Ethical statement

This study received approval from the Institutional Review Board of the University of Rwanda, College of Medicine and Health Sciences (Approval No:302/CMHS IRB/2022). Before data collection, all participants provided written assent, and their legal guardians signed written consent forms after being thoroughly informed about the study’s purpose, their involvement, and the study’s procedures. The research adhered to the principles outlined in the Declaration of Helsinki and complied with the regulations governing research involving human subjects in Rwanda.

Study design, setting, and population

This study employed a qualitative descriptive methodology to gather rich descriptions about the consequences associated with teenage pregnancies [15]. The study participants included 20 childbearing adolescents from four different health centers in Gatsibo district, in the Eastern province of Rwanda. Researchers interviewed five participants from the neighborhood of each health center.

Sampling and recruitment

A purposive sampling strategy was used to select adolescents who gave birth when they were between 15–19 years old [15]. After obtaining ethical approval from University of Rwanda, the research team sought permission from the mayor of Gatsibo Distinct to access the study settings. The permission letter was presented to the heads of the selected health centers, who connected researchers with community health workers (CHW). The latter identify and register pregnant women in the communities and were therefore well positioned to help recruit participants. Researchers explained the study’s purpose to the CHWs and provided them with recruitment posters, which were also posted at the health centers, so that anyone who wanted to participate in the study could contact the research team to set up an appointment. Researchers included only adolescent females aged 15–19 who became pregnant while residing in the selected communities.

Data collection instrument

In data collection, researchers used demographic questionnaire and a semi-structured interview guide developed from a thorough examination of the literature [16–19] and in consultation with two experienced researchers in the field of adolescent pregnancy. The study participants’ socio-demographic characteristics, such as age, education, marital status, religion, residency, household head, parity, antenatal visit, gestational age, and occupation, were collected prior to in-depth interviews. The interview guide featured invitational questions and probing questions that encouraged participants to express all consequences related to childbearing that they identified with. The interview was conducted in Kinyarwanda because this is the only language our participants were able to express themselves in.

The interview guide commenced with general questions such as: (1) In what circumstances did you get pregnant? (2) Can you tell me how you felt after getting pregnant, during pregnancy, and after giving birth? (3) What social problems did you experience during and after your pregnancy? (4) Did you experience any obstetrical outcomes related to getting pregnant as a teen? (5) Are there any other problems that we have not discussed?

Data collection

Participants who were invited through CHWs met one by one with two female co-investigators experienced in qualitative data collection in a clean and well-ventilated private room for an audio-recorded interview. The rooms were selected with the help of health center administration staff. Before the discussion, the co-investigators introduced themselves to the participants. They explained the purpose of the study and provided information about the risks and benefits of participating. The participants were given time to ask questions and provided with the researchers’ contact information in case of any questions or concerns. Participants under the age of 18 were asked to sign an assent form and provide a signed consent form from their legal guardians. Participants aged 18 and over signed informed consent. The co-investigators explained their role in the process of data collection and set ground rules that encouraged respect for one another and informed conversation. One female co-investigator conducted the interview while another took field notes. Because the questions caused some participants to recall painful experiences related to childbearing when they were in the adolescent phase, for some, it was necessary to pause the interview. Participants were counseled by both investigators, each of whom had mental health training. Because of the sensitivity of the topic, there was a pre-established protocol to manage emotional responses that entailed stopping the interview, counseling the participants, asking if they preferred to cease or continue the interview, and referring them to mental health professionals for further management and follow-up. Only five participants out of the twenty exhibited emotional responses such as crying and tight throat; these participants wished to continue the interview. Two follow-up calls were made after one week and one month, and the participants reported they were doing well. We reached data saturation after interviewing 20 participants because there was no new information. The shortest interview was 13 minutes and 22 seconds, and the longest was 27 minutes and 12 seconds. Daily memoing practice was done to ensure that co-investigator personal perspectives would not influence the interpretation of data. Data collection started August 30, 2022, and ended September 30, 2022.

Data analysis

Data were translated into English and transcribed verbatim by IT, JR, AN, VB, and BN, who are fluent in Kinyarwanda. Data were organized and coded using Dedoose software. Thematic analysis was used to generate and report themes through six phases including data familiarization, generating initial codes, searching themes, reviewing themes, defining themes, and reporting themes [20]. Four research team members, including two data collectors, were involved in data analysis to ensure that the data were accurately interpreted and conclusions were based on the data collected. Before beginning to code data and search for themes, the research team familiarized themselves with the entire data set first. The team members transcribed the data themselves to become more familiar with it. This provided a useful orientation to the raw data and served as the foundation for all subsequent steps. After familiarizing themselves with the data, research team members started the initial coding by taking notes on potential data items of interest, connections, and other initial ideas using the coding template. After this step, the research team members examined the codes and extracts in order to identify broad themes. The research team held three meetings to review and define themes. All team members agreed on the final themes reported in this manuscript.

Themes

Three main themes were identified during thematic analysis: (1) self-reported health outcomes; (2) socio-economic consequences; and (3) perceived structural barriers to access healthcare services (Table 2).

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Table 2. Themes and sub-themes.

https://doi.org/10.1371/journal.pgph.0003716.t002

Theme one: Self-reported health outcomes

Eight participants in this study reported experiencing physical and psychological problems during pregnancy and after delivery. Physical problems included prolonged labor and pain. Some participants said their skin turned yellow, which suggests anemia. Psychological problems included fear of disclosing the pregnancy, intense stress, anxiety, depression, feelings of guilt, and poor coping mechanisms such as sleeplessness and suicidal thoughts.

A few of the participants had premature deliveries, and others underwent cesarean section. Some participants reported experiencing anemia during pregnancy, and three reported high blood pressure.

For instance, one teen mother noted, “Throughout my pregnancy, I was weak, my skin was always yellow and that left me always feeling worn out.” Site 4, P2.

Another participant added, “I was referred immediately from the health center to the district hospital because my blood pressure was high and told that it would be severe.” Site 4, P5.

Thirteen participants experienced mental problems such as difficulty accepting that they were pregnant, fear of disclosing the pregnancy, and intense stress, anxiety, and depression related to the delivery process and altered relationships with their family members when they learned of the pregnancy.

One participant explained, “After learning that I was pregnant, I felt overwhelmed with despair but eventually accepted the reality of the situation." Site 4, P5.

Other participants expressed that, even though they had accepted giving birth, they experienced fear and intense stress related to pregnancy and the delivery process, as noted in one quote: "The fear I experienced was specifically related to the delivery process and unprepared parenthood." Site 1, P1.

Another participant added, "I was filled with fear and apprehension regarding my father’s reaction upon learning about my pregnancy." Site 3, P2.

Most of the study participants narrated that after learning that they were pregnant, they felt guilty and ashamed. For instance, one study participant explained, "I deeply regretted getting pregnant at my age, as it was an unplanned occurrence. It was a shame on my family." Site 1, P3.

Five participants reported that these psychological problems led to poor coping mechanisms. Some experienced trouble sleeping. As stated by one participant, “I felt depressed when I called the father of this child and found that the phone was off. After being discharged from hospital, I found it [phone] inaccessible. I could not sleep for a long time.” Site 1, P1.

A few other participants reported having suicidal thoughts, and some attempted to commit suicide, as reflected in the following quote:

“I attempted suicide using a lace, but during the act, I felt physical pain in my body, including headaches and earaches. The lace broke and fell off. On another occasion, I tried to end my life by going to Lake Muhazi, which was far from my home. However, while on my way, it started raining heavily, and I thought about my child being left alone at home. I quickly turned back and rushed home, where I found my child crying. Seeing my child in that state, I was overwhelmed with emotion, sought his or her forgiveness, and made a commitment to never engage in such actions again.” Site 4, P5

A few other participants reported that due to the lack of social support and being ostracized by their families, they did not want to raise their babies. They felt abortion was a solution. For instance, one participant explained:

Given the circumstances I was facing, my family decided to disown me, leaving me homeless. Throughout that difficult period, the idea of having an abortion crossed my mind. However, my conscience strongly opposed the notion. I struggled with these conflicting thoughts until I ultimately made the decision to give birth. Site 1, P2

The study participants reported that teenage pregnancy was associated with a variety of health concerns, such as mental health problems and poor physical health. This is likely due to the fact that teenage mothers often lack the support and resources needed to take care of their health.

Theme two: Socio-economic consequences

The participants in this study reported various socio-economic consequences of teenage pregnancy at individual and societal levels. These consequences included loss of future, lack of social support, stigma and discrimination, family conflict, school interruptions and dropout, and financial constraints.

Fifteen study participants narrated that after learning they were pregnant, they felt disappointed in their families, and others felt their dreams had shattered.

For instance, one study participant explained, "It was a very difficult time for me as I was worried about the future of my child… I couldn’t help but think about my own life. …. It was also hard for me to see my colleagues going back to school while I had to put my education on hold due to the pregnancy." Site 3, P2.

After getting pregnant or after delivery, teen mothers in this study reported lacking support from their partners and families. Most study participants reported being abandoned by their partners.

For instance, one study participant explained, “After engaging in sexual intercourse with my boyfriend and revealing my pregnancy, he informed me that I should have an abortion as he wasn’t ready for marriage. Thus, he did not support me.” Site 2, P3.

Another participant confirmed, “I was left alone by the man who had impregnated me, without any support or even providing the necessary materials as the delivery approached. This caused me a lot of stress and frustration, especially when I found out that he had gotten married to another woman.” Site 2, P2.

Teen mothers reported that their pregnancies led to family conflicts such as quarrels, misunderstandings between parents, and family separation. Family conflicts were found to be the primary source of psychological problems experienced by teen mothers after becoming pregnant. Some families are never able accept their child’s pregnancy, even rejecting their grandchild. On the other hand, teen mothers expressed that family support, when present, was the pillar of their wellbeing and psychological stability.

He [my father] was very harsh to me, to the extent that I lost my appetite due to his words. Even before, when he used to drink, he would treat me harshly by claiming that he didn’t give birth to a child like me and would speak unfriendly words to my mother, accusing her of my problems. It became difficult for me to eat in such a situation. Site 2, P1

Because my family didn’t accept my situation of being pregnant, it was a big challenge because no one cared about me. Even when I need something, they said to go and seek assistance from the [person] responsible for the pregnancy, while I was not aware of where he was. Site 1, P5

Some study participants revealed that they experienced stigmatization and discrimination from their peers and community because of their pregnancy. Among 20 teen mothers interviewed, 15 of them described becoming estranged from their peers, childhood friends, and schoolmates. Some of these peers now labeled them as prostitutes or misbehaved girls; they talked behind their backs saying they cannot give good advice because they got pregnant early.

For example, one participant noted, “My friends said they should no longer be with a bitch like me. They claimed that I could influence others negatively.” Site 1, P3.

Another participant added, “They broke up our relationship and shit me claiming that I am no longer a girl but [a] woman.” Site 4, P2.

All 20 interviewed teen mothers dropped out of school. Many became pregnant while they were still studying; however, a few became pregnant after they had dropped out due to other reasons. Only one teen mother wished to get back to school.

For instance, one study participant highlighted, “After getting pregnant, I became less interested in school activities. Finally, I dropped out.” Site 1, P4.

Lastly, teen mothers in this study reported some financial constraints as a result of getting pregnant. These long-term economic consequences were due to lack of employment opportunities, difficulty maintaining stable jobs, and childcare responsibilities, as reflected in the following quote:

You could have money and wish to buy something, but inevitably, you think about your child, my child lacks shoes, if I could buy them, how would I go to vaccination appointments…, I am going there without taking porridge or without shawl of my baby? without a baby umbrella then you think deeply about your life situation and realize that the reality of life changes. Site 3, P5

This was also confirmed by another participant who explained, “Having a child made it really difficult for me to complete my education and enroll in college. Finding a job without a diploma has proven difficult for me.” Site 4, P2.

Others reported difficulty finding a job due to their pregnancy status, as one participant noted, “… No one can give you a job when you are pregnant because they fear that you might fall and get injured. As a result, you can’t find money needed to buy things like baby clothes.” Site 1, P3.

Understandably, adolescents in this study faced several socio-economic consequences resulting from the loss of education and employment opportunities. These consequences included poverty, family instability, and difficulty accessing resources. This lack of opportunities profoundly impacted the adolescents’ ability to plan for the future, realize their dreams, develop self-efficacy, and gain access to the resources needed to succeed.

Theme three: Perceived structural barriers to accessing healthcare services

All study participants pointed out barriers faced by teen mothers when accessing health services. These barriers included adverse health facility requirements, being stigmatized by adult mothers in the healthcare environment, and healthcare providers’ negative attitudes toward teen mothers.

Teen mothers were challenged by health center policies and procedures concerning the first antenatal care visit, where they were required to be accompanied by their partner. Most of the teen mothers had conflicts with their partners, many of whom refused the pregnancy. Only one out of 20 interviewed teen mothers came with her partner for the first visit, and this participant was later abandoned by her partner.

They required that I bring my husband and explained to them that I was single and not married, they asked me to bring paper from the local leader proving that I don’t have a husband. After getting the required paper, they assessed me again and recommended that I have to bring my husband next time. I communicated with him but he declined. When I went back and said that he refused, they reassessed and registered me. Site 3, P2

Some study participants reported being asked about community health insurance while they could not afford to pay for it.

For instance, one participant reported, “You know, it’s very known that you can’t be received without a health insurance and I didn’t have it. So, I had to go back to the community health worker.” Site 2, P4.

Fear of being stigmatized by other adult mothers at the healthcare center was also reported by some study participants:

“I was not comfortable going to the clinic because it happened once other mothers asked me many questions. For example, one mother asked me how I got pregnant at a young age. I felt embarrassed and frustrated.” Site 3, P3.

These participants added that they were not comfortable going to antenatal care since they would meet with their neighbors and family friends, whom they did not want to encounter while they were pregnant.

A few other participants reported the healthcare providers’ negative attitudes toward teen mothers and described experiencing rude behavior and reproach.

For example, one study participant explained, "A nurse was giving me instructions and I could not follow them well, and she rudely said, ‘It’s not surprising that you are pregnant because you don’t listen.’” Site 1, P1.

Another participant added, "A nurse looked at me for a few seconds and asked me: How could you do this at this age? This is inappropriate at your age". Site 2, P2.

This illustrates that pregnant adolescents who accessed health services faced many challenges related to health center guidelines and procedures. These challenges included increased community stigma, even in the healthcare environment, and healthcare providers’ negative attitudes toward teen mothers. These challenges often cause pregnant adolescents to avoid seeking health services, leading to poor health outcomes for both mother and child.

Limitations

This study has some limitations. First, it was conducted in one district, so the findings may not be generalized to all teen mothers in the whole country. Second, the sample size included teen mothers from low-income families without social support. Participants with social support or from higher-income families might have reported different experiences. Third, almost all study participants lived in rural areas. This may have impacted the study results as rural areas feature different resources and support systems compared to urban areas. Finally, the study only included teen mothers with primary education, so the findings may not be applicable to those with secondary education. Future research should employ a mixed methods approach to better capture the consequences of teen pregnancy for mothers from differing educational backgrounds. Additionally, research should investigate the impact of social support and income on the consequences associated with teenage pregnancy in different communities. Finally, research should include more diverse participants such as health care provider and parents to better understand the topic.