We conducted 20 IDIs and 5 FGDs. The mean age of participants at study enrollment, prior to first sexual intercourse, was 19 years old for IDIs and 18 years old for FGDs (interquartile range [IQR] 18–19; 17–19, respectively). At the time of interview, after first sex was reported, mean age of participants was 20 years old for both IDIs and FGDs (IQR 19–21 for both). All participants had completed at least primary school education with 60% of participants reporting that they were enrolled in college or university level studies. Mean years of education for all participants was 12 (IQR 11–13).
Three primary themes around AGYW use of contraceptives emerged from our analysis of interview data: (1) AGYW perceived pregnancy to be undesirable, although this did not necessarily translate to increased uptake of contraception, (2) misconceptions about contraceptives led to avoidance of hormonal contraceptives, especially long acting reversible contraceptives, and (3) participants reported preference for emergency contraceptive (EC) pills as contraception, both personally and among their peers
Theme 1: AGYW describe pregnancy as an undesired present outcome
As AGYW in our study shared reflections on their early sexual experiences, the risk of unintended pregnancy was consistently highlighted as their greatest concern. This risk perception was rooted in a desire to avoid negative community perception and a fear of stunting life and educational opportunities. One participant noted in an FGD that:
“…a baby comes with responsibilities and changes the direction of your whole life, you stop schooling. What will happen if my family knows I am pregnant and I am not yet through with school?” (FGD 4)
For this participant, pregnancy would likely deter from continued schooling and damage relationships with family members. A number of participants also expressed worry that a pregnancy might lead to rejection and abandonment by their partners and, thus, feared the responsibility of having to care for a child without additional support:
“Some have fear of their boyfriends denying being responsible for the pregnancy. Like when you tell a partner that the pregnancy is his, he will deny because you don’t have evidence.” (FGD 5)
Another participant noted that she feared being perceived negatively by peers, recalling the experience of a classmate who became pregnant:
“I remember one day we were studying for exams and one lady was pregnant and her friend says ‘Ghaii [God]! She is pregnant’. Like if [this were] me I cannot imagine friends talking about me like that, no no…let me just stay away from pregnancy.” (FGD 2)
Participants also expressed repeatedly that AGYW perceived pregnancy to be less acceptable than the risk of contracting HIV or another sexually transmitted infection. One participant noted that “most [girls] fear getting pregnant, they don’t usually think of the diseases [HIV]” (IDI, 09). Another participant, describing her own experience, expressed: ‘I was not concerned with that [HIV], I was just concerned about getting pregnant” (IDI, 10). When asked in an FGD to expound upon this discrepancy, another participant explained:
“I hear that if you get HIV you will use ARV and nobody will know you have HIV, but with pregnancy everyone will know.” (FGD 4)
There was a consensus among participants that because pregnancy was not as discreetly manageable as HIV or other STIs, young women would be more likely to take preventive measures that would reduce their risk of pregnancy more readily than preventive measures to reduce HIV risk.
Theme 2: AGYW have knowledge of contraceptive methods but continue to describe concerns and misconceptions around contraceptive use.
When asked to detail knowledge regarding different kinds of contraceptives, participants felt that they and their peers were well-informed, with one participant in an FGD stating that:
“Most girls are informed in this era so it is all about ignorance. If you ignore the information definitely you will face the consequences, so most girls are informed. It is just ignored.” (FGD 4)
Another participant in the same group elaborated:
“I guess right now I don’t think there is a girl who doesn’t know all the ways of preventing pregnancies and STIs. I really concur with her that it is just ignorance. Even if you ask today a girl who has just finished with her high school on ways of preventing HIV and STIs, they will tell you all of them.” (FGD 4)
AGYWs were able to list and describe most major types of contraceptives, including injectables, EC pills, daily oral contraceptives, implants, condoms, and intrauterine devices. Many were able to detail important side effects and considerations, with one FGD participant stating:
“When using Depo-Provera [injectable contraceptive], a person gets side effects like having heavy menses, or suppressed menses.” (FGD 05)
Another interviewee noted that:
“From my observation many people prefer injections because it is easier to forget taking the daily pills because sometimes…let us say that you are on a journey and forgot the pill…” (IDI, 20)
However, alongside this general knowledge regarding contraceptives, there were also a number of misconceptions that emerged among participants, especially around long-acting reversible contraceptives (LARCs). One of the most commonly held misconceptions was that use of contraceptives, particularly before someone has successfully carried a pregnancy to term, would lead to infertility. This sentiment was expressed in the majority of interviews, with many participants noting that this misconception was their reason for not using contraceptives, especially LARCs:
“I didn’t want to take that medicine that they usually say people should take…I hear they are not good…they can prevent you afterwards [from having a] child.” (IDI 03)
Others expressed similar sentiments about a variety of contraceptives, with many young women noting that:
“Girls don’t like Jadelle [the implant], because that is spoiling them. If you have that [implant] and fail to get a child in future you will regret. However, it is not difficult to accept if you have already delivered.” (FGD 01)
“People say that the fertility is reduced. The fertility is reduced so many girls opt for P2 [the EC pill].” (IDI 16)
This widespread misconception that early use of contraceptives might have some effect on fertility spanned across contraceptive types. Participants noted that these misconceptions influence decisions about contraceptive use among young women, with one interviewee noting “you get discouraged by the beliefs people have out there” (FGD 03) and many participants expressing that perceived risk of infertility impeded many from trusting LARCs, injectables, and oral contraceptive pills as safe forms of pregnancy prevention. They described beliefs regarding the negative impact of hormonal and long-term contraceptives on reproductive organs, cancer, and miscarriage, all of which deterred AGYW from using LARCs and other long-term hormonal contraceptives.
Theme 3: EC pills were described as the preferred contraceptive choice among AGYW compared to longer acting, more reliable contraceptive methods
Among our cohort, the EC pills emerged as the most commonly discussed and popular form of contraception. As illustrated in prior themes, AGYW describe being motivated by a fear of pregnancy, yet, despite their adequate knowledge of contraceptive methods, also describe being reluctant to use contraception. When examining the actual contraceptives used by AGYW, they report that condoms, oral contraceptive pills and other long-term and hormonal forms of birth control were avoided by their peers, reflecting that:
“Not many people use condoms. The only thing they fear is getting pregnant but not HIV, so I do not think that the condoms work.” (FGD 01)
“You will get that…most girls in campus do not like having protected sex so you get that today they take P2 [the emergency pill], so they don’t care about themselves as long as I don’t get pregnant…the rest they don’t care.” (FGD 2)
“P2” (or Postinor 2), the EC pill, was discussed by participants as a popular choice of birth control, though they felt that their peers were often ‘misusing’ the EC pill by adopting it as a primary form of contraception. One participant noted that:
“There is the emergency pill but…when you use it so often it will not work. It should…only be used when maybe it [sex] was an accident…but mostly nowadays they are misused.” (IDI 12)
Easily accessible at pharmacies, the EC pill offers adolescent girls a convenient, low-cost way to access contraceptives, thereby minimizing the need to make return visits (to collect pills) or to schedule an appointment in a public hospital (for an IUD, implant or Depo Provera injection) in order to access pregnancy prevention. Participants also perceived the risk of side effects (including misconceived notions of infertility) to be lower with EC pills than with LARCs, making the EC pill the contraceptive method that they felt had the least consequences with use.