Perceptions of adolescents in low resourced areas 1 towards pregnancy and the choice on termination of pregnancy ( CTOP )

Curationis 30(1): 26-31 Teenage pregnancy, unsafe abortion methods and the high incidence of HI V infections among young people are of great concern to the South African public. Due to the lack of accurate information and understanding, some adolescents are forced to succumb to early motherhood from unplanned pregnancies or opt for back-street abortion with at times fatal results. A qualitative exploratory study was conducted in 2003 to determine the adolescents’ perceptions towards factors on the Choice on Termination of Pregnancy (CTOP) and the constraints in accessing TOP services. A purposive sampling technique that enabled experts such as health workers to identify suitable candidates for the investigation was employed. Twenty-four (24) adolescents residing in the predominantly rural area of Nkumpi-Lepelle in the Limpopo Province agreed to participate in the focus group interviews. The major findings indicated that most adolescents were uninformed about CTOP. This is attributed to the lack of coordination among health professionals and educators in the dissemination of information. The overwhelming majority of the respondents expressed discomfort at receiving termination of pregnancy services from the local public clinics and hospitals as they regarded such facilities as youth unfriendly. The adolescents also required provision of preand post-counselling services for adolescents who would like to terminate pregnancy. The following hypotheses were formulated for future in-depth studies: • If adolescents continue to lack information about CTOP, they will not be able to utilize available services to terminate unplanned and unwanted pregnancies. • If CTOP services remain inaccessible to the youth, the problem of back­ street abortion will not be eradicated. Correspondence address: MDM Makofane University of Limpopo P/Bag X I106 Sovenga 0727 Tel: (015)268-2291 Fax:(0015)268-2866 E-mail: makofaned@ul.ac.za Opsomming Tienerjarige swangerskappe, onveilige aborsiemetodes en die hoe voorkoms van HIV infeksies onder jong mense is van groot kommer vir die Suid-Afrikaanse publiek. As gevolg van die gebrek aan akkurate inligting en begrip, word sommige adolesente verplig om hulle aan vroee moederskap as gevolg van onbeplande swangerskappe te wend of die keuse van agterstraat aborsies te neem wat soms dodelike evolge het. The concepts ‘low resourced areas’ and ‘rural areas’ are used interchangeably.1

Die vernaamste bevindinge het aangedui dat die m eeste van die adolesente oningelig was oor die Wet.Dit word to e g e sk ry f aan die gebrek aan sam ew erking tussen g eso n d h e id s w erkers en opvoedkundiges in die verspreiding van inligting.Die oorgrote meerderheid van die respondente het ongemak aangedui met die be-eindiging van sw an g ersk ap sd ien ste van die openbare klinieke en hospitale aangesien hulle sulke fasiliteite as jeugonvriendelik beskou het.Die adolesente het aangedui dat hulle die voorsiening van pre-en postberading vir adolesente wat begeer om aborsies te ondergaan, verlang het.

Introduction and problem statement
Unsafe abortion is a health and socio economic problem of global concern.In many developing countries women know very little about abortion and have limited access to effectiv e co n tracep tiv e methods (Makinwa-Adebusoye, Singh & Audam, 1997:155).As a result, many wom en and ad o lescent girls may experience unplanned and unwanted pregnancies.Furthermore, the restrictive abortion laws, poor access to safe methods in termination of pregnancy, and cultural and religious beliefs are cited as some of the reasons that compel women and adolescent girls to resort to abortion under unsafe conditions.In Africa alone, an estim ation o f 3.7 m illion unsafe abortions were performed annually with approximately 23,000 deaths as a result o f unsafe p ro ced ures (M akinw a-Adebusoye etal., 1997:155).
The introduction o f the C hoice on Termination of Pregnancy Act No. 92 of 1996 (CTOP) was lauded in South Africa as a progressive move to allow women, irrespective o f age, socio-econom ic status, race or location, to access early, safe and legal termination of pregnancy upon request up to 12 weeks of gestation.Furthermore, the government made a commitment to make services accessible and available, especially to poor and previously disadvantaged women (Van der Westhuizen, 2001:2).
The statistics at St Rita's Hospital in the Makhudu-Thamaga sub-district revealed that an average o f600 deliveries occurred in young girls of between 14 and 20 years of age over a period of three years (1998)(1999)(2000).However, a considerable number of teenagers were treated for incomplete ab o rtio n s, suggestive o f illegal termination of pregnancy.
The implementation of the Reproductive Health Approach concerns empowering women, including girl-children, to ensure that they com prehend the fertility regulation and the choice to make an informed decision free of coercion and fear.In 1999, The Department of Health and Welfare in the Southern Region of the Limpopo Province identified the Burgersfort area as one o f the sentinel points for the high prevalence rate of HI V/ AIDS infections.A multidisciplinary team consisting of the Department of Health and Social Development and Education p ro fessio n als was estab lish ed and trained on how to teach life-skills and sexuality by incorporating the subject matter in the curriculum.The project included meetings with parents, school governing bodies, and the traditional leaders in the Bohlabela circuit.This exercise revealed to the researcher that almost all stakeholders were ill equipped with skills on how to approach and/or disseminate reproductive and sexuality related information.

Aim and objectives of the study
The primary aim o f the study was to explore the perceptions of adolescents from the low resourced areas towards the termination o f pregnancy as stipulated in the C hoice on T erm ination o f Pregnancy, Act No. 92 of 1996, in the N kum pi-Lepelle sub-district o f the Limpopo Province.
The objectives o f the investigation were to: • Determine the adolescents' perceptions towards CTOP.
• Formulate hypotheses for future in-depth studies.

Ethical considerations
Permission to conduct the study was obtained from the Ethics committee at the University of the North (currently known as the University of Limpopo) and the D epartm ent o f H ealth and Social Development in the Limpopo Province.
The re searc h er was also granted permission by the relevant traditional leaders with the understanding that after completion o f the project, she would organize an "imbizo" to provide feedback to the community.The parents o f all the participants who were under the age of 18 years and who had no objection to their daughters' participation in the study were requested to sign a consent form, while the participants who were above 18 years signed consent forms.Privacy, confidentiality, anonymity, and voluntary participation were observed (Bless & Higson-Smith, 1995:102-103).
The human rights of girls include their right to have control over and decide freely and responsibly on matters related to sexuality, sexual and reproductive health, free of coercion, discrimination and violence (Germain & Kyte, 1998:4).Thus, the recognition o f adolescents' rights is essential in reducing the high rates o f unplanned and unw anted teenage pregnancies, including large numbers of unsafe abortions in this age group.
A dolescents can only exercise their democratic rights if they are well informed about new developments, such as the existence of the CTOP Act.However, the health professionals have done little at community level to inform people about the CTOP Act (Varkey, 2002:2).It has also been noted that the youth in other countries are not always familiar with the existence of such Acts.For instance, the study conducted by Becker, Garcia and Larsen (2002:28) among 907 Mexican youth of both genders aged between 15 and 24 years, revealed that 54% did not know about the abortion law o f that country.To avoid having uniformed youth, Ehlers, Maja, Sellers and Gololo (2000:43) suggest that "Education about sex, pregnancy and contraceptives should commence at the age of 10, but not later that the age of 12." Adolescents, regardless of their socio economic background, usually have aspirations to become educated and an unplanned pregnancy can only jeopardize their chances of reaching the set goals.Kritzinger's (2000:557) study among teenage girls on South African farms revealed the fact that teenage girls had dreams to complete their high school education and proceed to tertiary institutions.Ehlers et al. (2000:43) purport that adolescent mothers are at risk of a higher m orbidity and m ortality rate during pregnancy and labour than adult women.Furthermore, they (Ehlers et al., 2000:43) estab lish ed that health problem s experienced by adolescents include anaem ia and sexually transm itted diseases including HIV/AIDS.Besides, physical immaturity that contributes to difficulties adolescents face during labour, they also experience shame, guilt and fear o f being discovered pregnant w hich may lead to a state o f psychological denial about the reality of the pregnancy (Greathead, Devenish & Funnell, 1998:155).
Evans (2001:2) purports that the ad o lesc en ts' decision to term inate pregnancy depends upon various factors such as the attitude of the parents, the baby's father, her peers, her personality, as well as cultural and public policy attitudes towards abortion.

Research design and method
A qualitative exploratory descriptive and contextual research design was employed to achieve the major goal o f the study.This type o f m ethod was deem ed appropriate because the study aimed at exploring and describing the perceptions o f adolescents from low resourced areas towards the termination of pregnancy as stipulated in the Choice on Termination of Pregnancy Act No. 92 of 1996 in the N kum pi-Lepelle sub-district o f the Limpopo Province.

Population and sampling
In 2003 Statistics South Africa reported that the population of the youth was 1 836 524, that was 11% o f the entire population in the country.The Nkumpi-Lepelle sub-district had an estimated population of 278 337 while at the time of the study the total population of female youth was unknown.
A n o n -p ro b ab ility convenient and purposive sampling techniques were employed to identify adolescents who were between 12-20 years old, assertive, had been engaged in health promotion activities and had the ability to express their own feelings w'ithout inhibitions, had some knowledge of the prevention of HIV/AIDS.Thirty-seven adolescents were identified with the assistance of experts such as nurses and educators.However, only 24 were found suitable for the project and participated with their

Data collection method and analysis
Three focus group interview s were conducted with eight members per group over a period of three weeks.These focus groups enabled the researcher to observe the participants' interaction and their sim ilar or divergent opinions on a particular matter (Neuman, 2000:274 andBabbie &Mouton, 2001:292).Guiding questions were utilized to elicit relevant information from the participants.Groups were given sufficient time to interact and deliberate on pertinent issues.This arrangement also alleviated the pressure on the researcher who did not have the assistance of a moderator, one of the shortcomings o f the study (Krueger, 1994).
To guard against any loss o f vital inform ation, all d iscu ssio n s were captured on audio-tape after permission had been obtained from the participants.These recordings were transcribed and the results were analyzed to identify themes and categories, using Tech's method of analysis (cited by Poggenpoel, 1998:343-344).

Results and discussion
The qualitative data obtained from focus group interviews are presented below.

Biographical data
As indicated in Table 1, 24 adolescents p articip ated in the focus group interviews.
The majority o f the participants were adolescents as their age ranged between 14 and 20 years.The median was 17 years.Generally, the participants' age and grade were compatible, indicating that they w ere not lagging behind educationally.

Familiarity with the contents of the CTOP Act No. 92 of 1996
The majority o f the participants in all three groups were unfamiliar with the contents o f the Act.One o f the respondents said: "They did not teach us about the Act at school."Only one participant confidently stated that she had heard about the Act from her aunt who was a professional nurse.However, she was not familiar with its content.O thers had not even heard that unw anted p reg n a n cy because 1 would not want my parents to discover my condition especially since they are trying very hard to make ends meet." "I would think about an abortion because I am not ready to become a mother and / would like to pursue my education and become a belter person."However, when probes were used to assess the participants' opinions on the rights of the pregnant woman, there was overwhelming support for the fact that termination of pregnancy should only take place with the informed consent of a pregnant woman.The participants were completely against the right of the father to the unborn child.This finding differs from the one reported by Evans (2001:2) that adolescents took the baby's father into consideration when taking decisions in pregnancy resolutions.
Even though the participants appeared to be pro-choice, the findings suggest that most learners are ignorant about the legislative developments occurring in the country.Their lack o f awareness also points to the gaps in the comprehensive Inform ation, E ducation and Communication (IEC) strategy adopted by the Limpopo Province to disseminate of information and provide support for R eproductive H ealth S ervices (Barometer, 1998:16).

Benefits from CTOP
The p articip an ts speculated that a woman who has a desire to terminate an unplanned and unwanted pregnancy w ould ben efit from this Act as it recognizes the wom an's reproductive rights.The Act also helps adolescents to make informed decisions about their future.

Factors that may compel participants to consider the termination of a pregnancy
The majority of the participants indicated a variety of factors that could lead them to co n sid er the term ination o f an unwanted pregnancy.The following were regarded as fundamental: • Fear of parents and shame.
• Inability to provide child care due to financial constraints, and • Attending school.
A few of the participants indicated that it would be because they were not ready for motherhood whilst others stated that it might occur as a result of rejection from their boyfriends while pregnant.Some of the responses were as follows: "I would consider an abortion for an The findings suggest that most of the participants value their relationships with their parents, education and their ambitions.The latter is supportive of Kritzinger's (2000:557) report that teenage girls' dreams are to complete high school and proceed to tertiary education.The participants' acknowledgement of their unpreparedness to becom e m others shows their increased awareness o f the dem ands children place upon their parents.
Even though the provision of counselling before and after the termination o f a pregnancy is not mandatory according to the CTOP Act No. 92 of 1996, it appears as though some adolescents would require such services to assist them in dealing with their fears and emotions w hich may im pede th eir social functioning in future, as is implicit in the following account: "/ w ill not be able to request fo r termination o f an unwanted pregnancy at any health fa c ility that does not provide counseling because / do not think / will be able to deal with the guilt feelings."

Dangers of back-street abortions
Generally, the participants were in agreement that back-street abortions have debilitating effects on the physical and mental health of many young women.Some of the consequences of back-street abortion were provided as, death, the risk o f contracting Sexually Transmitted Infections (S T Is) and H IV /A ID S, excessive bleeding, incomplete abortion, injury of the reproductive organs leading to infertility, risk o f psychosis and depression.
Even though the discussion aroused a trem endous argum ent am ong the participants, the findings are indicative o f their level of understanding o f the severity of the effects o f back-street abortions.

Prevention of unwanted pregnancy
The majority of the participants indicated that the use of a The participants' knowledge of biology and exposure to life skills programmes do not seem to have succeeded in mitigating the misconceptions or myths about the prevention of pregnancy.

The adolescents' access to health services
The general responses provided indicate that adolescents do not view health services accessible as some adolescents have to travel long distances to clinics while others were of the opinion that they did not regard the health services as youth friendly.Others expressed strong views about the harsh treatment pregnant adolescents receive from some o f the health providers who often overlook facto rs that may have led to the adolescents' situation.This finding implies that, for as long as there is a lack of support from the health professionals, many frustrated adolescents would still consider back-street abortions as the ultimate option for their situation.
Some of the participants were of the view that they would not feel comfortable seeking TOP services at the local clinics and hospitals utilized by their parents and relatives for fear of rejection and a lack of confidentiality.These feelings are captured in the following response: "Even though / uni pro-choice, I will never use local health fa c ilitie s to terminate an abortion, because such information may reach my fam ily and they would be very angry with me." They were also of the opinion that most adolescents are unable to confide in their parents due to the distant relationship that exists between adolescents and their parents.This situation compounds the pregnant adolescents' confusion.The general feeling o f the participants is represented by the following response: "The relationship between adolescents and parents is distant hence we are unable to discuss sexual matters with our mothers.Unlike women who live in urban areas, most o f our mothers are illiterate.They think that u'e learn everything from school." Evidently, most parents depend entirely on professionals such as educators and nurses to teach their daughters about the facts of life.
Major findings

Limitations of the study
The researcher conducted the study without the assistance of a moderator.This may have led to the loss of vital information.Even though focus groups helped to create a non-threatening environm ent for the participants to interact, it becam e apparent in this instance that some participants were uncomfortable discussing their first-hand knowledge of friends and acquaintances who had perform ed back-street abortions.

Recommendations
Based on the findings of this study, it is recommended that: counselling to ameliorate feelings of self-blame and guilt resulting from the loss.
pregnancy from February to December 1997, implying that the marketing of the service had not been adequate and effective.This happened despite the fact that the Province prides itself on the d issem ination o f a com prehensive W ithin three m onths o f the implementation o f the CTOP Act, 60% of nearly 7,300 terminations took place in the G auteng Province (Governm entGazette, 2001:39 and Dickson-Tetteh &  Billings, 2002:145).Conversely, the Limpopo Province had registered less than a thousand term in atio n s o f