Study design
The qualitative research design was seen as best suited to answer the research questions in this study. Qualitative research methods enable researchers to get an insider’s view of participants and their experiences [29]. The choice of a qualitative research design was primarily determined by the type of questions the study sought to address, that is, to gain a deep understanding of the experience of stress and coping among unmarried pregnant students. This design was appropriate as it fostered maximum co-operation and closeness between the interviewer and the participants and enabled them to narrate their experiences about pregnancy within the University.
Participants
Participants in the study were all female students at the Howard College Campus of the University of KwaZulu-Natal in Durban, South Africa. Participants were recruited if they met a set of inclusion criteria which included that they: were currently registered as students at the University of KwaZulu-Natal; were currently pregnant or in the puerperal period (less than six weeks post childbirth) at the time of the study; self-identified as being single or unmarried; were over the age of 18 years and were willing to answer questions regarding their pregnancy experience.
Because issues relating to pregnancy among young people are sensitive and therefore not openly discussed, it was not easy to recruit participants for the study. Therefore, we used the snowball sampling technique in this study. This is a type of purposive sampling that allowed participants to recommend others in their circle who met the inclusion criteria and were willing to participate in the study [30].
The first author (TMP) initially approached three pregnant young women who stayed in the same residence as her. She (TMP) discussed about the study with those young women and requested them to identify and recommend other students who were pregnant. Next, she (TMP) approached and invited those young women to participant in the study. The first author was a Master’s student and a young woman who had a pregnancy and delivered a baby while studying for her Master’s degree. She had received training on qualitative interviewing as part of her Master’s degree and additional training from the third author (OA). She conducted all the interviews drawing on her own pregnancy experiences to recruit participants. The rationale for that was that some of the participants might be ashamed to express themselves when being interviewed by the opposite sex. Gender of the interviewer can substantially affect the response rate in data collection [31].
More than 30 students were invited to participate in the study and 24 were selected to participate in the study with the others excluded mainly because they were past the puerperal period and two mentioned that they were not comfortable to discuss their pregnancy experience. Current pregnancy and puerperal period were considered because the study sought to explore pregnancy experience.
Data collection
Ethical approval for the study was obtained from the University of KwaZulu Natal Humanities and Social Sciences Research Ethics Committee in Durban (HSS/0584/015M). In-depth interviews were conducted using an interview schedule which contained open-ended questions. The interview schedule was designed to suit the context of the study setting and to encourage pregnant students to discuss their experiences. The schedule was also reviewed and approved by the third author (OA) who was the research supervisor. The questions contained in the interview schedule included the socio-demographic variables of participants and their partners, the antecedents of the pregnancy and the challenges of pregnancy.
The interviews were conducted in a private and quiet seminar room within the university. This gave them an atmosphere of safety and comfort in which they could talk about their personal experiences considering the sensitive nature of the topic. Each interview lasted approximately 40 minutes. The open-ended questions provided the participants with an opportunity to interact freely and to discuss their pregnancy experiences in detail. Written informed consent was sought and obtained from all the participants before the commencement of interviews. Permission to record the interviews was sought and obtained from participants prior to the interviews.
Data Analysis
The audio-recorded data was transcribed by the first author (TMP). The anonymity of the participants was maintained by assigning a pseudonym to each. We chose thematic analysis as the method of analysis for the data because it allowed us the opportunity to conduct iterations through careful reading and re-reading of the data in order to discover underlying meanings and patterns and to produce a detailed account of the phenomenon [32,33].
Next, the first author (TMP) performed the initial round of coding following the six steps described by Braun & Clark [34]. The first step in the process was familiarization with the data by reading and re-reading the transcripts to make summaries. Secondly, she (TMP) generated initial codes and this step was followed by identifying the emerging themes, which is the third step. Fourthly, TMP reviewed potential themes, particularly checking for inconsistencies and whether the themes overlapped. After that, the themes were defined and named. Lastly, a report was produced using quotations of what the participants said to illustrate the themes [34].
It is important to note that this process was not straightforward as presented but rather was iterative. The initial coding was then reviewed and modified by the third author (OA) after which the second author (PN) conducted a general review of the themes. All the authors revised, finalized and agreed upon the themes jointly.
Findings
In total, twenty-four unmarried students participated in the study (Table 1). Among these, twenty-two were pregnant and three were in the puerperal period.
Table 1 Socio-demographic details of participants (n = 24)
Participant pseudonyms
|
Age
|
Year of study
|
Gestational stage
|
Number of previous pregnancies
|
Mbali
|
20
|
1ST year
|
Seven months pregnant
|
None
|
Lindiwe
|
23
|
Honours
|
Eight months pregnant
|
None
|
Busi
|
19
|
1st year
|
Four months pregnant
|
None
|
Samantha
|
19
|
1st year
|
Three months pregnant
|
None
|
Nomthandazo
|
19
|
1st year
|
Four weeks puerperal
|
None
|
Bongiwe
|
21
|
3rd year
|
Three months pregnant
|
None
|
Bella
|
26
|
Honours
|
Six months pregnant
|
One
|
Kholeka
|
21
|
2nd year
|
Eight months pregnant
|
None
|
Zevile
|
23
|
3rd year
|
Five months pregnant
|
None
|
Rachael
|
22
|
2nd year
|
Five months pregnant
|
None
|
Thuli
|
21
|
2nd year
|
Eight months pregnant
|
None
|
Njabulo
|
24
|
3rd year
|
Six months pregnant
|
None
|
Khethiwe
|
24
|
2nd year
|
Four months pregnant
|
One
|
Minenhle
|
20
|
1st year
|
3 weeks puerperium
|
None
|
Barbara
|
21
|
2nd year
|
seven months pregnant
|
None
|
Khanyisile
|
22
|
2nd year
|
nine months pregnant
|
One
|
Thandeka
|
20
|
1st year
|
four months pregnant
|
None
|
Lerato
|
21
|
2nd year
|
Five weeks puerperium
|
None
|
Zinhle
|
23
|
3rd year
|
Six months pregnant
|
None
|
Thuli
|
20
|
2nd year
|
Three months pregnant
|
None
|
Liyana
|
26
|
Honours
|
Seven months pregnant
|
One
|
Siyanda
|
19
|
1st year
|
Four months pregnant
|
None
|
Nandi
|
23
|
3rd year
|
Seven months pregnant
|
None
|
Lindiwe
|
22
|
2nd year
|
Three months pregnant
|
None
|
Four of the participants had one previous pregnancy whilst it was the first pregnancy for the remaining twenty participants (Table 2). The findings are organized into six main themes identified from the analysis of the data: Parents’ knowledge of pregnancy and reactions; coping with the academic load; financial constraints during and after pregnancy; relationship problems with male partners; experiences of social stigma; and unexpected pregnancy experiences and adjustment.
Table 2 Summary of the socio-demographic details of participants
Parents’ knowledge of pregnancy and reactions
Most of the participants said that initially they had to hide their pregnancy as they feared facing their parents and the response they would receive after their parents learn about the pregnancy. Having to hide the pregnancy as they experienced the early symptoms was said to be a coping strategy. At the same time, the process of keeping the pregnancy from their parents was a stressor. Mbali, a first-year student was worried about the sanctions she feared her father was going to put in place once he became aware of her pregnancy. She explained that:
It’s been very difficult because as am talking to you, my parents don’t know about it [the pregnancy]. They are so strict, especially my father. He is so strict. He’s staying at Joburg [city of Johannesburg], [he’s] working there. I am pretty sure that he is going to cut me off [paying for her studies] because of the pregnancy. I know because this has happened to my sisters. That’s what he does. I’m stressed but am trying to control it because it’s not healthy for the baby [Mbali]
The participants used different strategies to hide their pregnancy. Some students who lived in campus residences opted to stay away from home and avoid meeting their parents because they were afraid of how their parents would respond if they found out about the pregnancy.
I told her [her mother] am not coming home this vac [school holiday] because I will be working. I won’t be working, it was just a way of not going home. Whenever my sisters get pregnant, my mother would not talk to them and would not take care of the baby [Zinhle]
It was even more stressful for participants when awaiting their parents’ reaction to the news of their pregnancy. Lindiwe who was about to complete her honors degree explained the difficulty of telling her parents about her pregnancy:
The whole stressful part was telling my parents and the family that, you know, I’m pregnant. That was like, for me, the most stressful part. It took me like, probably like three months to tell them [Lindiwe]
These responses show that pregnant students had a difficult time disclosing their pregnancy to their parents due to fear of sanctions from their parents. The desire by young women to keep their pregnancy a secret from their families also resulted in late initiation of prenatal care. The young women expressed initial uncertainty about the fate of their pregnancy. The desire to hide the pregnancy from their families and the shame of being seen by others while seeking antenatal care (ANC) also contributed to late initiation of ANC. Kholeka talks about starting ANC late because of this.
Having to hide the pregnancy from my father whenever he was around was an issue. I had to suck in my stomach, and I started going to the clinic very late, I was going at five months and the nurses were very angry [Kholeka]
Early presentation for ANC may contribute towards improved pregnancy outcomes yet late initiation of ANC was common among the participants some.
One of the more commonly reported stressors by the participants was the fear of their parents’ reaction to the news of their pregnancies. When they eventually disclosed their pregnancy, the relationship between the participants and their parents was strained, particularly their fathers, throughout their entire pregnancy. Most participants who had fathers reported previously having very close relationships with them before they got pregnant. However, they said this completely changed after they learned of their pregnancy. The tension at home was thus reported to be a source of stress in their pregnancy.
He [her father] wouldn’t speak to me, he speaks to me when he talks about how much I need, those things, he is just concerned with my education only but there is nothing more.…Things that have happened at home -the relationship [with her parents] is no longer the same. It affects me a lot. I feel neglected by my own family, I feel like they have abandoned me. They have the right to be like this, they have… but on the other side, I just feel like they are not fair. I know I made a mistake okay, fine. But the way they are doing it, it’s like, I don’t know how to describe this. It’s been difficult [Busi]
The effect that it had on my parents, cause [because] when my father found out that I was pregnant which was recently, he cried like a baby. My mom couldn’t talk like for a week or something. It was tough, I could not even study. I had examinations coming up in the next four days and I could not study. I would take my book, it was politics [the examination]. I would take my book and just start crying. They still can’t look at me in the eye especially my father [Samantha]
Most of the participants expressed guilt and regret over their pregnancy because of the turn of events in their homes. They felt that they had lost their parents’ trust and the relationships they had with them had been ruined because of the pregnancy. Generally, pregnancy was considered to be a disappointment to their parents and guardians who in most cases, were considered to be respected members of their community.
The pregnancy thing made me frustrated cause it’s going to break our relationship [with her father] now (with her father), yeah. It makes him sad, I even see in his eyes cause sometimes I think it comes back to his mind like ‘no, this child just ruined her life’ you know [Nomthandazo]
He [her father] kept saying to me “I trusted you so much and I still can’t believe it”. I started regretting and everything, as much as I had bonded with the baby. My father is a priest, so he is a well-respected man and people respect him. He doesn`t have much, he`s is just an average guy but people in our community do come to him for advice because he is a respectable man [Bongiwe]
In addition to the fear of being a disappointment, the participants were also concerned about how their pregnancy would negatively reflect on the position of their parents in the community.
Coping with the academic load
The physiological demands associated with pregnancy were a constant source of stress that affected participants’ academic work. Participants indicated that coping with the academic workload was difficult because they were constantly feeling tired and sleepy. Our study found that severe fatigue and nausea are usually accompanied by drowsiness. It is therefore not surprising that Rachel lost concentration in her academic work which resulted in poor grades:
I dropped so hard [referring to academic score] in first semester because it was when I found out I was pregnant, and everything was so messed up. I couldn’t concentrate, I couldn’t pay my full focus [attention] on my studies, I failed. When I was trying to study, I would be [feel] sleepy, I would get a book then feel drowsy and find myself sleeping so that affected me [Rachael].
While most of the participants did not take any active steps to cope, a few of them were able to draw on their inner strength in order to attend classes as indicated by an honours student called Zevile in the following excerpt:
Walking around has been such a hassle, even going for that one seminar is so hard- sore feet, my sore back but then that only happens now in my third trimester. But during my first trimester, my first trimester was bad cause I was so sick but then I had to force myself to go to class [Zevile]
On the other hand, some students had to seek alternative ways of coping with the pregnancy symptoms. To cope with the challenge of changing sleeping patterns coupled with severe fatigue, Thuli had to employ problem-focused strategies to help her focus on her schoolwork. She explains that:
Ah sometimes I have to sleep early and not study. I don`t know this baby (is) always tiring me hey, it’s too heavy and makes me hungry. My mother always says that I sleep too much now. I have to take some treatment (for energy) every day [Thuli]
Some participants mentioned that sometimes they had to make a difficult decision between seeking healthcare and attending to academic work. This sometimes resulted in not attending classes or missing examinations. This was common in the last trimester of pregnancy.
[Previous pregnancy]-I came here maybe I was about 6 months (pregnant). When I came on campus I usually did not attend all my lectures, (I) had to miss some of my lectures because I had to visit at the clinic to check if my baby is okay. She was born on the 3rd but she was supposed to be born on the 10th so I had to make it faster (opted for a caesarian section)…. [Current pregnancy]- Sometimes I have to leave early if I feel that I have a problem with the baby inside. I have to leave and go to the hospital and my appointments are usually on the day that am attending (lectures). I have to go see the doctor sometimes [Bella]
Being unable to attend classes and write examinations caused some participants to lag behind in their academic work. Bongiwe explained how she had missed an examination because she had just delivered her baby.
Last year I had one sup (supplementary examination) and I did not write it in the first semester when I was pregnant. I didn`t know that I had to come back because my baby was too small. I didn`t come back to write the sup so I have to do it this year. I have to do five modules and the sup that I missed last year. I’m really studying hard this year. I don`t sleep, I don`t sleep [Bongiwe]
The struggle to balance studies and pregnancy was a challenge that most participants struggled to cope with. Participants were constantly sleepy and hungry contributing to lack of concentration and academic challenges.
Financial constraints during and after pregnancy
Pregnancy came with its own financial demands which sometimes could not be met by the financial resources provided by parents. Lack of financial resources was a stressor that also affected health seeking because in certain cases, some participants did not have money for transportation to ANC services. One of the participants explained that:
When you’re pregnant you have to go to the clinic (antenatal clinic) each and every month and they [the clinic] are going to give you a date to come. And then when you have to go to the clinic, it happens that you don’t have money because you have to travel and get a taxi, then you don’t have money. Then I have to go around at res [student’s residence] up and down, borrowing money to go to the clinic then people will be like “I don’t have money, I don’t have money”. It’s so painful [Njabulo]
The issue of insufficient financial resources seemed to result from the low financial support from parents because of their disappointment and the unmet expectations of financial support from male partners. One participant spoke about receiving less money from her parents which she also had to share with her baby.
Now I have financial constraints because what [money] I get the baby gets half and I get the other half [Bongiwe]
When it came to hospital bills and preparations for childbirth, participants expected their partners to provide financial support. Some of the participants mentioned lack of financial support from the father of their baby during and after pregnancy which caused a lot of stress for them. One participant expresses her disappointment as she talks about the challenges she has experienced in trying to obtain financial support from the father of her child.
It’s a challenge, it’s a big challenge with finances he [father of her child] will make an issue and an issue and an issue and am like I told you I don`t work, I don`t have nothing yet [money]. So, for me that just hurts because I have realised that he just doesn`t wanna be ready and he just doesn’t care at all [Minenhle]
There was a concern from some of the participants when it came to choosing the hospital that they wanted to deliver their baby. Participants indicated that they did not have a choice because of their financial dependence on their partners and thus were unable to access the kind of medical facilities that they would have preferred.
If your partner decides that you have to go to a government hospital because he doesn’t have money to pay, there is nothing you can do so I think it’s a very devastating position to be in [Barbara]
In some cases, male partners were financially overwhelmed and did not have enough resources to assist their partner to prepare for the birth of the baby. This was mostly because, in addition to paying the medical bills, they also had to make arrangements to pay the ‘damages’ to the family of the pregnant partner as part of custom. Paying the damages, is a custom whereby a man is expected to pay an agreed-upon amount of money to a woman's family if he admits to having impregnated her out of wedlock. One participant in her final week of pregnancy said:
The circumstances surrounding the pregnancy [unintended] made it hard for us to be prepared-financially he wasn’t ready, and I wasn’t ready. Then he had to start making preparations to pay at home [damages to her parents] and he pays for all the medical bills and things financially really aren’t flowing too smooth for him. [Khanyisile]
The challenges with financial resources resulted in participants not being able to buy essential items during pregnancy.
She`s [her mother] only paying school fees and buying me clothes but not a lot of clothes. I have to wear my old clothes which are now small because of the pregnancy [Khethiwe]
Relationship problems with male partners
Young women in this study had expectations of support from their partners and unmet expectations from partners support resulted in conflict. Some participants reported that they had initially been told by their partners to have an abortion because they did not want to have a child. In the end, the relationship did not survive, and it ended within the first few months of pregnancy.
When I was telling my boyfriend I am pregnant, he asked me to do an abortion and I was like what the hell? I told him no, I wasn’t going to do it, so we argued. We continued dating but at the end of the day he still dumped me [Thandeka]
For some participants, constant arguments in the relationship resulted in a communication breakdown and eventually, the relationship came to an end. In cases where the relationship had ended, communication was only initiated when the participant desired certain needs to be met. Occasionally they employed emotion-focused coping strategies.
There was a time where we just used to fight and fight, there was a point he started disrespecting me and am like I can`t take this anymore. So, I decided to just cut off all communication and that’s what I did and stopped talking to him, cause even like now we don’t talk at all the only time I spoke to him is if I want something from him, if he doesn’t have it, then it’s okay [Lerato]
When my boyfriend left me (left her due to conflicts), I hated him! I would curse and send him sms [text] and threatening him, telling him if you don’t come back, you’ll never see your child and such and such [Busi]
The participants said that they experienced stress because of conflicts with their partners. Young women expected support from their partners and the lack of support from their partners was a source of frustration. Receiving support from their partner was the biggest expectation and the perceived lack of support caused some participants to feel neglected and hence regretful over their pregnancy.
I felt like he neglected me. I was so irritated and I was crying like a baby. I felt so sad and I felt like you know, I wish I was not pregnant, like at the same time I am like I love you baby [her unborn baby], but at this point in time, I wish I wasn’t pregnant [Zinhle]
Some of the participants who were no longer in relationships with their baby’s father said the amount of support they received from them was very minimal and in some cases no support was given at all. Some of the participants who had already had a baby reported that the baby’s father had not been to see the baby or sent any form of material or financial support for the baby.
He has not seen the baby from day one. I would say in a way, it’s like am just a single parent and decide for him (decisions) and the only time I get to tell him is I have decided on so and so and so. At times I don`t even consider his opinion. It’s just an opinion he won`t do anything about it [Thuli]
Unintended pregnancy in unstable relationships does not only have serious implications on maternal and child health but also on a child’s social identity when paternity is denied. The participants reported that sometimes their partners denied paternity of the child because they do not want to assume the financial obligations of parenthood. One participant shares her experience.
I got pregnant in February then towards the end of the month we broke up. So, I didn’t know like how I am going to tell the father of the baby because we already broke up. So, when I told him he refused, he just denied my pregnancy, started calling me names, insulting saying that I’ve been sleeping around. It was so painful I was crying each and every day [Liyana]
Experiences of social stigma
This study found that most young unmarried women feel a sense of shame because of their pregnancy. Several participants mentioned experiencing feelings of shame and embarrassment at school and in their communities because of their pregnancy. This was exacerbated when people would stare at them and that was considered to be a negative attitude.
Facing people, it’s been hard like you know some people stare at you like they’ve never seen a pregnant person before. There are so many girls that get pregnant on campus [Siyanda]
Society was also said to have double standards when it came to how they judged pregnant young women. People were said to show a different, more positive attitude when they noticed the presence of a male partner as compared to when a pregnant young woman was alone.
Walking around campus is a problem now with all the stares. It angers me and I think it’s so hypocritical in a way because their stare types change when am alone it’s like “you fell pregnant and you’re still studying” and then when my boyfriend is with me, the stare type changes all the way to “oh they love each other, how sweet” [Khanyisile]
Because of the negative attitudes from people around them and the fear of stigma, some participants said they experienced isolation and they had lost some friends in the process. One participant talks about how certain friends distanced themselves from her and she also felt she was different from her peers and hence isolated herself. This was initially accompanied by feelings of neglect, but she later came to accept it because she realized she was different from them.
Some of my friends ignore me due to the pregnancy because they don’t wanna walk with me to school and I also see myself as totally different from them. At first, I felt so neglected now I have accepted that am pregnant and things won’t be the same. I usually walk alone. Some friends will support me, some will not [Siyanda]
Some participants coped with the fear of social stigma by delaying ANC because they did not want to be seen by members of the community at antenatal clinics.
I was afraid that my neighbours will see me going to the clinic especially to the maternity department and they will start gossiping about me. At first, I was like eish they gonna say bad comments, you know how people especially townships [Zevile]
These findings show that the socio-cultural context of pregnancy among unmarried young women still plays a role in the discourses that society creates about early motherhood.
Unexpected pregnancy experiences and adjustment
Some participants said they had a negative experience of pregnancy, which was different from what they had perceived. They said they had had a completely different view of pregnancy before getting pregnancy and found it was difficult to adjust to their pregnancy status. Before pregnancy, they had expectations of getting special treatment, relaxation and being excused from certain things but found out that it was not always the case. They still had to meet their obligations at home and at school.
I thought it was lovely [pregnancy], I thought oh you get to be treated like a queen. I never really thought that unfortunately you need to toughen up, you need to pass your exams, you need to go to the clinic on your own, come home, you need to cook, you need to clean, you need to wash [Nandi].
One participant said she only realized after getting pregnant that pregnancy was not just a period that came and went away. She realized that pregnancy was the first step into motherhood, a lifelong role and responsibility that she found was not easy to accept.
I thought it was not something big, just the thought of having a baby, nothing much, that you have to stop certain things for that particular period of time when you’re pregnant. But when I became pregnant, it was different, like it changes the rest of your life. It’s not like that period only. It changes the rest of your life now you’ll have someone in your life, not just someone, but someone in a different way- someone who belongs to you, your responsibility, so that is a lifelong process and it’s not easy to accept [Lindiwe]
Some participants reported that pregnancy had caused a lot of changes in their lifestyle which they had to adjust to, and this proved to be difficult given their age and social context because they had to adapt to a new lifestyle.
So far being pregnant at a young age is not an easy thing cause we as youngsters we like partying, drinking, wearing short things so when you are pregnant when you are young, life tends to be not like it was before. Right now I have to wear something long, comfortable for the baby and also for me, the things I eat, I don’t have to go to parties anymore [Njabulo].