Pregnancy and protection: Perceptions, attitudes and experiences of Australian female adolescents

Article Outline

• Summary
• Introduction
• Methods
  • Participants
  • Data collection
  • Data analysis
• Findings
• Pregnancy…
  • “Baby now—no way!”
  • “Not my reality”
  • “If it happens it happens”
• Protection…
  • “Taking control”
  • “Contraception… not for me”
    • “Not worth the side-effects”
    • “Pill… not on my mind”
    • “Doesn’t always work anyway”
    • “Condoms are a hassle”
    • “Sex is better without condoms”
  • “Smart thinking goes out the door”
    • “Too drunk to care”
    • “Too hard in the heat of the moment”
  • “No need for condoms in our relationship”
• Discussion
• Limitations
• Conclusions and recommendations
• Acknowledgment
• References
• Copyright

Summary 

Background and purpose

Despite decades of research, development and evaluation of educational and promotional strategies to prevent teenage pregnancy, we have only a limited understanding of the strategies that are effective and why. This study sought to explore female teenagers’ attitudes, perceptions and experiences of contraceptive use, and describe the influence of this on pregnancy risk.

Methods

A qualitative approach was used to explore the contraceptive behaviour in a purposive sample of sexually active Australian females aged 14–19 years. Teenagers were drawn from three sub-groups: antenatal and postnatal services (pregnant-continuing); termination services (pregnant-terminating); and sexual health clinics (never-pregnant). Sixty-eight individual, semi-structured interviews were conducted. Thematic analysis was employed to analyse the data and generate a rich, description of contraceptive behaviour.

Results

Whilst participants were familiar with contraception, many used it inconsistently. Commitment to pregnancy prevention was firmly located within participants’ attitudes toward teenage pregnancy and parenthood, perceptions of pregnancy risk and perceptions of the costs and benefits of using contraception. Further, motivation to use contraception fluctuated in different contexts, such as romantic relationships.

Conclusions

Our research highlights the importance of attitudes toward contraception, pregnancy and parenthood in shaping teenagers’ motivation to use contraception. Educational and prevention programs must address the spectrum of attitudes underlying teenagers’ contraceptive and reproductive decisions in order to alter pathways to teenage pregnancy and early parenting.

Keywords: Teenagers, Contraception, Motherhood, Pregnancy, Termination

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Introduction 

Teenage pregnancy and parenthood remain significant adolescent health and social issues.¹, ² At 16 per 100 per year,³ Australia's teenage fertility rate is higher than most developed countries outside the United States and the United Kingdom.⁴, ⁵, ⁶, ⁷ In addition, Australia has one of the highest abortion rates in this age group, with the proportion of pregnancies ending in abortion having increased from 20% to over 50% over the past 30 years to 1999.⁷, ⁸ This figure has since remained stable.

Extensive literature confirms poorer outcomes for teenage mothers. Consequently, much research has been devoted to understanding the dynamics of adolescent pregnancy, in particular the underlying causes and consequences.⁹, ¹⁰, ¹¹, ¹² Whilst this has provided a useful conceptual basis for programs seeking to reduce adolescent sexual risk behaviour, such research has also been preoccupied with demonstrating the negative consequences of pregnancy for these young women and their children.¹³ Further, the perspectives of teenagers themselves are also often ignored.¹⁴, ¹⁵

A growing number of studies now suggest that, although teenage pregnancy may be perceived as problematic by society, young people may regard it differently.¹⁶, ¹⁷, ¹⁸, ¹⁹, ²⁰, ²¹ Further, in a climate where contraceptive use is considered the standard practice for sexually active adolescents,²² clinicians and educationalists often assume that adolescents want to avoid pregnancy, and those who do conceive do so unintentionally.²³ Yet increasing evidence suggests this is not always the case. Longitudinal research has shown that the level of control an adolescent maintains over their contraceptive behaviour is the strongest predictor of pregnancy outcomes; inconsistent and non-users of contraception have much higher odds of becoming pregnant compared to consistent users.²⁴ However, despite this obvious link between behaviour and outcome, we do not fully understand the basic processes influencing adolescents’ sexual and reproductive choices, including contraception use. Some have suggested that inadequate contraception use may result from more positive or ambivalent attitudes toward pregnancy and parenthood.¹⁷, ²¹, ²⁵, ²⁶ Alternatively, teenagers with a stronger commitment to avoid pregnancy have been shown to use contraception more consistently.²¹

The contraceptive behaviour of adolescents is a complex issue that must be investigated within multiple domains of influence.⁹, ²⁷ Survey research in this area often fails to capture the dynamic nature of contraceptive use in different contexts and over time. To overcome this, qualitative methods offer an effective way to explore the meanings assigned to personal experiences and describe the reasons underlying behaviour in its social context.²⁸

The findings presented in this paper form part of a larger study exploring the biopsychosocial antecedents of pregnancy and parenthood in sexually active female teenagers. Approval to conduct this study was obtained from the relevant hospital Ethics Committee. This paper reports upon teenagers’ attitudes, perceptions and experiences of contraceptive use and how these influenced pregnancy risk.

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Methods 

Participants 

A purposive sample comprising three sub-groups of sexually active females aged 14–19 years was recruited from adolescent antenatal and postnatal services (pregnant-continued), termination services (pregnant-terminated), and youth sexual health services (never-pregnant) in the metropolitan area of Perth, Western Australia. This recruitment strategy was chosen to provide diversity of experiences around the issues relevant to teenage pregnancy.²⁹ Participant characteristics are listed in Table 1. All Aboriginal participants were recruited from antenatal and postnatal services.

Table 1. Demographic characteristics of female adolescent participants (n=68).

Characteristic	Frequency	%
Age (years)
14–15	8	12
16–17	36	53
18–19	24	35
Ethnicity
Caucasian	60	88
Aboriginal	8	12
Pregnancy status
Never-pregnant	12	18
Pregnant-terminated (first pregnancy)	21	31
Pregnant-continued (first pregnancy)
Antenatal	16a	23
Postnatal	19b	28
Age first coitus (yrs)
<13	4	6
13–14	36	53
15–16	23	34
>17	5	7
Age first pregnancy (years) (n=56)
<16	15	27
16–17	32	57
>18	9	16

Potential participants were introduced to the study by clinic staff during their consultation. Teenagers were excluded if they were under the age of 14 years, had a known history of psychological distress or trauma or were recent refugees to Australia. Eligible teenagers were introduced to a research officer (RO) in the clinic waiting room. Teenagers were provided with an information sheet and given ample time to ask questions about the study. Upon indicating their willingness to participate teenagers gave written consent and provided a telephone number to be contacted on the following week to schedule an interview. Given the highly sensitive subject matter and need to provide absolute confidentiality, ethical approval for parental consent was waived in cases where teenagers were accessing medical services independently, had cognitive maturity to provide informed consent, and where parental involvement presented a risk to the teenager's emotional/mental/physical well-being.³⁰

Data collection 

A total of 68 semi-structured interviews were conducted between February and November 2006. This approach was chosen to explore broad topics related to the purpose of the research, yet also allowed the flexibility to follow key emerging issues. Four female post-graduate ROs, including one Aboriginal RO, were trained by members of the associate investigator team on interview techniques and effectively engaging with teenagers to ensure quality and consistency between ROs. The majority of interviews were carried out in participants’ homes. All interviews lasted between 45 and 90min and were audio-taped, transcribed and checked for accuracy.

Informed by a systematic review of factors associated with teenage pregnancy and set within a biopsychosocial framework, interviews explored the underlying reasons and context of teenagers’ decisions and behaviour. Broad, open-ended questions introduced topics and facilitated discussion around areas such as romantic relationships, sexual activity, contraception, pregnancy and parenthood. Where appropriate, prompts were used to elicit greater detail around teenagers’ thoughts, feelings and experiences. For example, probing statements such as, “can you tell me more about…” and “can you think back to how you felt when…” helped to contextualise and uncover implicit meanings in teenagers’ stories. The dimensions of topics investigated evolved over time, as data analysis informed subsequent inquiry.³¹

Data analysis 

Thematic analysis and techniques associated with constant comparison were used to identify and develop emerging patterns simultaneously with data collection. Initial codes were generated through line-by-line analysis, by which words and sentences were examined carefully to elicit rich meaning from teenagers’ accounts.³² This technique also assisted ROs to remain sensitive to subtle nuances in the data. Emerging concepts from each transcript were constantly compared against new data before being organised into more abstract conceptual themes. This iterative process ensured the analysis remained grounded in the participants’ experiences. Approaching saturation of themes, interpretations of the data were discussed in analysis workshops with project investigators and research staff. Diagrams and concept maps were used to establish relationships between themes and generate an explanatory model of behaviour.

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Findings 

Variation in teenagers’ contraceptive behaviour was symbolic of a divergent discourse around pregnancy and parenthood. The following section presents the findings under two broad headings of ‘Pregnancy’ and ‘Protection’, each containing major themes and sub-themes that describe teenagers’ attitudes toward pregnancy and parenthood and their subsequent experiences with contraception.

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Pregnancy… 

“Baby now—no way!” 

Never-pregnant (NP) teenagers described motherhood as their “worst nightmare”; something that would disrupt their lives and restrict their freedom as a teenager. Establishing a “healthy career”, “having enough money”, “owning a house”, “being married” and “being mature enough” were the dominant concepts behind their desire to postpone motherhood. One NP teenager said, “I have my life and my career and everything right in front of me and I don’t want to throw that away”. The NP group also prioritised “going out”, “having fun”, “travelling” and wanting to “live their life” before “settling down” with kids. Thus, the desire to “go out and have a good time” conflicted with their perceptions of being “tied down” with children. Further, the potential role of peer group norms on attitudes toward motherhood emerged through comments such as, “No one close to me is young with kids” and “you would lose most of your friends”.

“Not my reality” 

Pregnant-terminated (PT) teenagers held similar negative attitudes toward motherhood as NP teenagers. However, many in this group had dismissed their risk of becoming pregnant for various reasons. The decision to terminate their pregnancy therefore reflected a discordant relationship between their desire to postpone motherhood and inadequate use of contraception.

Many PT teenagers described their pregnancy as an “accident” or “unexpected”; something they “didn’t think would happen”. Inconsistent or non-use of contraception was driven by a sense of being “invincible” and believing pregnancy was something that “only happens to people that want it to happen or that plan it to happen”. For some, a lower perceived vulnerability to pregnancy was established through “one off” or repeated encounters of unprotected intercourse over time with no immediate consequences. For example (pregnancy) “It was in my mind but you just think it will never happen… Because you get away with it a couple of times and it doesn’t happen, and then it does”. In addition, a belief that “I didn’t think I could get pregnant” presented in a number of PT and PC teenagers. Exploring this further, some had questioned their ability to conceive, referring to physical barriers such as “irregular periods”. Four teenagers also described their experience with doctors and information received on the likelihood of becoming pregnant. For example, “I wasn’t supposed to be able to get pregnant… the doctor said, look I can’t tell you this on the books but I can tell you that you have a very small chance of getting pregnant ever”.

“If it happens it happens” 

For pregnant-continued (PC) teenagers, more positive or ambivalent attitudes toward pregnancy and parenthood had a clear impact upon their contraceptive behaviour. Comments such as, “I didn’t stop it from happening”, “it didn’t really bother me”, and “if it happens it happens” represented an alternative discourse to PT teenagers who simply failed to accept their risk of becoming pregnant. Regarding their pregnancy as, “unplanned but not unwanted”, the lower commitment of PC teenagers to use contraception was embedded within their higher expectations of motherhood. Whilst the majority were ambivalent to becoming pregnant, for example, “if it was going to happen it was going to happen”, more definite pregnancy intentions were evident in teenagers who directly attributed the decision not to use contraception to a desire for motherhood: “I really wanted to be a mum and when I found out I was pregnant I felt complete”. A higher intention to become pregnant was found in over half of the Aboriginal participants.

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Protection… 

“Taking control” 

A discourse of ‘taking control’ over contraception symbolised the commitment of NP teenagers to avoid pregnancy. “I don’t want to get pregnant so I’m going to use it”, therefore represented the dominant perspective of this group. Experiences of using both condoms and hormonal contraceptives were described. With regards to condoms, greater authority maintained over use with sexual partners was revealed through statements such as, “I wouldn’t have sex if he didn’t use anything” and “he didn’t have a choice”.

Some also spoke of their conscious decision to stop using condoms within a long-term and “committed” partnership. However, these teenagers were motivated to seek an alternative contraceptive for continued protection against pregnancy. Almost all NP teenagers were current users of the Oral Contraceptive Pill (OCP). Their stories of consistent daily use clearly distinguished them from teenagers who became pregnant unintentionally: “I like taking the pill because it's one of the most reliable methods. I always freak out that I’ve forgotten to take it even though I know I have checked the packet like five times a day”.

“Contraception… not for me” 

Whereas the decision not to use contraception for some PC teenagers reflected a greater desire toward pregnancy/parenthood, teenagers who wanted to avoid pregnancy more often attributed their inadequate use to perceived or experienced personal costs of using contraception. The following five sub-themes demonstrate the reluctance to use contraception and how this was rationalised.

For many who conceived, contraception use and method choice were strongly influenced by the experience of side-effects or information received from others in relation to this. The impact of hormonal contraceptives on physical appearance was a major concern. This had a negative effect on both the commencement and continuation of methods such as the OCP, the “injection” (Depo Provera) and the “implant” (Implanon). For example, one PT teenager recalled, “I got Implanon to make sure it wouldn’t happen again but it made me stack on weight”. Consequently, she had the Implanon removed and had recently terminated her second pregnancy. Personalising the experiences of others also made some teenagers reluctant to use contraception: “I don’t want that thing in your arm. I heard you get fat. My cousin she went on it. She used to be a size 8 now she's a size 16 because she got that put in her arm”. Finally, misconceptions of side-effects and a fear of perceived risks influenced the types of methods considered for several: “I heard of the injection… it affects bone density” and “for me the pill can cause breast cancer… I didn’t want to risk it”.

PT and PC teenagers often described the difficulties they experienced, or perceived, in using the OCP effectively. Some said they “always forgot”, whereas others has disregarded this method altogether because of their “terrible memory”. Lacking routine in their life and having difficulty getting into the “daily habit” was a common barrier. For example one PT said, “I am not really the type of person to do daily things. I can’t really wake up and take the pill everyday, I’ll forget. The next thing you know I will end up pregnant again”.

Scepticism surrounding the efficacy of contraception was described through personal experiences or in relation to others who had become pregnant whilst using contraception. In most cases, their doubt centred upon the reliability of condoms: “they break a lot of the time”, “they don’t always stay on” and “you can get holes in them”. Such accounts were used to justify why condoms were not used or used sporadically, with two PT teenagers directly attributing their pregnancy to condom failure. A number of NP teenagers held similar perceptions of condoms, yet this had motivated them to commence the OCP for “extra security”. For example, “I don’t think condoms are very good at all like with contraception. I’d rather have the security of knowing like I’ve got the pill too”.

Considering condoms as an inconvenience and something that interrupts sex had an important influence on teenagers’ motivation to use this method. Many PT and PC teenagers formed negative attitudes toward condoms based upon the preparation and action required for effective use: “I don’t really like them because they’re annoying, like just having to go and get them and everything… you have to stop what you’re doing and go and get them”. In these instances, condom non-use was simply attributed to a stance of “I couldn’t be bothered”.

Considering sex to be “so much better without them” was also often expressed to justify decisions on condom cessation for PT and PC teenagers. Seeking a more pleasurable and intimate sexual experience, these girls had prioritised the immediate gratification from not using condoms over potential consequences. Drawing upon personal experiences, negative associations such as “uncomfortable”, “lack of sensation” and “feels fake” had formed the basis of their lower motivation to use condoms consistently. Several also referred to their partners’ preference to not use condoms: “Condoms. They don’t work because males don’t want to use them half the time…his Dad never used one…they reckon it feels better when they don’t wear one or something”.

“Smart thinking goes out the door” 

A substantial number of PT and PC teenagers described similar circumstances when condom use was “just not something that pops into your mind”. “Too drunk to care” and “too hard in the heat of the moment” were two common explanations derived from their personal experiences.

Alcohol consumption was often linked to instances of unprotected intercourse. From being “tipsy” to “off your face” to “stone drunk”, teenagers spoke of contraception being “the last thing on your mind”. For those who regretted such experiences, they spoke about “not thinking straight”, being “out of control” and “not prepared” as to why they had not used a condom. However, several others were less regretful, which was revealed through the notion of being “too drunk to care”: “If you’re just off your face it's the last thing you’re going to want to think about. I didn’t really care”.

Together with the influence of alcohol, being “caught up in the heat of the moment” was an important barrier to consistent condom use for some PT and PC teenagers. Comments such as “smart thinking goes out the door” and “mature thoughts go out the window” reflected their lower control over condom use during the “heavy moment” of intercourse. As another explained, “When it's the heat of the moment you don’t think of it, like you’re both all heated up, you’re not going to think oh let's stop now and put a condom on. It just happens”. Further, being prepared for occasional “spur of the moment” sexual encounters by ensuring condoms were available was less likely for PT and PC participants.

“No need for condoms in our relationship” 

The way teenagers defined their relationship and the characteristics of their partner influenced the consistency and duration of condom use. Perceptions of relationship stability and being “in love” were used to justify why condom use had changed over time. As one teenager recalled, “We used condoms for a couple of months. And then I don’t know what happened, we just fell in love with each other too soon”.

For teenagers who became pregnant, perceived consequences of unprotected sex often diminished earlier in their relationship, for some within 2 or 3 months. “Knowing” and “trusting” their partner was “clean” led to a belief that sexually transmissible infections (STIs) were of no concern. Thus the incentive to use condoms declined. The transition to condom non-use had greater implications for these teenagers as they were less likely to replace condoms with an alternative contraceptive.

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Discussion 

Conceived within a developmental context, theoretical models of health behaviour assume that young people engage in risky behaviour because they have perceptions of low personal vulnerability to risk, are complacent about potential consequences and may fail to rationally consider the costs and benefits of their decisions and behaviours.³³, ³⁴, ³⁵ This was true for many teenagers in the present study. Contraceptive behaviour and subsequent pregnancy risk seemed linked to an appraisal process comprising two attitudinal dimensions: (1) attitudes toward behaviour (contraception) and (2) attitudes toward behavioural outcomes (pregnancy/parenthood). Aligning with Gage's³⁴ conceptual framework of adolescent reproductive choices, this suggests that teenagers’ motivation to use contraception fluctuated with the perceived advantages and disadvantages of pregnancy and parenthood, as well as their appraisal of the costs and benefits of practicing contraception.

Exploring the meanings and expectations associated with pregnancy and parenthood, our findings support earlier studies that suggest teenagers who perceive pregnancy and childbearing negatively are more likely to regard contraception in a positive manner and adopt a consistent protective regime.²¹, ²⁴ This was particularly evident for NP teenagers who were firmly committed to avoid pregnancy/parenthood. The reverse also appears true. Exploring why pregnant adolescents did not use contraception prior to conceiving, Stevens-Simon et al.²⁰ found that lower motivation to use contraception was most often embedded within a more positive or ambivalent outlook to childbearing; over one-third of teenagers attributed their decision to not use contraception to wanting or not minding if they became pregnant. This was reminiscent of the pre-pregnancy desires captured from PC teenagers in the present study. Several longitudinal studies have also reported a relationship between an adolescent's strength of desire to avoid pregnancy and contraceptive use.¹⁷, ²¹, ³⁶ In one study, a lower desirability to postpone childbearing was associated with a lower likelihood of regular contraceptive use and being three to four times more likely to give birth over a 2-year period.²¹ Taken together, these results suggest that for pregnancy and early parenting to be avoided, negative attitudes toward this must be strong enough to motivate the adoption of preventive behaviour.²¹

Yet, our data also revealed a discordant relationship between pregnancy attitudes and contraceptive behaviour in teenagers who had underestimated their personal risk of pregnancy. In most cases reflecting the behaviour of PT teenagers, decisions to initiate and continue with contraceptive methods were more often influenced by their beliefs about the costs and benefits of protection. Perceived individual and interpersonal costs of using contraception (for example unpleasant, difficult to use, inconvenient, side-effects) were important obstacles to effective contraceptive use and closely align with the experiences of teenagers described in previous qualitative studies.¹⁸, ³⁵ Decisions regarding contraception were also often made in the context of situation-specific factors common in the lives of adolescents, for example, drunken sexual encounters or perceptions of their romantic relationship. This suggests that an adolescent's perceptions of the costs and benefits of contraception may change in different contexts, leading to a greater likelihood of unprotected intercourse in teenagers with a lower commitment to avoid pregnancy.³⁷, ³⁸

Finally, the altered pathways to pregnancy discovered in PC and PT teenagers contribute to the growing literature on adolescent pregnancy intentions. To date, results on this have been mixed and conclusions limited by loose definitions and difficulty obtaining accurate measures.²⁵, ³⁶ Although our exploration relied upon teenagers’ reconstructions of past events and behaviour, the disjunction between pregnancy intentions and contraceptive behaviour clearly emerged from PT teenagers. Set within their lower perceptions of risk to pregnancy, the motivation to adopt preventive behaviour declined with their evaluation of the costs of using contraception. Others investigating why adolescents with no desire to become pregnant do not use contraception consistently have concluded that a lower commitment, or ambivalence to remain non-pregnant rather than intentions to become pregnant more accurately explain contraceptive behaviour.²⁵, ³⁶ Thus efforts to conceptualise teenagers’ pre-pregnancy intentions must recognise that the same behaviour (not using contraception) may reflect intentions or ambivalence to become pregnant or lower commitment to use contraception.³⁶

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Limitations 

There were several limitations to this study. Firstly, our findings were based upon teenagers’ retrospective descriptions of contraceptive use and pregnancy experiences, which may have been reconstructed differently over time, particularly in those interviewed during or after pregnancy. However, sampling from different pregnancy groups and using qualitative methods of inquiry were intended to lessen these limitations. Secondly, our conclusions would be potentially strengthened by capturing the perspectives of teenagers not yet sexually active, or those not accessing clinical services for contraception. However, ensuring saturation of concepts among higher-risk sexually active females was important to understand the pathways leading to unplanned pregnancy.

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Conclusions and recommendations 

This investigation offers some explanation as to why teenagers do not use available forms of contraception consistently, if at all, that goes beyond lack of knowledge and limited access. Given this study strengthens the notion of contraceptive use being the behavioural link between pregnancy attitudes and reproductive outcomes, sexual health policy makers and clinicians must remove themselves from the assumption that adolescents are motivated to avoid pregnancy. Whereas those with strong negative attitudes to early pregnancy and parenthood are more likely to protect themselves effectively, teenagers with positive or ambivalent views are more likely to use contraception inconsistently. These attitudes are clearly related to a range of other experiences and beliefs, such as low perceived risk of pregnancy, costs of contraception use, relationship, partner, peer and other contextual and cultural factors. Understanding these factors and how they interact and influence attitude formation and contraceptive use requires further qualitative exploration using the perspectives of teenagers themselves. In particular, greater insight into the specific cultural experiences of Aboriginal teenagers and their attitudes and beliefs around pregnancy, parenthood, contraception and abortion is needed.

Further, as inconsistent or non-use of contraception may reflect a lower commitment to avoid pregnancy or lower motivation to use contraception, safe sex and pregnancy prevention programs must address the spectrum of attitudes held by teenagers in relation to contraception, pregnancy and parenthood. This also suggests the need to reconstruct simplistic notions about the relationship between intentions and behaviour when exploring teenagers’ sexual and reproductive decisions.¹⁸ Taken together, interventions seeking to reduce an adolescent's risk of pregnancy must consider both unintended and intended pathways, attend to negative and positive perceptions of parenthood and acknowledge the costs and benefits that teenagers’ associate with contraception.

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Acknowledgment 

We declare that the content of this paper is original; that each author participated meaningful; and that if the paper is accepted copyright is to be transferred to the Women and Birth: Journal of the Australian College of Midwives.

This project was funded by NHMRC.

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