-yearold participant).

eme 8: Effects of Teenage Pregnancy.
e participants in each of the discussion groups mentioned that pregnancy affects them not only physically but also psychologically, physiologically, and emotionally. "I had wrong peer groups who led me into trouble" (19 years old).

Subtheme: Orphans.
In the two focus group discussions, some participants mentioned that they are orphans, parents died when they were still young and these rendered them vulnerable to teenage pregnancy. e guardians and grandparents were unable to support them while at school.
"I am an orphan, my parents passed on when I was still young, my guardians took care of me but they could not support me at school financially so I ended up in the hands of a man who tried to support but made me pregnant before I completed school" (19 years old).
"I am an orphan, my grandparents could not support me at school and I was left with no choice but to get married" (19 years old). 3.9.4. Subtheme: Parental Pressure. In one of the group discussions, one of the participants mentioned that she had parental pressure. e parents wanted dowry and since the girl respected her parents, she had to go for marriage.

"My parents wanted dowry and I had no choice" (19 years old).
3.9.5. Subtheme: Sexual Experimentation. Some of them confessed having been stubborn; they could not heed to the parental advice and went on their own engaging and experimenting in sex. ey preferred to explore and receive advice from the peers than the parents. Adolescence is a rebellious stage where the teens are so wild; do not listen to counseling even when parents are able to provide everything they needed. eir stubbornness led them into pregnancy.

"I failed to listen to parents' advice, I became too stubborn. My boy friend used to give money and these worsen everything and I thought I had everything. I could not turn down my boyfriend's proposal till he made me pregnant" (19 years old and 18 years old).
"I felt it was time to try these things and we had competition due to high demand of good things which the boy friend could provide" (19 years old).
We also explored the ways they thought adolescent pregnancy could be prevented in the community, what services an adolescent mother could expect to receive while at the health facility, and ways government can help the affected mother.

eme 10: Ways ey ought Adolescent Pregnancy
Could Be Prevented. Most participants from each discussion group mentioned that teenage pregnancy could be prevented through health education, abstinence, family planning, being patient, counseling and guidance, listening to parental advice, avoidance of wrong peer groups, education of girl child, and provision of basic needs to girls by the parents.
"Teen pregnancy can be prevented through health education about the dangers of early pregnancies" (18 years old).
"Teenage pregnancy could be prevented by abstaining from sex until the right age reaches" (19 years old).

"Use of family planning methods and patience could help in prevention of teenage pregnancy in our community" (15 years and 19 years old).
"Teenage pregnancy can be prevented through counseling the teenage girls by telling them reality of what happens to them. Tel them of the real problems she has gone through so that they do not fall victims of circumstances" (17 years old).
"Girls should avoid bad peer groups and listen to advice from parents" (16 and 18 years old).
"Parents should provide young girls with basic needs" (15 years old).

eme 11: Suggestions on Services Teenage Mothers Expect to Receive from the Health Facility.
A number of study participants suggested that they wished to receive Maama kits, parental love and care, counseling and guidance, strengthening of free treatment services, health education and counseling on care of the baby, family planning, mosquito nets, and enough number of staffs to attend to them. Mama Kit is a basic kit for normal delivery that is distributed to all expectant mothers attending antenatal care clinic in public facilities in Uganda but is also sold. It contains essential items for a clean and a safe delivery by mothers [23].
"We expect to be given mama kits during our pregnancy from this health facility" (19 years old).
"We expect to be given parental love and care from the health facility by both the doctors and the midwives and not shouting at them" (19 years old).
"I expect to receive counseling and guidance by the health workers from the health facility" (17 years old).

"I expect to receive proper examination by the nurses/ midwives and the doctors for all the patients" (18 years old).
"I expect to receive health education and counseling on how to care for the baby and nutrition" (19 years old).
"I expect the health facility to be giving family planning advice to the young girls" (15 years old).
"Mothers should be given mosquito nets, free treatment" (17 years old).

eme 12: Suggestions on How the Government Should
Help ose Already Affected

Discussion
Being an adolescent/teenage mother brings with it different feelings and challenges. What is directly known is that these adolescents have got enormous responsibilities in addition to their needs as adolescents [19,24]. Research has shown that these challenges not only affect the current generation but also spill over to the next generations [25]. Although it has been a long time held view that adolescent pregnancy is catastrophic in ones' life [14], research also suggests that it may actually form the 'backbone' and turning point of one's life from that describable as 'irresponsible' to a more responsible and meaningful life, once one is offered the necessary support [18,26].
In our study, several adolescents expressed positive feelings of becoming a mother, being looked at as one who has grown up in the community and having achieved what other adults had strived to achieve but in vain. Being a mother felt good. is finding was similar to one in a study in Australia among the African born refugee [27], Belgium [28], and one in Ghana [29]. Motherhood, however, also brought some mixed feelings and experiences. It was associated with stress, fear of labour pains, damage to the reproductive system, and anxiety of caring for the baby.
is was further compounded by lack of the partners' support in addition to disapproval by community members, family, and rejoicing teenagers that had earlier dropped out of school for various reasons. Research elsewhere has shown similar findings and reported that spouse support, immediate family support, and school administrators support were critical in elevating these young ladies' self-esteem, resumption of school, and completion of college education [18,24,27].
In our study, the findings indicated that the community negatively perceived adolescent pregnancy and such a girl was described as spoilt and thus not worth interacting with, especially by the nonpregnant adolescents, not worth wasted school fees, an outcast by parents and community, and a source of shame to their families. is was similar to findings in studies in Ghana and South Africa [29,30]. ese findings are echoed by the adolescent girls themselves who stated that the community was more positive of one who conceived after marriage, at age above 18 years (legal age for marriage in Uganda) [31]. In this study, the adolescents further described what the culturally acceptable sequence of events is: marriage and then pregnancy and therefore deviation from this norm was typically met with a negative view of the adolescent girl and her pregnancy [13,31]. e negative sentiments by the community are not only in Africa but also have been expressed elsewhere, though still in the same population of Africans [27].
is finding further agrees with a study in South Africa that shows that generally African cultures disapprove of adolescent pregnancies [32]. e negative view is further amplified by the adolescents' expression of repercussions of adolescent pregnancy on school attendance as expressed in other studies. Moreover, related research has shown that keeping girl child in school is a way of averting adolescent pregnancy and motherhood [20,33,34]. e stigma starts form the girl herself to the school community. Some may be expelled or asked to return after giving births [14,31]. A study by Kaye further stressed that even when these adolescents come to health facilities, they are stigmatized by health workers [11]. is finding is in contrast to the one by Phoua Xiong among the Hmong communities because the latter takes it as a norm [25]. But it is worth noting that the acceptance in the Hmong community is for 'face saving' in order to create harmony [35]. e disapproval of teenage pregnancy by the community and friends leads to these mothers contemplating and at times executing abortions [29,31,32]. ese negative sentiments coupled with restrictive laws on procurement of abortion services are sought to undermine efforts aimed at curtailing maternal mortality [36][37][38]. In our study like in the above studies, some girls had attempted to abort but failed.
Poverty was highlighted as one of the reasons these girls got pregnant. ey expressed their parents' desire for dowry, failure of the parents to provide tuition, scholastic materials, and other basic needs. is affirms that poverty is a driver of adolescent pregnancy and childhood marriages [29,39]. is finding further emphasizes the concept of transactional sex phenomenon in Uganda and other parts of Africa [29,31].

Reasons for Becoming Pregnant.
A score of participants explained that it is their experimentation of sexual intercourse that got them into pregnancy. ey confessed to not listening to parents' advice but rather relying on their peers. eir peers advised them to have sexual intercourse as a sign of love. In addition to sex experimentation and peer pressure, others blamed this on orphanage and parent pressure. ese latter two were all related to the inability of the parent or guardian to provide for the adolescent girl, while in some cases the parents wanted dowry. ese findings were similar to a study in Ghana where adolescents expressed the same reasons, but, in contrast to Ghana study, there was no adolescent who got pregnant because she did not know that indulging in sex could get one pregnant [29].
Despite the physiological and economical vulnerability of these adolescents, they managed to carry their pregnancies till delivery. Some though expressed regret dropping out of school, being labeled as outcasts, spoilt and money wasters, and lacked support from partners and community. ese sentiments are in agreements with studies elsewhere [19,29,31]. eir economical vulnerabilities were further expressed in the lack of utilities when they visited public health facilities. Several of these adolescent mothers suggested that economic empowerment projects, especially those that encompass technical skills, and social and moral support aimed to help the mother return to school after giving birth, and strengthening the defilement law would better the girl child. Worth noting is that Uganda has got a very stringent law on defilement [40] but with a lot of implementation challenges especially due to weak legislation and out-of-court settlements between the plaintiff and offender [41, 42].

Conclusion
e study builds our understanding of the unique features, challenges, and desires of these adolescent mothers, which services to provide to them, and ways of how to address the problem from their own perspective. It further emphasizes the need for champions in parent/s' love and provision of counseling and family planning services in the fight against adolescent pregnancy. Most are willing to go back to school and pursue their goals and thus need tremendous family and community support. Adolescent mothers further thought that strenthening and implementaion of the defilement laws would offer more protection against the vice.
e study further showed that most of these adolescents are in consensual relationships and rarely attempted abortion.

Suggested Areas of Research
What are the lived experiences of adolescent fathers?

Strength of the Study
We demonstrated that adolescents have a say in their pregnancy and could help us design the programs that benefit them during antenatal care and in everyday life thereafter especially equipping them with skills.

ANC:
Antenatal care MRRTH: Mbale Regional Referral and Teaching Hospital SSA: Sub-Saharan Africa SRH: Sexual and reproductive health UDHS: Uganda Demographic and Health Survey WHO: World Health Organization.

Data Availability
e data used to support the findings of this study are available from the corresponding author upon request.
Ethical Approval e study was cleared by the Cure Children's Uganda-Research and Ethics Committee (CCHU-REC), and then Mbale Regional Referral and Teaching Hospital Institutional Review Board (MRRTH-IRB) provided the administrative clearance.

Consent
Individual informed written consent was obtained from each study participant prior to taking part in the study. For those below 18 years of age, consent as emancipated minors in accordance with Uganda National Council of Science and Technology guidelines was obtained. Modest transport refund was given to them at the end of the focus group discussions to enable them to travel back and attend other businesses of interest.

Conflicts of Interest
e authors declare no conflicts of interest.

Authors' Contributions
CV and NJ conceptualized the idea. GWJ supervised protocol writing and data collection. CV, NJ, and GWJ carried out the analysis, interpreted the result, participated in drafting the manuscript, revised the manuscript, and approved the final manuscript for submission. All authors read and approved the final manuscript.