PROBLEMS ENCOUNTERED BY TEENAGE MOTHERS IN THE SOUTHERN HHO-HHO REGION OF SWAZILAND Ms

A qualitative, explorative, descriptive and contextual research approach was followed to study the problems experienced by teenage mothers in the southern Hho-Hho region of Swaziland. The findings of transcribed in-depth individual interviews indicated that the major problem encountered by the participants was the lack of knowledge, advice and emotional support before, during and after their pregnancies. Parents, partners, peer groups, health personnel, teachers, church leaders and communities failed to empower the teenage mothers with knowledge and skills to prevent pregnancy or to facilitate motherhood. This lack of support impacted on the social, cultural, economic, spiritual and emotional dimensions of the teenage mothers. These effects caused problems for the teenage mothers, their families and their communities which could be addressed by multi-disciplinary approaches and intersectoral collaboration.


INTRODUCTION
According to Swaziland's Motherhood Audit Report (1997), out of the 6 756 babies delivered at health services in the Hho-Hho region during 1996, 12 were delivered by teenage mothers aged 10-14 years; and 1 520 were delivered by teenage mothers aged 15-19 years. Thus teenage mothers (aged 19 or younger at the time of the baby's birth) comprised 22.67% of all women who delivered babies in this area during 1996.
Although no health services exist in Swaziland for the special needs of the adolescent and adolescent mothers the above-mentioned statistics indicate the importance for such a service for this vulnerable group. The most important developmental task of adolescence is inter alia to develop into mature adults who can establish mature relationships with the opposite sex, prepare for a vocation, become economically independent and prepare for marriage. The abrupt assumption of parental responsibilities precludes the successful resolution of teenage development and may have adverse effects on the future life of the teenage mother.
The vicious circle of early motherhood, poor education and poverty, leading to more children and greater poverty, has been well documented in many countries.
To attempt to make a difference in the lives of the teenage mothers and to break the above-mentioned vicious circle, it is important to determine what problems the teenage mothers in the Hho-Hho region of Swaziland are experiencing, as nothing has been documented of the unique problems encountered by teenage mothers in this area. Once the problems experienced by the teenage mothers in this region were known, recommendations could be made to improve the health services and support systems to address the unique problems of the teenage mothers in the southern Hho-Hho region of Swaziland.

PURPOSE OF THE RESEARCH
The purpose of the research was to explore and describe the problems experienced and reported by the teenage mothers themselves. This information could then form the basis for recommendations to enhance the quality of life of teenage mothers and their children in the southern Hho-Hho area of Swaziland.

OBJECTIVES OF THE RESEARCH
The objectives of this research focused on the southern Hho-Hho region of Swaziland and

RATIONALE OF THE RESEARCH
It was on the basis of the following discussion that the research area was selected: • Teenage mothers experience unique problems because they are often not physically, socially, culturally, emotionally, spiritually, economically and educationally ready to deal with motherhood.
• Teenage mothers frequently do not have the necessary support or they do not make use of the available support systems in the southern Hho-Hho region of Swaziland to help them deal with their problems.
• Knowledge obtained from the research findings could be implemented to improve the services offered by the health care system to the teenage mother thereby meeting the unique needs of the teenage mother more realistically.

STATEMENT OF THE PROBLEM
Little was known about the problems that the teenage mothers in the southern Hho-Hho region of Swaziland were experiencing. Before any health service or support service could be planned for the teenage mothers, it was essential that an in-depth study, to understand their unique problems as they experience it, be conducted.
From this problem statement the following research questions were derived: • Do the teenage mothers in the Hho-Hho region of Swaziland experience any physical, social, cultural, emotional, spiritual, economic and educational problems, and how do they experience it? • Which support systems do the teenage mother make use of in the community?
• What recommendations can be made that would enable the health care services in the southern Hho-Hho region of Swaziland to help solve the problems experienced by teenage mothers?

Research design
As this research investigated the problems experienced by teenage mothers on a daily basis it adopted the qualitative paradigm to gain insight through discovering meaning, exploring the depth, richness and complexity inherent in the daily lives of teenage mothers (Burns & Grove, 2001:61).

This research was:
• descriptive as detailed pictures of the problems of the teenage mothers, as experienced by themselves, were described; • explorative as it explored the problems of teenage mothers regarded to be a relatively unknown phenomenon in the southern Hho-Hho region of Swaziland; and • contextual as it was executed within the context of teenage motherhood in the southern Hho-Hho region of Swaziland.

Population and sample
The research population comprised all teenage mothers aged 19 or younger living in the southern Hho-Hho region of Swaziland. The sample comprised those teenagers who met these criteria and who were willing to be interviewed by the researcher. The selection criteria for inclusion in the purposive sample included that each participant had to • be a female between the ages 10 and 19 years, in order to be a teenager; • have at least one child to be a mother; • be single because married teenage mothers might have more and/or different support systems than single or unmarried teenage mothers; • be willing to take part in the research and to be interviewed by the researcher; and • reside in the southern Hho-Hho region of Swaziland to be geographically accessible to the researcher.

Research instrument
In-depth individual interviews were conducted to obtain in-depth knowledge of the problems experienced by the teenage mothers. It also allowed the teenage mothers to share information without restrictions imposed by literacy problems, and to elaborate on certain problems in their own words. It therefore enabled the researcher to obtain in-depth, dense descriptions enhancing the researcher's understanding of each participant's world (Babbie, Mouton, Vorster & Prozesky, 2001:287 (1990:136-42). Consequently the dimensions described in this theory provided the basis for the interview schedule to study the problems encountered by teenage mothers in the southern Hho-Hho region of Swaziland holistically.

Ethical aspects
Permission to conduct the study was obtained from Swaziland's Ministry of Health, authorities at the Hho-Hho regional health office and Mbabane public health staff. Written consent was obtained from the authorities to conduct the research in two comprehensive community health clinics in the Hho-Hho region of Swaziland. Each possible participant was informed about the purpose of the research and requested to participate by granting a personal interview with the researcher. Written consent was obtained from each participant after she was informed about her rights.
No harm was done to any participant, no remuneration was paid for participation and no rights were compromised by declining participation. Each participant remained free to withdraw her participation at any stage or to refrain from answering any specific question. Although each participant signed consent prior to each interview, these documents were kept separately from the transcriptions and translations of the interviews.
The researcher was the only person who could link any consent form to a specific interview. This information was destroyed after the completion of the research report.

Analysis of the data
The transcripts of the in-depth interviews were pre- The following reasoning strategies were used to describe the chain of events: • Analysis -This reasoning strategy divides the complex whole into parts, code and define the parts.
• Synthesis -This process identified relationships between concepts and categories.
• Bracketing -The initial literature review was done to familiarise the researcher with problems encountered by teenage mothers in different parts of the world, and to become knowledgeable about research designs used to investigate these problems. During the interviews and analysis of the data the researcher bracketed preconceived ideas and attempted to understand all the facets of the problems encountered by teenage mothers in the southern Hho-Hho area of Swaziland as told by these participating teenagers themselves. Only broad questions were asked and no efforts were made to ask questions which could confirm or refute previously reported research results.
• Intuiting -Bracketing enabled the researcher to focus on the problems encountered by teenage mothers as experienced and as told by the teenage mothers during the interviews. Intuiting required absolute concentration and complete absorption with the data obtained (De Vos et al. 1998:337). Intuiting was achieved by reading and rereading the transcriptions many times before attempting to identify specific sub-themes, relevant to each theme from the structured interview schedule. The QRS NUD*IST program was of great assistance as it helped to systematise the analy-sis of the data, enhancing rigour during the data analysis process without sacrificing the relevance of the data.

Trustworthiness
The criteria used to evaluate the trustworthiness of the research findings in this research were credibility, transferability, consistency and neutrality. These individuals agreed that they recognised the description of the problems experienced by the teenage mothers as presented by the data analysis (Babbie et al. 2001:287). As the analysis of the data was done by computer using the QRS NUD*IST computer programme, the decision trail can be audited for quality assurance purposes.
• Transferability: The findings of this research will not necessarily be applicable to other communities and settings and the findings can therefore not be generalised to the teenage mothers throughout Swaziland. The same results could be obtained if a similar study was done in the same setting. Attempts were made to present sufficient descriptive data to allow comparisons with data from future studies in the same area on the same topic (Babbie et al. 2001:276;De Vos et al. 1998:350).
• Consistency: The same findings would be found if the study was to be replicated with teenage mothers in a similar context. The interviews with teenage mothers generated similar findings. Interviews were conducted and analysed until data saturation was reached, when no further new themes or new sub-themes could be identified and when no further novel data could be categorised under any theme or sub-theme because the same data kept on reappearing from the analysis of sub-sequent transcribed interviews.
• Neutrality: The following steps were taken to ensure neutrality and increase the trustworthiness of the research findings.
-A relaxed atmosphere was created in which the participant felt free to share her perceptions, problems and experiences with the researcher.
-Enough time was allocated to each interview so that no participant was pressurised to provide answers within a specific time limit but could portray her everyday lived experiences from her unique perspective.
-The participants, as well professional nurses working with teenage mothers, evaluated the findings and agreed with the research results.
-Although a literature review was conducted, it was only done to help the researcher to ask appropriate questions.
-The truth value and applicability of the findings was an indication that neutrality was achieved (De Vos et al. 1998:350).

RESEARCH RESULTS
The findings of the interviews indicated that the teenage mothers in the southern Hho-Hho region of Swaziland experienced problems in almost all the dimensions of a holistic human being. However, the most important problems related to the lack of information from significant others (ignorance in all dimensions) as well as the lack of support from individuals and institutions.
It must be noted that it was difficult to separate the problems completely as they were intertwined. The   Their partners were generally much older than themselves as reported by a teenage mother as follows: "I don't know his age, but he is older than me and he is working". These partners most probably have had sexual relationships before, however, these teenage girls believed that if they are involved in a steady relationship they are not at risk of contracting HIV/AIDS,

Biographical information
The personal information about the teenage mother and significant others.

Physical problems
The difficulties the teenage mother has experienced through becoming and being a teenage mother related to her body and physical health status.
3. Social problems ... dealing with mutual relationships with significant others such as parents, partner, family, peers; as well as with socialisation, recreation and role models. Teenagers in Swaziland, similarly to those in the USA, might be described as feeling "... invincible and therefore do not anticipate any risk for the consequences related to their behaviours" (Aretakis, 2000:688). That is, they may not believe that sexual activity will lead to pregnancy, as two of the participants reported: "I never knew that I would become pregnant". "Ignorance is the cause" [of my pregnancy]. "When teens become pregnant, they do not believe that the negative outcomes they are advised of could come true. Many teens believe that they are unique and different and that everything will work out fine" (Aretakis, 2000:688).

Educational problems
Educational problems are problems experienced in the formal educational system whereas ignorance is the result of a lack of information or knowledge obtained usually informally in all the identified themes.
It was clear from the analysed data that once students became pregnant they were expected to leave school as expressed by two of the teenage mothers as fol- leg'), umjende-vu ('something that may not be enjoyed by anyone') or libondza-lisuta ('the one whose system has become loose'). These insulting expressions are used to warn every girl ... not to follow in the footsteps of the unfortunate young woman who has failed to conform to the prescribed norms" (Dlamini, 2000:75-76).
No teenage mother indicated that she sought termination of pregnancy services that remain illegal in Swaziland. No one mentioned anything about emergency contraceptives which could have saved her from becoming a mother if she had the knowledge to access these.

Financial problems
The teenage mothers were generally from poor fami- attitudes towards pregnant teenagers contributed to their late attendance of antenatal clinics. As researchers continue to report greater physical pregnancy-related risks for teenagers than for adults (Boult & Cunningham, 1992:1;Hallerstedt, Pirie & Alexander, 1995:1139, this absence of physical problems among these teenage mothers cannot be explained without access to their obstetric records. One teenage mother indicated that she never attended the antenatal clinic during her pregnancy: "I never went to the clinic during the pregnancy. There was no need, I was not sick and it was a little far".

Spiritual problems
Some teenage mothers felt guilty because they let their parents down. Their perceptions that their communities rejected them and that people gossiped about them caused them to discontinue their church activities, aggravating their feelings of isolation and alienation. They knew that their church does not condone premarital sex and therefore did not risk being seen at church gatherings. They considered themselves to have sinned, not expecting forgiveness for their sins of engaging in premarital sex. They reportedly lost faith in God and in people on whom they wanted to rely but who did not provide much needed support to them. CONCLUSIONS money the most". This finding correlated with that reported in the USA by Nord (1992:310) who found that a disproportionate number of teenage mothers (more than 75%) were poor and had limited education.
The Swazi teenage mothers could not rely on financial support from the fathers of their babies. No teen-

Physical problems
All the participants were healthy and no serious health problems were reported during their pregnancies, labour or puerperium periods. These findings were un-

LIMITATIONS OF THE STUDY
The interpretation of the conclusions of the study, and the recommendations based on these conclusions, need to consider that the research was limited by: • focusing on single teenage mothers in the south-

RECOMMENDATIONS
The solutions to the holistic problems of the teenage mothers cannot be found in the activities of a single individual or service. The solutions can only be found through the co-ordinated effort of the multi-disciplinary and intersectoral team.
Any initiative planned or programme implemented should have the approval and backing of government and should be closely monitored by authorities to ensure that they continue. The community should also be involved in all phases to ensure that they are planned and implemented with the special needs of the teenagers in the community in mind.
A multi-disciplinary intersectoral team approach should be fostered which should include all the stakeholders and interested parties involved in the well-being of teenagers and teenage mothers.
The recommendations focus on enhancing the teenagers' quality of life and on issues to be addressed by future research projects.

Enhancing teenagers' life in Swaziland
Various persons and institutions reportedly failed to provide knowledge and skills to teenagers to make informed choices about their future lives. The various stakeholders should therefore take the necessary steps to rectify this problem.

The role of government
The government should ensure that legislation, policies, services and manpower are available to provide the teenagers with knowledge about contraception and with the ability to access contraceptive services should they wish to do so. Education about sex and contraceptive issues should be provided to school children by the time they reach the age of 11, as that was the reported mean age for menarche. Specific policies should be compiled and implemented at clinic level to enable teenagers to acquire and use contraceptives effectively. Teenagers should also be knowledgeable about emergency contraceptives. Long-term problems of teenage mothers in the Hho-Hho region of Swaziland can be addressed by assisting them to complete their education.

The role of the health services
The health services can play a major role in the prevention of pregnancies and in facilitating motherhood among the teenagers. These services already exist in the southern Hho-Hho region of Swaziland, but they can improve their service delivery by: • addressing the under-utilisation of contraceptive services by teenagers; • visiting teenage mothers who default on clinic visits; • organising teenager-friendly services over weekends; • visiting schools and youth clubs to share information about puberty, sexual issues, pregnancy and contraception (including the use of condoms); • supplying condoms at strategic places; • counselling teenage mothers about contraceptives and parenting skills; and • organising clubs for teenage mothers where they could share their problems and jointly try to find solutions for them.

The role of teachers
As the child is in the company and care of the teacher for the largest part of the day, the teachers should make the most of the opportunity to educate and support the teenagers in school. The teachers should: • offer sex education in school or get experts to do so; • motivate teenagers to develop their talents, knowledge and skills in order to obtain the best education possible as a means to improving their individual financial and social status; • enable pregnant teenagers to attend school as long as possible and to return to school as soon after their deliveries as possible; and • motivate pregnant teenagers to complete their education in spite of numerous challenges.

The role of the communities
A high incidence of teenage pregnancies in any community could indicate that the community malfunctions as such.
• The community as a whole needs to talk to their children about sexual issues before the onset of menarche -from approximately the age of 10.
• Church officials should visit the teenage mothers and counsel them about their needs and help them and their families to find solutions to their problems. Teenage mothers need to be invited to rejoin their previous church activities to reduce their feelings of isolation and alienation.
• The members of the community could establish crèches attached to schools to enable the mothers to feed their infants and to attend school. The government should subsidise such childcare facilities to the ultimate benefit not only of the teenage mothers and their children, but of the communities and even of the Swazi nation as a whole.

Recommendations for further research
• Research should be done to incorporate the views of family members, friends, and teachers to broaden and perhaps confirm the teenage mothers' perceptions reflected in this research report.
• Follow-up research should be done on this group of teenagers to determine how they and their children coped with these problems and what strengths they developed over time. This is essential as more than 20% of the babies delivered in the Hho-Hho area during 1996 had teenage mothers. should be developed, implemented and tested.

CONCLUSIVE REMARKS
The teenage mothers in the Hho-Hho region of Swaziland felt that their parents, teachers and health care personnel failed to support them. They believed their sexual partners, peers and the television who promised them the world and a happy and romantic