Approximately 21 million pregnancies occur in girls aged 15–19 years in low- and middle-income countries every year, and approximately 12 million give birth (World Health Organization, 2022). Adolescent pregnancy is a major health problem (Oner et al, 2012) and is considered the primary cause of mortality in women aged 15–19 years old (United Nations Population Fund, 2007). Iran has a large population of adolescents and the age-specific fertility rate in this group rose from 25 to 31 per 1000 adolescents between 2010 and 2020 (Moridi and Aminshokravi, 2018; Bahari et al, 2021; World Bank, 2023). According to Iran's population policy, it is predicted that the fertility rate of Iranian adolescents will rise by 2025 (Mohammadi et al, 2016).
However, there are differences in adolescent fertility rates across the country, with Sistan-Baluchestan and Guilan having higher and lower rates of adolescent pregnancy respectively. It is noteworthy that based on the religious and cultural context of Iran, women give birth following marriage (Mohammadi et al, 2016; Moridi et al, 2019), and so are often confronted with marriage, pregnancy and mothering, as well as the transition to adulthood, simultaneously.
Studies have shown that adolescent pregnancy leads to higher rates of health problems and negative outcomes, including medical complications, lower educational achievement and socio-economic consequences (Pinzon et al, 2012; McCarthy et al, 2014). In addition, adolescent pregnancy is perceived as an undesirable social phenomenon (Pinzon et al, 2012; McCarthy et al, 2014).
However, some studies have found that pregnancy can have positive effects on the life of adolescent pregnant women (Herrman and Nandakumar, 2012). The perceived benefits to adolescent pregnancy include developing better relations with parents and family, feelings of happiness when performing expected gender roles (Rosengard et al, 2006; Rocca and Harper, 2012), feelings of responsibility, maturity (Rosengard et al, 2006; Herrman and Nandakumar, 2012) and independence (Spear and Lock, 2003) and the stabilisation of self esteem (Hertfelt Wahn, 2007).
In the context of Iran, family laws are based on patriarchal and androcentric values and rules. Under Iranian law, women's fertility has a significant role in their marital life, in which the spouse of an infertile woman is legally permitted to leave and divorce her at any time he wishes (Alamin et al, 2020). Additionally, a woman's properties completely belong to her spouse in the event of her death, but if a woman without a child becomes a widow, only a quarter of her spouse's assets will belong to her; the rest go to the man's family (Shadman and Vedadhir, 2020). Hence, the Iranian context can directly affect the formation of a woman's identity, and encourages women to have children to protect the family and her matrimony (Shadman and Vedadhir, 2020).
An adolescent's response to pregnancy is strongly influenced by the cultural, social, political and religious context of the community. Therefore, it is important to understand adolescents' perspectives of this phenomenon, which can lead to better insight and promote knowledge for those who are responsible for providing services to adolescents (Spear and Lock, 2003).
The dominant focus of universal studies on adolescents' experiences of pregnancy has been on those outside of a marital relationship (Mohammadi et al, 2016; Moridi et al, 2019). This study explored a new and different perspective, that of adolescent pregnancy within a marital relationship among Iranian women, as the total rate of adolescent marriage in Iran rose from 10.3% to 11.2% between 2006 and 2016 (Azimi, 2020). These experiences can be guidelines in the design of health promotion programmes and developing mental and physical health promotion strategies tailored to the needs of adolescents.
Methods
This descriptive qualitative study used a thematic analysis approach (Braun and Clarke, 2006), and was conducted by combining data from urban and rural primary healthcare centres. All centres and all available eligible women were selected from all towns and villages of the Guilan province in the north of Iran. The study was conducted from November 2017 to October 2018.
Participants
This study used a purposive sample of participants, in order to gain a broad spectrum of views. The inclusion criteria were married women aged 14–18 years, who were pregnant, living in the Guilan province, spoke and understood Persian and were willing to participate in the study. A total of 24 women were included.
Data collection
Data were collected through individual unstructured, face-to-face in depth interviews with the 24 participants. Data collection and analysis were simultaneous and analysis began with the first participant's interview.
The telephone numbers of potential participants were selected from the registry lists of urban and rural primary healthcare centres and used to contact the women, who were provided with information about the study. If she agreed to participate, the place, time and date of the interview were determined at the participant's convenience.
During the interview, the participants were asked a series of general questions, which were put together by the authors following a literature review and pre-tested in the first five interviews. The questions were:
- ‘Please explain your experiences of pregnancy’
- ‘Please tell me how you felt when you found out you were pregnant?’
- ‘Has anything changed in your life since you became pregnant? If so, what would that be?’
- ‘How do you deal with the changes in your life?’
- ‘Who has been most helpful to you during pregnancy?’
- ‘Could you describe your thoughts and perceptions about yourself as a mother?’.
These questions were then followed by probing questions (eg ‘what do you mean exactly?’, ‘would you please explain more?’, ‘could you please give me an example of that?’, ‘What does that mean to you?’) for clarity and insight into each response. Each participant's interview lasted approximately 1 hour. Data saturation was obtained after the 24th interview, after which no new concepts or categories were developed. Interviews were audio recorded and transcribed by the first author, who also made field notes. Participants were then asked to complete a short demographic questionnaire.
Data analysis
Data were analysed using thematic analysis (Morse and Field, 1995; Braun and Clarke, 2006). The first author read the transcriptions line-by-line and coded the data, until all interviews were explored and checked. Meaning units as words and sentences relevant to adolescent women's experiences of pregnancy were identified and labelled with code. Connections between codes were examined to cluster them into meaningful groups, capturing the general overview of participants and their patterns of experience (Morse and Field, 1995). These were organised into sub-themes and formed themes. MAXQDA10 qualitative software was used to manage the data analysis.
Trustworthiness
The following strategies were used to ensure trustworthiness in this study. First, according to the study question, thematic analysis was used under careful supervision of the research team. Second, all interviews were conducted with an interviewer who was trained in conducting qualitative research and interviewing techniques. Third, the interviewer had prolonged engagement with the data that were collected from the interviews. The researcher developed trust and connected with the participants, considering a variety of perspectives and co-constructing the meaning of adolescent pregnancy.
The first four interviews were coded independently by each author, after which interpretations were compared. If the interpretations differed, they were discussed until a consensus was obtained. At the end of the study, member checking and peer check methods were used. The printed transcribed file was returned to the participants to match the accuracy of the data with their experiences. Additionally, the transcripts, codes and categories were sent to four impartial professors in nursing, public health and social sciences to review the credibility of the extracted categories and sub-categories. Finally, the researcher aimed to choose participants with maximum variation in age, from extended and nuclear families and from urban and rural settings. In addition to audio records and transcripts, multiple data sources, including field notes, observation, memos and diaries were used.
Ethical considerations
This study was part of a doctoral dissertation, which was approved by the Ethics Committee of the Research Deputy at Tarbiat Modares University (IRB code: 52/6601). In addition, each participant and her spouse or family member signed a written informed consent letter before the interview.
Confidentiality and anonymity were maintained at all stages of the study. All data were stored in a password protected file on the researcher's computer. The findings are disseminated in summary form, with no identification of individual participants, who have been given pseudonyms for anonymity.
Results
The 24 participants' sociodemographic data are shown in Table 1. Their ages ranged from 14 to 18 years and all participants were Iranian.
Table 1. Participants' characteristics
| Characteristic | Mean (range) |
|---|---|
| Age (years) | 16.375 (14–18) |
| Gestational age (weeks) | 29 (8–41) |
| Gravidity | 1.16 (1–2) |
| Parity | 0 (0–1) |
| Duration of marriage (months) | 19 (4–48) |
| Years in education | 7.583 (5–11) |
A total of 980 primary codes were extracted from the interview data and were then compared to one another and categorised into 5 main themes. The main themes and sub-themes are shown in Table 2.
Table 2. Themes and subthemes
| Theme | Subtheme |
|---|---|
| Skeptical confronting pregnancy | Hope and satisfaction |
| Frustration and regret | |
| Intelligent self care | Paying attention to preventative healthcare |
| Being responsible | |
| Embracing the pregnancy | Resorting to spirituality |
| Changing feelings | |
| Effective support from others | Supportive roles |
| Empathy | |
| Mixed perceptions of pregnancy | Perceived threats |
| Perceived opportunities |
The five themes that emerged to express the participants' experiences of the process of pregnancy were that they were sceptical when confronting the pregnancy, engaged in intelligent self care, embraced the pregnancy, received effective support from others and had mixed perceptions of pregnancy. These themes were formulated from 10 theoretical sub-themes.
Sceptical when confronted with pregnancy
The early response of many participants was to be sceptical about the pregnancy. Participants reported experiencing contradictory feelings that oscillated between willingness and unwillingness to continue the pregnancy. The participants were exposed to simultaneous dual feelings of hope and satisfaction, as well as frustration and regret.
Some participants expressed that they decided to become pregnant completely actively. The reason for this decision was a desire to experience motherhood and an interest in parenting.
‘When my sister was born, I cared for her myself. When I look at a child, I have a good feeling; kids are cute, like my sister. Also, when I hear other mothers talking about their children, I always want to be able to experience the same feelings’.
Parvaneh, 14 years old
Some stated that they had to accept the pregnancy passively and fight the desire to abort the child, despite their unwillingness to do so. Some were afraid of the guilt of abortion and others were concerned about their spouse or family's reaction.
‘When I found out I'm pregnant, I did not believe it at all but I did not have any choice…At first, I did not want to be pregnant, but after the pregnancy, I could not abort the child because [according to Islamic law], it is a sin’.
Zeynab, 18 years old
Some participants reported that they had hope and motivation for their life, as a child could eliminate loneliness in the future.
‘When I wake up in the morning, from his kicking, I become more hopeful for the future of my life…my life will become sweet by his birth’.
Azadeh, 17 years old
However, other participants experienced a sense of uncertainty and desperation, as they felt that they were unprepared to take on and accept the maternal responsibilities that they believed accompanied becoming a mother. These feelings created a sense of doubt and some began considering abortion instead of continuing with the pregnancy.
‘I was upset. Why did I listen to my husband and accept to get pregnant at this age? As I regretted it, I said “now how can I raise my baby?” It would have been better to get pregnant at least 2 years after marriage’.
Negar, 18 years old
In addition, there were economic barriers, as limited financial resources caused frustration and regret about the pregnancy for some participants.
‘I did not want to get pregnant at all because of financial problems…I would like to give birth to several children if our financial situation was better because I love kids’.
Mandana, 17 years old
Intelligent self care
One of the strategies that the participants used to cope with pregnancy-related concerns was intelligent self care. This included activities such as paying attention to preventative healthcare and ‘being responsible’. These strategies involved five main areas: information acquisition, following treatment, change in lifestyle, increasing responsibility for personal life and taking responsibility for the child's care.
After becoming pregnant and accepting the pregnancy, all participants sought the best available care for their pregnancy and followed appropriate advice from healthcare professionals, including medical orders and para-clinic tests.
‘I follow all of my physician's orders, [such as] sonography, laboratory tests, counting the fetus movement and so on. Also my husband pays a lot of attention to following them as well’.
Sedigheh, 16 years old
The majority of participants also changed elements of their lifestyle in order to safely care for themselves and their babies during pregnancy.
‘My daily habits changed [because of the] pregnancy, now I must pay attention to some things…for example, I am a tailor, but now I cannot do it because of the pregnancy…I was a person who went to the market every week but now, I must rest at home’.
Mahin, 17 years old
Becoming pregnant led to an increased sense of responsibility for personal life. The participants reported believing that they should try to improve their financial condition for the sake of the child.
‘Childbearing is a very big responsibility. I should try harder to provide a good life for my child. I should take care of my husband's health, so he can work more for a better life’.
Negar, 18 years old
Pregnancy created more responsibility for the participants' husbands in their personal life and childcare.
‘My husband did not pay any attention to me and our life; he always went out with his friends. Since I became pregnant, he works a lot to gain more money for our life. In the mornings, he is farming and in the afternoons, he works in a shop’.
Fariba, 16 years old
Embracing the pregnancy
The third theme, embracing the pregnancy, included behaviours such as ‘resorting to spirituality’ and ‘changing feelings regarding the pregnancy’.
Some participants struggled with pregnancy-related concerns, and turned to spirituality for support. Belief in God's will and fate was a main contributor to participants' strategy for coping with concerns, especially for those who had an unwanted pregnancy.
‘It was unexpected and we were shocked…at first, my husband was confused and said it was a bit early, but I said whatever God wants’.
Zeynab, 18 years old
Some participants relieved stress through religious practices, such as praying and invocation.
‘My sister has a deeper connection than me with God. She said that every morning she prays for me. She tells me “do not be worry, God will help you”. She calms me with these words’.
Setareh, 15 years old
As their pregnancy progressed, participants reported that their feelings changed. At first, some participants, especially those who accepted the pregnancy passively or who felt frustration or regret, did not have any positive feelings regarding their pregnancy. However, as the pregnancy went on and they felt the fetus inside themselves, their interest in having a child and motherhood grew.
‘When I found out that I was pregnant, I was shocked because I did not want a child. But when you wake up every morning with that and the pregnancy is with you everywhere, gradually I got used to the pregnancy changes, I embraced being pregnant’.
Parvaneh, 14 years old
Effective support from others
The influence of others, including family, peers and healthcare providers, could be either a facilitator or a barrier to safe care.
‘My husband cares for me a lot and does not let me do heavy work. He cleans the house and cooks the food. Also, my parents take care of me, they perform all of my duties’.
Raha, 14 years old
‘My mother took complete care of my first child, now she is dead and I do not know how I will take care of the second child. Also, my husband works out of the house from morning to night and he is not present at home to help me’.
Masoumeh, 17 years old
Mixed perceptions of pregnancy
Some participants were unhappy about their pregnancy, and thought about perceived issues with being pregnant and raising children. Some felt that pregnancy would diminish their life through social isolation, being unable to perform a mothering role and fears of pregnancy consequences and childbirth. Some were concerned about their relationship with their husband.
‘I feel that my spouse is rejecting me because he doesn't want the child’.
Maryam, 18 years old
Similarly, some felt that there would be limitations to having a child, for example because it would be impossible to continue their education, have a job or make financial progress.
‘Whenever I want to go somewhere such as a market or a party, I have to carry two babies alone and it is cumbersome for me…Therefore, I prefer to stay at home’.
Mandana, 17 years old
‘I do not think I will be able to care for a child due to my young age and lack of my mother's aid because she has died’.
Saeideh, 18 years old
Some participants were upset by negative feedback that they received from others.
‘My mother-in-law did not show me to her friends because she thought others may say that they married their son to a child and she immediately became pregnant’.
Parvaneh, 14 years old
However, others believed that pregnancy had improved their lives and made them more independent and confident. Participants reported feeling that their pregnancy had, brought about a better marital life, a fundamental change in their life and eliminated loneliness.
‘Now, I'm really a mother, I feel proud. I am nurturing a person in my body and I am going to add a person to the community. Now, I feel I have become more independent’.
Arezo, 18 years old
‘My spouse is 10 times closer to me…my spouse does anything that I want at any time. After pregnancy, my spouse changed, his kindness increased, I feel that he loves me more’.
Farnaz, 17 years
‘I'm usually alone at home…I always think that when the baby grows up, we will go everywhere together, I will play with her, and my house will be filled with sound’.
Azadeh, 17 years old
Discussion
The present study aimed to explore adolescent women's experiences of pregnancy. The results demonstrated that these experiences varied, including women feeling sceptical when confronting pregnancy, embracing the pregnancy and having mixed feelings about it. Participants reported to engage in intelligent self-care in response to their pregnancy and relied on effective support from others.
Similar results have been found in studies of other populations of adolescent women. A grounded theory study by Sriyasak et al (2016) found that Thai adolescent women struggled with the physical and social changes that resulted from pregnancy, often as a result of working in order to save money for future family needs. Parenthood became a turning point, as teenagers changed their behaviours and lifestyle during pregnancy, and adapted them to improve their relationships with their partner and their family. Family commitments were a facilitator, through support given by their families. Being a parent encouraged them to explore ways to manage the new role by engaging in activities and re-establishing life goals.
However, the perceived consequences of pregnancy in the present study were different from Sriyasak et al (2016) who found that adolescent parents coped with parenting roles by engaging in parental activities and re-establishing life goals, in particular through traditional gender roles such as a mother staying home to care for children or a father being the breadwinner. However, in the present study, Iranians adolescent had mixed feelings about pregnancy. This could be the result of the different context and alternate methods for participant selection as Sriyasak et al (2016) included women from the second trimester of pregnancy until 6 months after birth and mothers' perceptions of pregnancy consequences may differ after birth.
Many of the present study's participants felt sceptical when confronting the pregnancy. Other studies have demonstrated that adolescent women experience contradictory feelings when they discover that they are pregnant (Mohammadi et al, 2016; Sadler et al, 2016; Macutkiewicz and MacBeth, 2017; Moridi et al, 2019). One reason for these conflicting feelings is a result of defying common social expectations of adolescent women, such as going to school and finding an income-generating job. In their review study of adolescent pregnancy intentions, Macutkiewicz and MacBeth (2017) identified that both positive and negative attitudes were present. They suggested that adolescents displayed contradictory and incoherent attitudes towards pregnancy that were in line with their developmental stage, which was characterised by variability in their identity and beliefs. The participants in the present study exhibited similar responses; even participants who had accepted their pregnancy willingly felt feelings of frustration and regret, and those who accepted the pregnancy as a result of others' influence also felt satisfaction and hope as well as more negative feelings.
The present study participants reported two key strategies when coping with pregnancy, intelligent self care and embracing the pregnancy. The self-care strategy was predominant in adolescent women who accepted their pregnancy actively and felt hope and satisfaction. For those who felt regret and frustration, their main strategy in response to pregnancy-induced stress, was attempting to embrace the pregnancy. Sriyasak et al (2016) similarly reported that in response to the stress of an unintended pregnancy, Thai adolescent women used active and passive strategies, including following a societal wedding tradition, changing their behaviours and lifestyle, adapting to changing relationships with their family and partner and being concerned about childrearing.
Based on the present study, although some participants considered their pregnancy and their newfound identity as a mother to be a positive event, a lack of preparation for undertaking the responsibilities of childcare led some to find pregnancy unexpected and difficult. The simultaneous occurrence of challenges such as the transition to adulthood, marrying young and an early pregnancy contributed to making acceptance of pregnancy more difficult. The perceived support from participants' husbands, family and healthcare providers helped with these issues. Previous studies have similarly reported that social support was a helpful resource for promoting a successful transition to adolescent motherhood (Tanner et al, 2013; Mohammadi et al, 2016; Sadler et al, 2016; Sriyasak et al, 2016; Macutkiewicz and MacBeth, 2017; Khaleghi et al, 2019).
As a consequences of their pregnancy, the present study's participants experienced a spectrum of perceptions that ranged from expecting improvement of their future life, to expecting it to diminish. Positive perceptions in adolescents with higher perceived support and acceptance from family were predominant. They felt that pregnancy would lead them to become more responsible, and provide empowerment, independence, enthusiasm, appreciation and improvement for their marital life.
However, negative perceptions about the possible complications of future life for a woman and her child were also reported. Adolescent women with less support and acceptance, and who felt less prepared for becoming a mother, experienced a more negative perception. Mixed perceptions of pregnancy are consistent with several previous studies (Carvalho et al, 2010; Mohammadi et al, 2016; Sadler et al, 2016).
Limitations
The main limitation of this study was that the participants were selected from among women visiting primary healthcare centres or a selected hospital, meaning that the voices of women who did not attend antenatal care visits or chose not to participate were not represented. The study also focused only on the experiences of adolescent women who were pregnant at the time of the study, and did not include those who had recently given birth.
Conclusions
According to the results of this study, adolescent women in Iran who become pregnant experience varied responses. One of the predictors of their perceptions of pregnancy was perceived support from family, society and the healthcare system. Therefore, it is important that families, communities and healthcare systems provide comprehensive support for adolescent women. Ensuring these women are supported may have positive effects on the quality of life of young mothers and their babies.
The results of the present study may inform the development adolescent friendly maternal care services. The data indicated that care given to adolescent mothers should take into consideration not only the theoretical and chronological aspects, but also psychosocial and cultural factors related to parenthood in this social group. Further studies should be conducted in the context of other cultures and religions to truly gain insight into this phenomenon.
Key points
- Adolescent women who become pregnant experienced contradictory feelings that oscillated between willingness and unwillingness to continue the pregnancy.
- In response to pregnancy-related stress, adolescent pregnant women used two strategies: intelligent self-care and embracing the pregnancy.
- Effective support from those around them was significant in facilitating management of pregnancy-related stress.
- Many of the participants had mixed perceptions of their pregnancy, alternating between perceived threats and opportunities.
CPD reflective questions
- Why might adolescent women feel mixed emotions when they discover that they are pregnant?
- How does cultural and religious context affect perceptions of adolescent pregnancy?
- Have you ever provided care to a pregnant adolescent? Was their experience informed by their cultural or religious background?