The mean age of the 40 women participants was 25 years (SD: 4.5years). The majority (70%) had competed their high school education or beyond, but 58% had no paid work and 18% depended on a social grant for income. Most (78%) had one or more prior pregnancies, 13% had prior abortions. Half (54%) did a pregnancy test at home; the remainder had the first test for this pregnancy at a health facility. Half (50%) had partners who were supportive of their decision to abort this pregnancy. Gestational age at time of pregnancy confirmation was more than 7 weeks for majority (65%). Half (55%) had used the injectable, 33% had used dual contraceptive methods (injectable and condoms) in the past and 15% had no prior usage of any method.
Three main themes with subthemes emerged in the interviews and discussions with women participants. Main themes included pregnancy recognition, experience with confirming the pregnancy and women’s knowledge of fertility, the menstrual cycle and when to test for pregnancy
1. Pregnancy Recognition
Women’s own recognition of pregnancy
Although many women detected pregnancy signs and symptoms, often they did not link them immediately with the possibility of being pregnant and waited to gain better clarity on how to interpret them. Postponement was often a consequence of having previously missed a period without being pregnant, having irregular periods or not keeping track of their menstrual cycle.
Well, I definitely thought that maybe my, my period has skipped a month because why, normally it does that sometimes, it skips a month or 2 and then it comes back again…but then when the second month came and I still didn’t get.. my period, that’s when I started realising okay, it could be possibility that I might be pregnant.” (IDI)
The role of the “other” in recognizing this pregnancy
Women mentioned that others, including family members, friends, partners or work colleagues noticed pregnancy signs and symptoms. This recognition of pregnancy by others in their social networks frequently acted as a catalyst for women to seek confirmation of pregnancy. Some recounted very supportive actions by their partner in helping them do their first test.
“My boyfriend, ja, he commented on my boobs immediately and it’s even his friends suspected [I might be pregnant] you see.” (IDI)
“…yes, my boyfriend did suggest to me [to take a pregnancy test] and he told me that yoh I sleep a lot…I would have not done that [tested, had he not encouraged me] …because I was scared [of the pregnancy] …I needed someone to talk to me and then he did talk to me……he was the one who was the one doing the pregnancy test.” (FGD)
The prospect of pregnancy, hesitation to confirm pregnancy
Women elaborated on their reactions to the pregnancy, their worries, anxieties and indecision around what to do and how a pregnancy would affect their life choices. Reasons for initial hesitation in seeking confirmation by testing varied with some preferring to wait for their period to commence while others were worried about how partners might react. These initial delays ranged from one week to three months.
“I was very angry [when I suspected I was pregnant] coz I, I did prevent it even though I knew that I missed, I skipped my pills but then there was a time that I thought like I want, I want, maybe I’m going to keep the baby because it’s a blessing. But then on the other side I thought of myself and I thought of my life and I’m not ready [Participant reported waiting 2 months before testing] (IDI)
“Yes I was, I was a bit scared [to test] because I already have 2 kids so I didn’t know how my mom and them would take it and things like that, so I was going through emotional time...” [Participant reported waiting 3 months before testing] (IDI)
2. Experiences with confirming the pregnancy
Home- versus clinic-based testing
Just over half of the participants tested at home. Many felt compelled to self-test for reasons including taking responsibility for their own bodies or being concerned about the passage of time and missed periods. In contrast, reasons for preferring to test at a health care facility (HCF) included being afraid to confirm pregnancy alone; concerns about doing tests incorrectly and considering it a waste of time and money knowing they would ultimately need to confirm at the clinic.
“I felt like it, it’s my own responsibility to, to check, to know what is happening on my body. Especially since I noticed that I missed my period because I was waiting for my period and then when I didn’t come I started to, to panic and, and I thought I should go with, without consulting anyone.” (FGD)
“I’m scared to find out myself, I don’t know how to react, it’s better when there is someone, a professional who knows these, these things.” (FGD)
Cost and quality of tests
Women commented on the variation in cost of home pregnancy tests and raised concerns about the accuracy of the more affordable tests. Many purchased multiple (two to three) home pregnancy tests to confirm their pregnancy before visiting a health care facility. Reasons for multiple tests included wanting to be certain about and not trusting the result(s). Some reported disbelief at the result and wanted to seek definitive confirmation at a health care facility.
“I did it at home…I had to be like certain, certain, certain so I had to buy the most expensive test that I could get. And then, …because I was in disbelief the first time I got a more expensive one and it was so much money because I didn’t believe that I was pregnant. But then to make sure I made sure that I bought the most expensive ones which would equal it’s more trustworthy… I went to a clinic immediately the day after because I still didn’t trust the pharmacy test… I was shocked…the first thought was I’m not the problem, the test is the problem” (FGD)
3. Knowledge of fertility, the menstrual cycle and when to test for pregnancy
Timing of the fertile period
Some women demonstrated accurate knowledge about fertility and menstrual cycle events. They seemed familiar with the word “ovulating” and understood that this meant they were more likely to fall pregnant. Some knew about the “fertile window” but admitted not keeping track of their cycle, but for the most part there was limited understanding about fertility of risk of pregnancy.
“…on day 14 of your cycle your egg gets released from your ovaries and then, it’s, that’s the most fertile time coz then the sperm can go and fertilise it because it’s been released into the fallopian tubes so ja, that’s it, day 14, if you count your cycle you should know but who does, I don’t…” (FGD)
“I don’t know anything about that [fertility period] but the only thing that I think or, is that when you are in your periods you are more likely to get pregnant.” (IDI)
“I thought it [fertility period] was a little before or after your period.” (IDI)
When to test for pregnancy
Most participants confided not knowing about optimal timing for early pregnancy testing. Some thought testing should wait until physical changes became apparent. Many thought testing could be done as soon as five days after having unprotected sex whilst others thought it better to wait one week to a month.
“I know it’s a couple of days or a week [after unprotected sex you can test for pregnancy], I think, I’m not sure anymore.” (IDI)
“I thought it was too soon take the test after I’d missed my first period because I thought maybe it was coz of the sickness and, and coz I’d missed 1 before because of that and so I thought to give it a bit more time because I knew if you do test too early it’s kind of irrelevant.” (IDI)
Providers’ and policy makers opinions
Health care providers and policy makers suggested a range of interventions aimed at strengthening pregnancy awareness generally, and self-awareness specifically. Abortion providers acknowledged the efforts by government with a national campaign aimed at empowering young women and adolescent girls but stressed that more is needed to reach a broader audience through schools, television and other media channels.
“I’ve always said there’s not a link between missing your period and think ah, maybe I’m pregnant, it isn’t there….there should be much better sexual education at schools I think the, there should be the, the TV, the radio the, the papers, magazines, it should be all over.” (Physician, abortion provider to public and NGO sectors)
Other suggestions were to utilize community-based services to raise awareness around early pregnancy testing and to expand access to testing at community level, outside of clinics alternatively doing away with the need for women to open a folder in order to take a pregnancy test at a clinic. Communities’ lack of trust in the accuracy of commercially available pregnancy tests was noted as a barrier, to be addressed though information dissemination. Some providers highlighted the need for easier access to pregnancy tests for within clinics. A suggestion was to have readily accessible free pregnancy tests in dispensers located in clinic spaces as a mechanism to overcome clinic-based barriers such as the need to open a folder and to allow for privacy.
“well nobody waits in a, queue if they come in for condoms because you’ll find condom boxes in the entrance of the facility, you’ll find condom boxes in the toilets, you’ll find condom boxes in the counters where the clerks are and people walk in. But when it comes to a pregnancy test unfortunately, you have to take a folder out for you”. (Nurse abortion provider, public sector)
“Firstly there’s a need to increase awareness of the risk of being pregnant particularity if a woman is having unprotected intercourse – that would be self-awareness…. Secondly would be access… there’s a misunderstanding in the community that you need to see a doctor to confirm the pregnancy. That is incorrect… a commercially available urine pregnancy is relatively accessible and cheap…its an access point.” (Policy maker, provincial government)
“I would imagine that it should be something that any woman could walk in and say I just want, go to, you know to like the triage room or the family planning room and say I’d like a pregnancy [test] and she could take it and test without anyone knowing. Coz that would also be, so I think ease, not having to open a folder, not having to explain yourself to somebody and then also not having to divulge the test result to anybody. So that would be useful rather than somebody else having to test it for you, because I think especially for people in the community who might know people they don’t always want everybody to know that they’re pregnant” (OBGYN consultant abortion provider, public sector)