1

An Exploratory Study of Indonesian Adolescents’

Reproductive Practices and their Experiences during
Pregnancy and Early Parenthood

Andari Wuri Astuti

Submitted in accordance with the requirements for the degree

of
Doctor of Philosophy

The University of Leeds

School of Healthcare

October, 2017
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The candidate confirms that the work submitted is her own and that appropriate
credit has been given where reference has been made to the work of others. This
copy has been supplied on the understanding that it is copyright material and that
no quotation from the thesis may be published without proper acknowledgement.

© 2017 The University of Leeds and Andari Wuri Astuti.

The right of Andari Wuri Astuti to be identified as Author of this work has been
asserted by her in accordance with the Copyright, Designs and Patents Act 1988.
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Acknowledgement

I would like to thanks to Allah, for showering me with kindness, love and to bring
me to this PhD study.

I am also really aware that my PhD study would not be possible without support
from many parties. My sincere gratitude to my supervisors Dr Janet Hirst and Dr
Kuldip Bharj, house of guidance, advice, help, encouragement, and inspiration in
every single milestone throughout my PhD study, I am sure that both your support
will doubtless never be paid. I am really grateful and feel very privilege for having
you both as my supervisors.

I also would like to thank to the Indonesian Government, Ministry of Research,

Technology and Higher Education that provides financial support for my PhD
study at the School of Healthcare, the University of Leeds, United Kingdom. I also
would like to thank the University ‘Aisyiyah of Yogyakarta (UNISA) where I am
employed, I am so blessed to have such encouraging people within UNISA both
when I am in Yogyakarta and whilst I am away for my PhD study.

I extend my heartfelt thanks to participants in this study and my colleagues in

research fields. My PhD colleagues in School of Healthcare and a huge number
of my Indonesian colleagues both in Leeds and Indonesia whom have helped
both academically and otherwise.

Last of all, I would like to express my biggest thanks to my husband Sigit

Kusmaryanto for his endless support, unconditional love and has been patient
whilst I am thousands of miles away from home. My son, my hero, my source of
happiness, Fairuz Gitan Danadyaksa who accompanied me during this PhD
journey. I would say that every single page of this PhD thesis is dedicated to you
both. To my parents and my sister, who supported me in choice I made. My
parents in-law, brothers and sister in-law, thank you for being supportive and I
love you all.
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Abstract
Introduction: Globally, the World Health Organisation (WHO) have reported
approximately 16 million adolescent pregnancies per year, of which 95% are
reported to occur in low-lower and middle-upper middle income countries.
Indonesia, is one of the low-lower and middle-upper middle income countries;
and data indicates that during 2012, 48 per 1,000 pregnancies occurred at the
aged 15-19, of these 0.02% were aged 15 or less. This study is the first research
of its kind in Indonesia to explore, illuminate and understand Indonesian
adolescents’ reproductive practices and their experiences during pregnancy and
early parenthood.
Methods: This is an exploratory qualitative research conducted over a period of
three years, consisting of three studies, a qualitative systematic review (study 1),
an in-depth study of adolescents during pregnancy (study 2) and an in-depth
study of young parents (study 3). Four couples participated in study 2 and twelve
young parents participated in study 3 (including eight young mothers and four
young fathers). One-to-one in-depth interviews were used for data collection,
thematic analysis was used for data analysis and N Vivo was employed for data
management.
Findings: This study revealed that adolescents engaged in premarital sexual
relationship due to a loving relationship, whilst knowledge related to preventing
pregnancy and Sexual Reproductive Health (SRH) services was limited and
resulted in unplanned pregnancies. When unplanned pregnancy occurred, the
couples were forced by their parents to get married to ’fit in’ with cultural and
societal norms of not having children outside of marriage. However, it brought life
difficulties within adolescents’ marriage relationships i.e. coping with stress,
stigma, judgement, social exclusion, education termination, financial difficulties,
jobs, role divisions, breastfeeding and children care. Foucault's theory of power
is used to interpret findings.
Conclusions and recommendations: Power of culture and religion within
Indonesian society played a critical role in adolescents’ complex experiences
through their unplanned pregnancy, marriage and parenthood. Indonesian
adolescents require timely and accessible SRH education and services to
increase their knowledge and understanding around SRH practices so that they
can make informed decisions about sexual reproductive practices and prevent
unplanned pregnancies. Evidence based care pathways are essential to support
and empower young parents during their journeys that they can undertake their
parenting role effectively. Future research is invaluable which might evaluate
service models initiated to meet the health and social needs of the adolescents
during pregnancy and early parenthood.
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Table of Contents
Acknowledgement .......................................................................................3
Abstract ........................................................................................................4
Table of Contents.........................................................................................5
List of Table ..................................................................................................9
List of Figure ..............................................................................................10
List of Abbreviation ...................................................................................11
Chapter 1 Introduction ..............................................................................12
1.1 Introduction.....................................................................................12
1.2 Context, overview and rationale of the research ............................12
1.3 Context of the research ..................................................................15
1.3.1 The geographic, social and economic landscape..................15
1.3.2 Social and cultural context of sexuality and reproduction ......17
1.4 Power and society to set the context of research ...........................17
1.5 Aim of the research ........................................................................21
1.6 Research questions ........................................................................22
1.7 Research purpose ..........................................................................22
1.8 Objectives of research ....................................................................22
1.9 Reflections of the research prior to data collection .........................23
1.10 Structure of the thesis.....................................................................25
1.11 Summary ........................................................................................27
Chapter 2 Background ..............................................................................28
2.1 Introduction.....................................................................................28
2.2 Incidence of adolescent pregnancy and parenthood ......................28
2.3 Reasons why adolescents engage in sexual relationships leading to
adolescent pregnancy ....................................................................31
2.4 Risks associated with adolescent pregnancy, childbirth and
parenthood .....................................................................................34
2.5 Policy context: adolescent pregnancy and parenthood ..................36
2.6 Summary ........................................................................................37
Chapter 3 Research Worldview, Methodology, Methods and Ethical
Consideration ....................................................................................38
3.1 Introduction.....................................................................................38
3.2 Research worldview .......................................................................38
3.3 Methodology: qualitative research ..................................................39
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3.3.1 Research design ...................................................................41

3.3.2 Description of the research ...................................................42
3.3.3 Methods for study 2 and 3 .....................................................44
3.4 Ethical consideration ......................................................................47
3.5 Ethical approval, access to the field and participants .....................49
3.6 Researcher effect and researcher bias...........................................50
3.7 Positionality ....................................................................................51
3.8 Rigour of the research ....................................................................52
3.9 Summary ........................................................................................54
Chapter 4 : Study 1: Health and Social Experiences of Pregnant
Adolescents and their Partners in Indonesia and Other Low-lower
and Middle-upper Middle Income Countries: A Qualitative
Systematic Review ............................................................................55
4.1 Introduction.....................................................................................55
4.2 Aim .................................................................................................55
4.3 Objectives.......................................................................................55
4.4 Methods..........................................................................................56
4.5 Data synthesis ................................................................................81
4.6 Findings ..........................................................................................83
4.6.1 Theme 1: I am Pregnant .................................................................84
4.6.2 Unplanned .............................................................................85
4.6.3 I wanted a baby .....................................................................85
4.6.4 Conception, pregnancy and physiological changes ..............86
4.6.5 Preserve or terminate pregnancy ..........................................87
4.6.6 Theme 2: Support ...........................................................................88
4.6.7 Parents ..................................................................................88
4.6.8 Partner/ husband...................................................................89
4.6.9 Wider family members ..........................................................89
4.6.10 Community and religious leaders ..........................................90
4.6.11 Healthcare providers .............................................................91
4.6.12 Theme 3: Consequences of the adolescent pregnancy ................92
4.6.13 Stigmatisation and shame .....................................................92
4.6.14 Education and work ...............................................................93
4.6.15 Symptoms of complications...................................................94
4.6.16 Distress and regret ................................................................94
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4.6.17 Theme 4: After the birth of the baby .............................................95

4.6.18 Experiences during labour and when the baby is born ..........95
4.6.19 Resilience..............................................................................96
4.7 Discussion ......................................................................................97
4.8 Strengths and limitations noted within this study 1 .......................100
4.9 Conclusion....................................................................................101
4.10 Summary ......................................................................................101
Chapter 5 : Study 2 An In-depth Study of Pregnant Adolescents and
their Partners during the Pregnancy .............................................103
5.1 Introduction...................................................................................103
5.2 Aim and objectives for study 2 ......................................................103
5.3 Methods........................................................................................103
5.3.1 Study population, sampling technique and sample size ......103
5.3.2 Inclusion and exclusion criteria ...........................................104
5.3.3 Recruitment .........................................................................105
5.3.4 Data collection.....................................................................106
5.3.5 Data analysis.......................................................................110
5.4 Findings ........................................................................................117
5.4.1 Characteristics ....................................................................117
5.4.2 Process of participant recruitment .......................................119
5.4.3 Emerging themes ................................................................120
5.5 Discussion ....................................................................................147
5.6 Summary ......................................................................................153
Chapter 6 Study 3: An In-Depth Study of Young Parents’ Health and
Social Experiences ..........................................................................155
6.1 Introduction...................................................................................155
6.2 Aim and objectives of study 3 .......................................................155
6.3 Methods........................................................................................155
6.3.1 Study population, sampling technique and sample size ......155
6.3.2 Inclusion and exclusion criteria ...........................................156
6.3.3 Recruitment .........................................................................157
6.3.4 Data collection.....................................................................158
6.3.5 Data analysis.......................................................................161
6.4 Findings ........................................................................................163
6.4.1 Characteristics ....................................................................163
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6.4.2 Process of participants’ recruitment ....................................164

6.4.3 Emerging themes ................................................................165
6.5 Discussion ....................................................................................186
6.6 Summary ......................................................................................190
Chapter 7 Discussion and Conclusion ..................................................192
7.1 Introduction...................................................................................192
7.2 An overview of the research aim, research questions and key
findings .........................................................................................193
7.3 The dominance of culture and religion upon adolescents’
experiences ..................................................................................195
7.3.1 The dominance of the power of culture and religion upon policy
and practice.........................................................................202
7.3.2 The dominance of the power of culture and religion within
family ...................................................................................207
7.3.3 The dominance of the power of culture and religion upon the
individual and spirituality .....................................................213
7.4 Strengths and limitation of the study.............................................220
7.5 Originality .....................................................................................221
7.6 Implications of the research..........................................................222
7.7 Recommendations .......................................................................222
7.7.1 Recommendations for practices ..........................................223
7.7.2 Recommendation for research ............................................225
7.8 Disseminations of the research ....................................................226
7.9 Conclusion....................................................................................227
7.10 Reflection after the process of data collection ..............................228
7.11 Summary ......................................................................................229
References................................................................................................231
Appendixes
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List of Table
Table 1-1: Research questions, objectives and type of study ...............23
Table 3-1: Rigour of the research and application within this PhD
research ..............................................................................................53
Table 4-1: PEOS framework and inclusion limits ....................................56
Table 4-2: Included studies and indexed sources ..................................61
Table 4-3: Main characteristics of the included papers ..........................64
Table 4-4: Grading process for appraising the included papers ...........76
Table 4-5: Phases of thematic synthesis adapted from Thomas and
Harden (2008) .....................................................................................82
Table 4-6: Examples of quotes about ‘unplanned pregnancy’ ...............85
Table 4-7: Examples of quotes about ‘I wanted a baby’ .........................86
Table 4-8: Examples of quotes about ‘conception, pregnancy and
physical changes’ ..............................................................................86
Table 4-9: Examples of quotes about ‘preserve or terminate’ ...............87
Table 4-10: Examples of quotes about ‘support from parents’..............88
Table 4-11: Example of quotes about ‘support from partner’ ................89
Table 4-12: Examples of quotes about ‘support from wider family
members’ ............................................................................................90
Table 4-13: Examples of quotes about ‘community support’ ................90
Table 4-14: Examples of quotes about ‘support of healthcare provider’
.............................................................................................................91
Table 4-15: Example of quotes about ‘stigmatisation and shame’ ........92
Table 4-16: Examples of quotes about ‘education and work’ ................93
Table 4-17: Examples of quotes about ‘symptoms and complication’ .94
Table 4-18: Examples of quotes about ‘distress and regret’..................95
Table 4-19: Examples of quotes about ‘experiences of labour and when
baby is born’ ......................................................................................96
Table 4-20: Example of quotes about ‘resilience’ ...................................96
Table 5-1: Inclusion and exclusion criteria ............................................104
Table 5-2: Interview questions of study 2 ..............................................107
Table 5-3: Data analysis process............................................................110
Table 5-4: Profile of participant ..............................................................118
Table 6-1: Inclusion and exclusion criteria of study 3 ..........................157
Table 6-2: Interview questions of study 3 ..............................................159
Table 6-3: Profile participants of the study 3.........................................163
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List of Figure
Figure 1-1: Indonesian map ......................................................................16
Figure 2-1: Adolescent fertility rate across countries from 2000-2010 .29
Figure 2-2: Annual births per thousand female adolescents from 2007-
2012 .....................................................................................................31
Figure 3-1: Design of research .................................................................41
Figure 4-1: Search strategies for the systematic review ........................59
Figure 4-2: Themes and subthemes of study 1 .......................................84
Figure 5-1: Example of N Vivo on managing sources ..........................116
Figure 5-2: Example of the use of N Vivo for analysis ..........................117
Figure 5-3: Process of approaching adolescent participants for
recruitment to study 2 .....................................................................119
Figure 5-4: Themes and subthemes that emerged from study 2 .........121
Figure 6-1: N Vivo as data management for study 3 .............................162
Figure 6-2: Process of approaching adolescent participants for
recruitment to study 3 .....................................................................164
Figure 6-3: Themes and subthemes that emerged from study 3 .........166
Figure 7-1: Overview of main findings from study 1, 2 and 3 ..............194
Figure 7-2: Model to show dominance of the power of culture and
religion on Indonesian adolescents’ unplanned journey .............197
Figure 7-3: Word cloud of experiences and aspects that contributed to
adolescents’ experiences of unplanned pregnancy, marriage and
parenthood. ......................................................................................199
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List of Abbreviation

AIDS : Acquired Immuno Deficiency Syndrome

ANC : Antenatal Care

ASSIA : Applied Social Sciences Index and Abstract

BKKBN : Badan Kesejahteraan dan Keluarga Berencana Nasional

(Indonesian National Family Planning Coordination Board)

CASP : Critical Appraisal Skills Programme

CINAHL : Cumulative Index to Nursing and Allied Health Literature

CRD : Centre of Review and Dissemination

EMBASE : Excerpta Medica Database

GDP : Growth Domestic Product

GNI : Growth National Income

ICM : International Confederation of Midwives

IMoH : Indonesian Ministry of Health

ISB : Indonesian Statistic Board

KEMAS : Kesehatan Masyarakat

KUHP : Kitab Undang Undang Hukum Perdata (Indonesian Civil-Law

Code)

NGOs : Non-Government Organisations

NHS : National Health System

PEOS : Population, Event, Outcomes, Study

PHC : Public Health Centre

PRISMA : Preferred Reporting Items for Systematic Reviews and Meta-

Analysis

SHREC : School of Healthcare Research Ethics Committee

SRH : Sexual Reproductive Health

UNICEF : United Nations International Children's Emergency Fund

UNPF : United Nations Populations Fund

WHO : World Health Organisation
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Chapter 1 Introduction

1.1 Introduction

This chapter presents the context, overview and rationale for the PhD research
and explains the geographic, social and economic landscape in Indonesia. Social
perspectives and expectations regarding pregnancy and childbirth amongst the
Indonesian community are described in this chapter. Furthermore, the concept
of power, society and relationships are presented, in order to help situate the
research and provide a local context. This chapter also presents the aim of the
research, along with research questions, purpose and objectives. Personal
reflections are also explained in order to provide insight into why this research
held a personal journey. The structure of the thesis is provided to give a brief
overview of what is included in each chapter.

1.2 Context, overview and rationale of the research

Globally, the WHO, have reported approximately 16 million adolescent

pregnancies per year, of which 95% are reported to occur in low-lower and
middle-upper middle income countries (WHO, 2014a; WHO, 2014b) (See
Chapter 2 Section 2.2). Indonesia, is one of low-lower and middle-upper middle
income countries; during 2012, 48 per 1,000 pregnancies occurred at the aged
15-19, of these 0.02% were aged 15 or less (Indonesian Ministry of Health IMoH
(2013). However, there are no official routinely collected data to accurately report
the number of adolescent pregnancies in Indonesia, particularly pregnancies
conceived before marriage (Chandra, 2013). Pregnant adolescents are a concern
in low-lower and middle-upper middle income countries because of associations
with poorer maternal and perinatal health outcomes (WHO, 2009). In addition,
adolescents are likely to have high illiteracy and lower education levels, poorer
sources of sexual and reproductive health support and a lack of infrastructure for
example services and trained human resources in low-lower and middle-upper
middle income countries (Chandra-Mouli et al., 2013).

Pregnant adolescents have attracted attention by researchers and government

for some time in Indonesian. For example, exploration of unsafe abortion among
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unmarried female adolescents (Djohan et al., 1993; Sedgh and Ball, 2008a),
reported that female Indonesian adolescents attempting to terminate their
pregnancies by taking traditional medication, practicing traditional abdominal
massages or seeking illegal abortion services. In contrast, other academic
researchers evaluated adolescent reproductive health education (Holzner and
Oetomo, 2004; Hull et al., 2004) which were pilot projects to educate Indonesian
adolescents about SRH. However, there has not been any research conducted
in Indonesia exploring adolescents experiences during pregnancy and
parenthood, particularly including male adolescents as participants.

At the national level, the Indonesian government has implemented a programme

of interventions which aimed to minimise the number of adolescent pregnancies
i.e. enabling adolescents to access SRH education and improving healthcare
providers’ skills in public health centres on SRH counselling particularly for
unmarried adolescents; conducting campaigns in schools; and distributing leaflet
about SRH for adolescents (IMoH, 2005). Additionally, the Indonesian National
Family Planning Coordination Board (NFPCB) established a multi-sector
response programme involving the Indonesian Ministry of Health (IMoH); the
Ministry of Social Affairs and Community; and the Ministry of Religion known as
National Program of Youth Friendly Health Services (IMoH, 2005). In this
programme, the healthcare sectors i.e. public health centres had responsibility to
provide healthcare services. This involved education, campaigning and
counselling related to adolescents SRH. Meanwhile, schools, religious leaders,
and local Non-Governmental Organisations (NGOs) had responsibilities to
enable adolescents to access SRH services by campaigning in order to increase
public awareness. The programmes also involved social and religious leaders,
schools and local NGOs as the programme was expected to increase awareness
across the public and community (IMoH, 2005). This programme was a pilot
project and was implemented in three provinces by establishing youth centres in
schools. It also involved students as peer educators. However, only about 20%
out of 2,340 adolescents accessed the youth centres (IMoH, 2005) and the
number of adolescents pregnancies was still 35 per 1,000 pregnancies in 2007
(IMoH, 2007).
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Between 2008-2013, the government established 18,011 youth centres spread

through 33 Indonesian provinces (BKKBN, 2013). The aim of the project was to
improve adolescents’ access to SRH services in order to reduce the number of
pregnancies (IMoH, 2010). The youth centre establishment also involved health
workers, social and religious leaders, local NGOs, schools and universities in
order to gain greater participation of adolescents (BKKBN, 2013). However, there
were less than 10% of the 18,011 youth centres with adequate service provision
due to a limited number of trained staff, poor campaign materials and poor
effectiveness of programme and strategies (BKKBN, 2013). Furthermore, the
youth centres were focused on promotion and prevention, such as a campaign of
‘no sex before marriage’, ‘no marriage before 20’ and ‘safe dating’ that was
described as having a relationship without premarital sexual intercourse (IMoH,
2013). There has also been a programme involving adolescents called “GenRe”
which means a group of adolescents as a ‘generation’ that have awareness and
are involved in promoting SRH among their peers. However, the programme has
been evaluated to have limited impact since the number of adolescent
pregnancies has increased from 35 per 1,000 pregnancies in 2007 up to 48 per
1,000 pregnancies in 2012 (IMoH, 2013). More recent data related to the current
episodes of adolescent pregnancy is expected towards end of 2018.

In 2015 the government rebranded the programme with a focused campaign to

delay marriage (BKKBN, 2015). The focus of the programme was to turn
adolescents attention away from marriage to education, vocational training,
employment and income (BKKBN, 2015). This campaign also involved religious
leaders, parents, community leaders and a numbers of adolescents in a model
called ‘Duta Genre’. A focus was to promote avoidance of marriage before the
age of 20 (BKKBN, 2015). Even though it has been implemented in recent years,
there has been no official data related to the programme outcome. However,
given that 9% of the adolescent population reported having sexual relationships
before marriage (IMoH, 2010), delaying marriage was unlikely to address
premarital sexual relationships lead to adolescent pregnancy. Therefore, it is
plausible that in order to prevent adolescent pregnancies, easily accessible SRH
education needs to be provided which could improve knowledge of adolescents
as well as empower them to make a better choice regarding their sexual
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behaviour and when they already engage in premarital sexual relationship it may
be useful to provide a contraception advice service available to them.

Given the data that there are number of adolescents who experience pregnancy
in Indonesia, there is no specific research exploring experiences of adolescents
during pregnancy and their early parenthood. Therefore there is a need to explore
such issues in an Indonesian context. Additionally, the views of male adolescents
as respondents are lacking. Therefore, the aim of this PhD research was to
explore Indonesian adolescents’ reproductive health and their experiences during
pregnancy and their early parenthood period, particularly involving female and
male adolescents as participants. Details of literature related to adolescent
pregnancy and early parenthood is presented in Chapter 2.

1.3 Context of the research

As the research was conducted in Indonesia, this section provides a summary of

the geographic, social and economic landscape of Indonesia and the social and
religious context of reproduction in order to guide the reader.

1.3.1 The geographic, social and economic landscape

Indonesia has a population of 249.8 million and consists of 17,000 islands which
lie between Asia and the Australia continent (Indonesian Statistics Board (ISB,
2013). There are five major islands; Sumatra, Kalimantan, Sulawesi, Papua and
Java. The most densely populated island is Java where the capital of Indonesia,
Jakarta is located. Indonesia is categorised administratively into 33 provinces i.e.
10 provinces located in Sumatra and small islands nearby, six provinces are in
Java and small islands nearby, five provinces are in Kalimantan; six provinces
are in Sulawesi, two provinces are in Papua and the rest of the provinces
dispersed in small islands in between Papua and Java. Each province has
municipalities and every municipality has districts (IMoH, 2012). In terms of the
demographic profile among the adolescent population, Yogyakarta is one
Indonesian province which has a large number of adolescents with different
ethnicities, religions and home island origins, because it is known as the students’
city where most of the best schools and universities are located (ISB, 2013).
Parents from different provinces or islands are more likely to send their children
 16

to study and stay independently in Yogyakarta. Yogyakarta was purposively

selected as a research field because of practicalities, however, in order to have
similar a context with other cities in Indonesia, participants were recruited from a
sub-urban area called Gunungkidul municipality which has the highest number of
adolescent pregnancy among other municipalities in Yogyakarta province.

The large number of islands and population has given rise to diversity of
ethnicities, languages, religions and economic status (ISB, 2013). There are
about 300 ethnic groups with their own languages (IMoH, 2012). The official
national language (written and spoken) is Bahasa Indonesia which every
Indonesian has been taught in their early years. In terms of religion, there are five
official religions; Islam, Christianity (Protestant and Catholic), Hindus, Buddhist
and Confucianism (ISB, 2013). Furthermore, Indonesia is classified as lower
middle income country with 3,580 USD per capita based on Gross National
Income (GNI) (Bank, 2016). Meanwhile, based on Gross Domestic Product
(GDP), it achieved good economic growth which is 5% per capita in 2016. The
following is an Indonesian map and the arrow indicates Yogyakarta province
where the study was conducted.

Figure 1-1: Indonesian map

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1.3.2 Social and cultural context of sexuality and reproduction

Diversity of ethnicity, language and religion is evident in Indonesia and many

people still uphold traditional conservative views about sexuality and
reproduction; these remain taboo as topics of conversation even for adults
(Situmorang, 2003; Hellwig, 2011). Adolescents therefore often access
inadequate information from informal sources such as peers, internet websites
and the media (Utomo et al., 2010). Furthermore, the internet and social media
are very popular among Indonesian adolescents. A survey among 9,442
unmarried adolescents reported that 90% of adolescents had accessed
pornography from internet sites to gain information about sexual matters and 9%
experienced sexual relationship without any contraception after accessing
pornography sites (IMoH, 2010; Panji, 2014). Such adolescents are therefore
more likely to be vulnerable to adolescent pregnancy (Budhyati, 2012).

In general, Indonesians culturally have values which prohibit premarital sexual

relationship. If pregnancy occurs before marriage it is considered as out-with
cultural values and there is likely to be an early marriage arranged and most likely
judgement and shamefulness would be experienced (Holzner and Oetomob,
2004 ; Butt and Munro, 2007). Some adolescents have subsequently
experienced negative treatment from community such as social exclusion and
isolation (Situmorang, 2003). In addition, adolescents are less likely prepared to
engage in married life, particularly when their marriage is due to premarital
pregnancy (Hofferth and Goldscheider, 2010). Adolescents were also more likely
to have an added burden such as financial instability as they were less likely to
have completed education and established work, as well as lacking the capacity
to be a parent (Pudrovska, 2009). Given evidence that there were likely that
culture has strong influences on sexuality and reproduction within an Indonesian
context, the following section presents theories of power and society to set the
context of this PhD research.

1.4 Power and society to set the context of research

This section draws attention to a concept of power in the context of society and
relationships in the postmodern sociological perspectives. It is important to
 18

understand power, society and relationships in this thesis because this research
aimed to explore phenomena in an Indonesian society i.e. Indonesian
adolescents experiences during their pregnancy and early parenthood in an
Indonesian context. This concept of power will be used as a lens to explain and
explore the findings of this PhD research. It is fundamental to understand the
concept of power in society and human relationship. This is because in practical
everyday life, power appears in people’s interactions, communication, and
negotiations, showing perspectives and aspirations as well developing their life
goals (Kelly, 2013; Harish, 2014).

The theorist of choice is Foucault (1978) whose conceptual theory of power was
shaped by knowledge and decentralised. This is because he explains that power
is everywhere and comes from everywhere (Guedon, 1977; Gaventa, 1993;
McLean and Rollwagen, 2008). Therefore, it is plausibly appropriate to be used
as a lens to describe power among Indonesian society relations.

“Power is everywhere; not because it embrace everything, but

becomes it comes from everywhere”(Foucault and Hurley, 1979)
page 93.
This quote suggests that individuals can be powerful, power is practised in
individual’s everyday life, it is created from social relations, it relates individuals
to one another and not only top to down approach. For example, there are many
countries such as Brazil, Argentina, Thailand, Taiwan and Indonesia, that the
government includes multi-sectors departments, national NGO’s, community
leaders, as well as adolescents to campaign SRH in order to improve public
awareness (Gogna et al., 2008; Antonio et al., 2012; Areemit et al., 2012; Chiao
and Ksobiech, 2015). It is evident that the government considers organisations,
grass roots communities and individual to have the potential power to raise public
awareness and guide social behaviour. It also reflects that in this particular case,
power not always came from top i.e. government to down i.e. grass roots
communities, but it can also come from community leaders, national NGOs as
well as individual adolescents themselves.

Foucault’s broad and interactive theory is favoured because his thinking

challenge previous authors who generally describe power as threating,
 19

oppressive and a top-down approach in politics and government, Foucault

focuses on power relations in social system (Guedon, 1977).

“We must cease once and for all to describe the effects of power in
negative terms: it ‘excludes’, it ‘represses’, it ‘censors’, it ‘abstracts’,
it ‘masks’, it ‘conceals’. In fact power produces; it produces reality;
it produces domains of objects and rituals of truth. The individual
and the knowledge that may be gained of him belong to this
production” (Foucault, 1991) page (194).
The quote above presents Foucault’s concept of power as either positive or
negative. In a positive way in some traditional community context where women
become sub-ordinate, power can be used as sources of strength to empower
women and to promote their involvement, raise critiques for development and
struggle for justice, whilst in a negative way, power can be used to prevent
women’s participations and or aspirations and the fulfilment of women’s rights
(Regmi et al., 2010a; Wamoyi et al., 2011). For example in Bangladesh, power
was used in a positive way in a case when government developed a programme
to empower women including young mothers through entrepreneur skills
development in order to enhance their access to finance and jobs (Schuler et al.,
2010). In contrast, an example when power was used in a negative way can be
seen in Bangladesh when pregnant adolescents were excluded from school due
to policy practices (Sabates et al., 2010).

Foucault also discusses “biopower” which refers to the ways in which power
manifests itself in the form of daily practices and routines through which
individuals engage in self-surveillance and self-discipline (Foucault and Hurley,
1990). In the concept of “biopower”, individuals naturally have power that can be
expressed as an instinct or desire (Foucault and Hurley, 1990). For example,
where premarital sexual relationship is prohibited such as in Indonesia, there
were many adolescents whom behaved self-surveillance and self-discipline to
avoid such behaviour, whilst evidence also showed that other Indonesian
adolescent also led their intention to engage in premarital sexual relationships
(Purdy, 2006; Rissakota, 2014). Therefore, it is more likely that power can also
be seen in each individual for controlling their intention whether to engage in
premarital sexual relationship or not.
 20

Foucault’s concept is important to understand how both the power of individual

and society are implicated in mixing people’s behaviour (Dowding, 1996; Pylypa,
1998; Klepec, 2003; Ewing, 2008). There are studies that used Foucault’s
concept of power. For example, power can be used to raise awareness and
improve the knowledge of people in health and sexuality regulation and
management by inviting individuals to address their own behaviours as a matter
of their own desires (Allen, 2009; Amuchastegui and Parrini, 2010). It can also be
seen in Indonesian health programme interventions that power is intended to be
used positively, to reduce the number of adolescent pregnancies, the Indonesian
government put effort into the establishment of friendly youth centres in order to
attract adolescents for accessing SRH education and services in public health
centres (BKKBN, 2013). It was expected that by educating adolescents about
SRH, there would be an improvement in adolescents’ awareness related to SRH
and practices. Power also has been used positively by community and religious
leaders in supporting SRH programme interventions i.e. providing information to
the adolescents and their parents about how to get SRH services access and
campaigning ‘no sex before marriage’.

However, there was also power that has been used negatively in many societies,
for instances, social exclusion, stigmatisation and/ or judgement when people are
out-with society expectation (Kumar et al., 2009; Stillman et al., 2009). Power has
also been extended by the Indonesian government by using government
authority for instance pregnant adolescents and their boyfriend have to marry in
order to be legally accepted as certified couple. If couples reject marriage, they
will not be able to have legal birth certification for their children. In regards to the
social exclusion, Foucault (1991) also uses the history of punishment in order to
illustrate the larger social movement of power and examine how changing power
relations affected punishment from the aristocracy to the middle classes. For
example in monarchical law, corporal punishments were key punishments and
torture was part of most criminal investigations. Punishment was ceremonial and
directed at the prisoner's body. It was a ritual in which the audience was
important. On the other hand, in the postmodern era, punishment is a procedure
for reforming individuals as subjects; it does not use marks, but signs.
 21

Modern power to punish is theoretically based on the supervision and

organisation of bodies in time and space (Foucault, 1991; Strenski, 1998). The
description given by Foucault explains how power has been used to construct
people’s behaviour by using supervision and organisation of bodies. Similarly, in
Indonesia there is evidence that culture and religion also strongly influences how
people behave (O'Shaughnessy, 2009). Some people believe that God is their
end of life goal therefore has empowered them to have individual commitment
and self-regulation without any supervision from others (Adeney-Risakotta,
2014). For example in everyday life, some people in Indonesia practically have
individual commitment to do prayer in their daily life without anybody asking them
to do so.

Other concept in regards to power which also explained by Foucault that when
power is also related to resistance, he said:

“Where there is power, there is resistance, and yet, or rather

consequently, this resistance is never in a position of exteriority in
relation to power.” (Foucault and Hurley, 1990) page 95.
In a social relationship power is not always being used to oppress others, rather,
power is more likely to be used to influence people to behave like a power holder
expects. For example, previous research evidence showed that in India, South
Africa, Turkey as well as Indonesia where patriarchy values are strong within
community, there has been a growing number of feminists who empower women
to gain equality in their social life (Sen, 2008; Pretorius, 2009; Goknar, 2013;
Adeney-Risakotta, 2014). Having an understanding of a theoretically explanation
of power relations in society, it is evident that in society relations sources of power
come from each individual, it can become either a positive or negative influence
on peoples’ live and behaviour, it does not always come from the top to the down
and it may also come with resistance. Hence, Foucault’s explanations of power
relations in society seems appropriate to be used as a lens to help explain and
explore the findings.

1.5 Aim of the research

This research aims to explore, illuminate and understand Indonesian
adolescents’ reproductive practices and their experiences during pregnancy and
 22

early parenthood. It was set in the context where adolescent pregnancy and early
marriage due to sexual relationships is out-with cultural and religious
expectations.

1.6 Research questions

There are three research questions:

1. What are the health and social experiences of pregnant adolescents and
their partners in Indonesia and other low-lower and middle-upper middle
income countries?
2. What are Indonesian adolescents’ experiences during pregnancy?
3. What are the experiences of Indonesian young parents after the birth of
their baby in Indonesia?

1.7 Research purpose

The purpose of this study was to explore and illuminate Indonesian adolescents’
reproductive practices, and their experiences during pregnancy and early
parenthood, so that we can understand their experiences on a social context and
understand how some adolescent behaviour is out-with cultural and religious
expectations. It was anticipated that these findings will inform and shape health
and social services relating to reproductive health provided for adolescent
Indonesians.

1.8 Objectives of research

The table 1-1 describes the research questions, objectives and type of research
that have been conducted.
 23

Table 1-1: Research questions, objectives and type of study

Research Questions Objectives Type of

Study
What are the health and Qualitative
1. Explore and synthesise health and
social experiences of Systematic
social experiences of pregnant
pregnant adolescents Review
adolescents’ and their partners in
and their partners in Indonesia.
Indonesia and other 2. Explore and synthesise health and
low-lower and middle- social experiences of pregnant
upper-middle income adolescents’ and their partners in
countries? other low-lower and middle-upper
middle income countries.
3. Compare and contrast the
experiences of pregnant
adolescents and their partners
between Indonesia and other low-
lower and middle-upper middle
income countries.
What are Indonesian In-depth
1. Explore the experiences of
adolescent experiences Study
pregnant, female Indonesian
during pregnancy? adolescent residents in Indonesia.
2. Explore the experiences of male
Indonesian adolescents who have
a pregnant Indonesian girlfriend
whilst resident in Indonesia.
3. Compare and contrast between
female and male Indonesian
adolescent experiences whilst
resident in Indonesia.
What are the health and 1. Explore young mothers’ health and In-depth
social experiences of social experiences after the birth of Study
Indonesian young their baby.
parents after the birth of 2. Explore young fathers’ health and
their baby in Indonesia? social experiences after the birth of
their baby.
3. Compare and contrast health and
social experiences and life
changes of young Indonesian
mothers and fathers.

1.9 Reflections of the research prior to data collection

Family was one of the influencing factor for the researcher to continue my
education into higher level. Although where I grew up, there were not many
women who continued their education into a higher level (most of them finished
 24

their high school and work). Since being a child I was encouraged and supported
to gain education into higher level. Whilst, there was a culture for giving more
opportunity to be educated to men rather than to women, my family have a value
to support children to have education for better future as well as being financial
independent women. Particularly, my mother had always said that ‘women or wife
need to be educated in order to be able to earn money and for not being
financially dependent to others, then when something unexpected happened,
their world will not end’. My mother is a single parent since I was 12 years old
because my father passed away. She was financially struggling at first after my
father passed away due to having no skill and education to manage our grocery
shop and lumberyard which were our family financial sources, but she then
coped, managed and continued these shops by having a specific training skill
about business management.

Such experience was more likely influencing my mother to send her children into
higher education and that experience also led myself to continue education into
undergraduate study programme which led me to become a professional midwife
and then further a member of academic staff at midwifery department, University
of Aisyiyah Yogyakarta (UNISA). As a member of academic staff, developing skill
and capacity in academic matters are required and it became one of stimulations
for me to plan to continue study into master and then PhD education. By
opportunity, I was selected as one of Indonesian government scholarship
awardee to continue master and PhD education. The University of Leeds was
one of list of universities suggested by Indonesian government for PhD
scholarship awardees.

Started from that time, I began to think about topic area for research. The choice
about adolescent pregnancy was because of my personal experience that the
number of pregnant adolescents was growing in around researcher’s
neighbourhood. Additionally, experience as a professional midwife and member
of an academic staff in midwifery department enabled researcher to have update
issues related to women and reproductive health in Indonesia including
increasing number of adolescent pregnancy. An academic conference and
seminar related to reproductive health also become one of stimulation to explore
more about evidence related to adolescent pregnancy. There was an assumption
 25

that female adolescents should be the most suffering people when pregnancy
occurred. Experience of midwifery practices and living at the similar context
influenced my assumption related to pregnant adolescents burden. According to
Morse (2001), the background of the researcher, will be valuable in providing a
variety of perspectives. Being a midwife and a member of academic staff in a
midwifery department in Indonesia led the researcher to be able to locate the
potential research topic in Indonesia.

Initially, I was working from the stand-point of wanting to understand the

experiences of pregnant adolescents and aiming to identify the best healthcare
services model for them by comparing maternal health services in the United
Kingdom and Indonesia. However, at the process of literature searching for
research evidence related to adolescent pregnancy in Indonesia, there was a
very limited research evidence found, specifically about adolescent experiences
during pregnancy and parenthood, including males as participants. Evidence also
showed that there were no specific healthcare services for pregnant adolescents
in Indonesia. Therefore, a comparison study could not be undertaken and it
seemed appropriate to focus on the exploration of Indonesian adolescents’
reproductive practices and their experiences during pregnancy and their early
parenthood, including female and male adolescents as participants. An
exploratory qualitative research was selected as it was deemed appropriate to be
used to reach the aim of this PhD research. Details of the qualitative exploratory
research is explained in Chapter 3. As this was the first experience of qualitative
research; it was assumed that it would be a challenge and that I needed to learn
more about conducting qualitative research and methods. Several training
courses related to qualitative research have attended and helped me to
understand and guide the process of conducting qualitative research. Detail of
the reflection after data collection will be described in Chapter 7.

1.10 Structure of the thesis

This thesis includes seven chapters; Chapter 1 introduces key issues about topic
of interest, context, challenges and aims of the PhD research and provide a local
Indonesian context. Chapter 2 provides background of adolescent pregnancy
 26

and parenthood in low-lower and middle-upper middle income countries specific

context in order to develop understanding about adolescent pregnancy in low-
lower and middle-upper middle income countries. Given that study 1 (Chapter 4)
is a qualitative systematic review of the experiences of pregnant adolescents and
their partner in Indonesian and other low-lower and middle-upper middle income
countries, this background underpins the topic of interest.

Chapter 3 presents the research paradigm, methodological approach and

methods employed in the PhD research. It also presents the research design and
methods, ethical process and procedures, ethical issues, researcher effect and
researcher bias, positionality and role of the researcher are also presented. The
rigour of the research marks the end of this chapter. Chapter 4 reports details of
the methods, process and findings of study 1 which is a qualitative systematic
review of health and social experiences of pregnant adolescents and their
partners in Indonesia and other low-lower and middle-upper middle income
countries. A discussion of emergent themes and findings is also provided.

Chapter 5 describes detail of the methods and process as well as the findings of
study 2 which is an in-depth study of Indonesian adolescents’ reproductive health
and their experiences during pregnancy. The discussion and interpretation
related to emergent themes and findings of study 2 is also presented. Chapter
6 details methods and process as well as findings of study 3 which is an in-depth
study of young parents’ experiences during their early parenthood. The
discussion and interpretation related to emergent themes and findings of study 3
is also described.

Chapter 7 provides an overarching discussion of the studies conducted which

uses Foucault’s concept of power relationships in society to explore, draw
together and help explain findings. Wider literature is used to support and debate
findings in a social context. Furthermore, implications, recommendations,
dissemination and conclusions are described in this chapter 7. It is also examines
how the findings can inform health and social care practice for the Indonesian
government, public and other low-lower and middle-upper middle related to
adolescent pregnancy and parenthood.
 27

1.11 Summary

An overview of the Indonesian local context and a rationale for the study is
presented in this chapter, along with the geographic, social and economic
landscape in Indonesia. The concepts of power, society and relationship are
presented. The aim of the research, along with research questions, purposes and
objectives, reflection of the researcher and structure of the thesis are included.
The following chapter presents a background for the PhD research.
 28

Chapter 2 Background

2.1 Introduction

The background provides an overview of adolescent pregnancy and parenthood

in the context of low-lower and middle-upper middle income countries. The
incidence of adolescent pregnancy and parenthood, reasons of why adolescents
engaged in early sexual relationship and risks associated with adolescent
pregnancy, child birth and parenthood are provided. The background is
presented in order to bring an overview of adolescent pregnancy and parenthood
in the context of low-lower and middle-upper middle income countries.

2.2 Incidence of adolescent pregnancy and parenthood

Adolescent pregnancy in general refers to pregnancy among young women aged

15-19 (WHO, 2014a). The United Nations International Children's Emergency
Fund (UNICEF) defines adolescent pregnancy as a pregnancy that occurs
among female adolescents under the age 19 (UNICEF, 2009). Meanwhile,
adolescent parenthood is described as primarily adolescents who give birth to
and elect to parent a child (WHO, 2008; UNPF, 2013). Adolescent pregnancy is
a global issue as it potentially brings adverse health and social consequences for
both mothers and children (WHO, 2014a; WHO, 2015). Data shows that 3 million
unsafe abortions lead to maternal mortality caused by unplanned adolescent
pregnancy and babies born to mothers under 20 years of age face a 50% higher
risk of being stillborn or dying in the first few weeks versus those born to mothers
aged 20-29 (WHO, 2014a). Additionally, adolescent pregnancy that is associated
with early childbearing is more likely to contribute towards poor health outcomes
among female adolescents, particularly when there is no adequate healthcare
support (Koniak-Griffin and Turner-Pluta, 2001; WHO, 2015). Details of health
and social experiences of pregnant adolescents and their partners are explained
in Chapter 4 as part of the qualitative systematic review study.

The Figure 2-1 describes trends of adolescent fertility rate from 2000-2010 across
countries according to WHO (2011). There is no specific data reporting the rate
of adolescent parenthood, however, the rate of adolescent pregnancy seems to
be an indicator of adolescent parenthood. Overall actual rates of adolescent
 29

parenthood are unclear. According to the United Nations Population and Fund
(UNPF) (2013), 95% of the world’s births are in low-lower and middle-upper
middle income countries and nearly a fifth of all women become pregnant by the
age of 18 in low-lower and middle-upper middle income countries (UNPF, 2013).
Furthermore, female adolescents under 15 account for 2 million of the 7.3 million
births that occur among female adolescents (WHO, 2014a).

Figure 2-1: Adolescent fertility rate across countries from 2000-2010

The health and social issues associated with adolescent pregnancy are a concern
across countries (UNICEF, 2009; WHO, 2014b). Figure 2-1 shows that there is
variation of adolescent fertility rate, it is notable that the UK rates in this data were
similar to middle income countries such as India, Thailand and Iran. However, the
UK has infrastructure to support teenage pregnancies and opportunity for
adolescents to continue education. It is therefore likely that pregnant adolescent
in the UK will have better specific support needed in both health and social
aspects. Meanwhile, in low-lower and middle-upper middle income countries,
 30

they were still struggling with the lack of resources, number of staff, and
appropriate trained healthcare providers, which reflect they still had challenges in
infrastructure and human resources (Chandra-Mouli et al., 2013). Adolescents
pregnancy which occurred across low-lower and middle-upper middle income
countries therefore are more likely to have lack of adequate health and social
supports and consequently have greater risk of adverse maternal and child health
outcome (UNPF, 2013; WHO, 2014a). Although the figure 2-1 provides brief
overview of the rate of adolescent pregnancy globally, this background focusses
on low-lower and middle-upper middle.

Figure 2-1 shows that the highest adolescent’s fertility rate occurred in low- lower
and middle- upper middle income countries, mostly in Sub Saharan African
countries. Whilst, Nepal, Laos and Afghanistan were lower income countries in
Asian countries which also experienced highest rate of adolescent fertility.
Additionally, in American countries there were Venezuela, Honduras and
Nicaragua were also low-lower and middle-upper middle income countries which
experienced high number of adolescent fertility rate. On the other hand, almost
all of the high income countries such as Canada, Norway, Sweden, Japan and
Australia had the lowest adolescent fertility rate. A striking feature is China which
is a middle income country, yet reported the lowest adolescent fertility rate. This
could be the result of the policy of ‘one child only’ which was introduced since
1979 to reduce the Chinese population (Currier, 2008; Beal-Hodges et al., 2011).
Possible reason also it may related to social culture within Chinese people,
evidence shows that Chinese have a strong tradition emphasising education
which subsequently influenced people’s behaviour to continue higher education
and delay childbearing (Zhenzhen et al., 2009; Cai, 2010). Furthermore, the
picture in Figure 2-2 describes trends of annual births per 1,000 female
adolescents.
 31

Figure 2-2: Annual births per thousand female adolescents from 2007-
2012
The figure 2-2 shows that there is consistency between the rate of adolescent
fertility in figure 2-1 and the annual birth rate. The highest annual births occurred
in low-lower and middle-upper middle income countries, and lowest annual births
were in high income countries. Therefore it may be that adolescent pregnancies
in these countries were not being terminated, which may indicate adolescent
parenthood.

2.3 Reasons why adolescents engage in sexual relationships

leading to adolescent pregnancy

Sexual relationships leading to adolescent pregnancy and parenthood in low-

lower and middle-upper middle income countries are reportedly due to four key
reasons across a range of low- lower and middle-upper middle income countries:
customs and traditions; limited knowledge about SRH and limited access to
contraception; peer pressure; and sexual abuse that leads to rape (WHO, 2008;
WHO, 2014a). Many of these reasons are also associated with living in poverty;
low self-esteem and low educational ambitions (Fenn et al., 2015).

Customs and traditions relating to adolescent pregnancy (WHO, 2015), such as

early marriage, are common practices in some low-lower and middle-upper
 32

middle income countries such as in Afghanistan, Pakistan and Bangladesh (Bott

et al., 2003; Were, 2007; Ferdousi, 2014; Naveed and Butt, 2015). Furthermore,
social conditions such as poverty also contribute to early childbearing and leads
to adolescent pregnancy (Schuler et al., 2006; Juma et al., 2013). Marriage
among female adolescents may be a strategy for a family’s economic survival
because when female adolescents marry, they would become the husband’s
financial responsibility, lessening the financial burden on her own family (Schuler
et al., 2006; Pande et al., 2011; Lemon, 2016). Moreover, in a community where
premarital sexual relationships is considered shameful and immoral, early
marriage has also been reported as a strategy led by parents, to prevent their
children from premarital sexual relationship such as in Egypt (Pradhan et al.,
2015; Sieverding and Elbadawy, 2016). In Indonesia, legislation from 1974
restricting child marriage underpinned a women’s movement (Bedner and Huis,
2010). Marriage is therefore is expected among those aged 20 and above in
general Indonesian context (Purdy, 2006; Buttenheim and Nobles, 2011).

Limited knowledge of SRH amongst adolescents is also a factor related to

adolescent pregnancy (WHO, 2014a; Fenn et al., 2015). For example in South
Africa, a qualitative exploratory survey revealed that 61% amongst 147 pregnant
adolescent reported having inadequate knowledge of SRH which may have
contributed to their pregnancy (Mushwana et al., 2015). Additionally, in Malawi
Kaphagawani and Kalipeni (2017) reported that lack of knowledge related to SRH
contributed to 30% adolescent pregnancy occurrence amongst 422 participants.
In Uganda, evidence reported adolescents were experiencing a lack of education
related to SRH and missing understanding about contraception which led to their
pregnancy (Atuyambe et al., 2015). Evidence also reported that missing an
understanding related to contraception has high risk of adolescent pregnancy
(Were, 2007; Fenn et al., 2015). For example, in Tanzania and Malawi evidence
reported that fear of side effect, disapproval from partner and condoms
disappearing were cited by pregnant adolescent for not using contraceptives,
suggesting that many adolescents had poor understanding related to
contraception (Nyakubega, 2009; Kaphagawani and Kalipeni, 2017).
Furthermore, literature also suggests that limited access to contraception also
contributed to high rates of adolescent pregnancy (UNPF, 2013). In some low-
 33

lower and middle-upper middle income countries such as in Indonesia, Malaysia,

Bangladesh and Egypt, contraception can only be legally accessed by married
people and abortion is offered only for medical reasons, particularly where
continuation of pregnancy is assessed to be harmful to maternal health (Chandra-
Mouli et al., 2013). Whilst, premarital sexual relationship is prohibited in some
low-lower and middle-upper middle income countries like in Indonesia and Egypt,
it does occur (Kumar et al., 2009; Utomo et al., 2010; Sieverding and Elbadawy,
2016). It is more likely that limited access to contraception therefore consequently
led to adolescents engaged in sexual relationship without contraception (Dalby
et al., 2014; Borovac-Pinheiro et al., 2016), which a has high risk of adolescent
pregnancy occurring.

Peer pressure to engaging in sexual relationships and consequently intercourse

was reported to be an important factor that shapes adolescent attitudes including
sexual behaviour (Tomé et al., 2012). There was a study conducted in South and
South East Asian countries which shows that among 500 female and male
adolescents, 10 % of them were engaging in sexual relationships because of a
lack of confidence to resist peer pressures (Wong et al., 2009). Furthermore,
evidence from studies in China, Ghana, Brazil, and Malaysia also show that
having peers who practice sexual relationships was associated with adolescents
having sexual relationships (Yan et al., 2010; Antonio et al., 2012; Ahmadian et
al., 2013; Bingenheimer et al., 2015). However, there was no particular data
which explained how a big number of peers could influence adolescents’ sexual
relationship involvement.

The prevalence of sexual abuse leading to rape female adolescents ranges

between 15% and 40% in sub-Saharan Africa (Kilonzo et al., 2009). Evidence
from Malawi showed that most sexually active among female adolescents had
the first sexual relationship with a man older than them and 56% of female
adolescents experienced forced sex with resulting in adolescent pregnancy
(Munthali et al., 2014). Furthermore, a study conducted in Ghana explained that
18 % of 700 female adolescents experienced sexual abuse and consequently
were raped whilst of school age, of which 75 % of them had to leave school due
to pregnancy (Bingenheimer and Reed, 2014).
 34

These factors contributing on adolescent pregnancy above are associated with

poverty, low self-esteem as well as low educational ambitions (Ganchimeg et al.,
2014; WHO, 2014a; Fenn et al., 2015). Research shows that early sexual
experiences and pregnancy are characteristic of poverty environment (Asrar,
2015). That is because in many of the cases, the families are in poverty and one
less daughter is one less mouth to feed therefore child marriage for their daughter
is a coping economic strategy for a poor family (Ferdousi, 2014). Furthermore,
low self-esteem has also been identified as a factor that leads to sexual
relationships leading to adolescent pregnancy (Ganchimeg et al., 2014). There
was evidence present from previous research conducted in Nigeria, Vietnam and
Zimbabwe that female adolescents experienced receiving pressure to engage in
sexual relationships from their boyfriend or their boyfriend refuse to use a
condom, whilst female adolescents lack confidence to resist the sexual
relationships, in which such practices are increasing the risk of adolescent
pregnancy (Klingberg-Allvin, 2007; Osaikhuwuomwan and Osemwenkha, 2013;
Mutanana and Mutara, 2015). Additionally, in terms of education, low education
ambition or lack of opportunities in formal education has also been identified as
increasing the risk of adolescent pregnancy. In Nicaragua, Bangladesh and
Kenya, female adolescents who are not attending school have a high risk of
adolescent pregnancy because they are more likely to be vulnerable to engaging
in early marriage and becoming pregnant afterwards (Were, 2007; Lion et al.,
2009; Pradhan et al., 2015).

2.4 Risks associated with adolescent pregnancy, childbirth and

parenthood

This section outlines some health risks associated with adolescent pregnancy,
childbirth and parenthood. Health and social experiences amongst pregnant
adolescents are presented as part of qualitative systematic review in Chapter 4.
Evidence shows that adolescent pregnancy brings adverse physical and
psychosocial outcomes for both young mothers and children as well as for young
fathers (Chandra-Mouli et al., 2013; WHO, 2014a). In terms of maternal health
outcomes, pregnant adolescents are twice as likely to have pregnancy and
childbirth related complications compared to older women (Saxena et al., 2010).
 35

The underdeveloped pelvis in younger adolescents may contributes to difficulties

in childbirth than adults or mature adolescents, who have fully developed bone
structure (Sulaiman et al., 2013). In terms of perinatal health outcomes, babies
born to adolescents under the age of 18 years old have a 50% increased risk of
dying before they reach the age of one than babies born to women in their
twenties (Edirne et al., 2010; Ganchimeg et al., 2014). It is also possible that the
increased risk of poor pregnancy outcomes in the adolescent pregnancy is
related to difficulties in accessing healthcare services and receiving less prenatal
care. Research also indicates that pregnant adolescents are less likely to receive
prenatal care than older women, often seeking it only in the third trimester
(UNFPA, 2013).

A study conducted in Malaysia reported that among 177 adolescent pregnancies

and births, there were 24.3% who had preterm births, 24.1 % had low birth weight,
and 4.5% with very low birth weight (Sulaiman et al., 2013). Furthermore,
evidence from Nepal shows that among 672 adolescent mothers, 53% had
complications in their pregnancies and delivery process i.e. preterm births
(27.5%), hypertensive disorders of pregnancy (20.17%), premature rupture of
membranes (18.21%), abortion (14.57%), anaemia (8.12%), low birth weight
(16.86%), and stillbirths (5%) (Yasmin et al., 2014). Additionally, in India among
4,908 adolescent pregnancy cases 30% of them experienced complications i.e.
preterm births (17.1%), severe Pregnancy Induced Hypertension (PIH) (17.1%)
and severe anaemia (11.4%) among the mothers, low birth weight (77.2%) and
perinatal mortality (8.6%) (Mohite et al., 2014).

Furthermore, previous research showed that adolescent mothers are over twice
as likely as adult mothers (10–12%), as well as their non-parenting peers (8–
12%), to experience severe depression to warrant a clinical diagnosis (Lewinsohn
et al., 1994). In addition, men who fathered before aged 20 were found to have
significantly greater anxiety and higher rates of depression than men who first
fathered during their 20s (Heath et al., 1995; Quinlivan and Condon, 2005; Lee
et al., 2012) and a consequence of lower educational attainment, had a less
prestigious occupation, more unstable marriage and were less physical healthy
compared to their peers whom delayed childbearing (Taylor, 2009). Adolescent
mothers typically had a lower level of education or job skills, making them
 36

financially dependent on their husband, or turn to family, or foster care for seeking
supports (Gillmore et al., 2008). Further health and experiences related to
adolescent pregnancy and parenthood will be explain as a part of systematic
review in Chapter 4.

2.5 Policy context: adolescent pregnancy and parenthood

In response to adolescent pregnancy and parenthood across low-lower and

middle-upper middle income countries, WHO published a guideline for preventing
adolescent pregnancy and poor reproductive outcomes (WHO, 2011a). The
guideline focuses on six domains which were: preventing early marriage;
preventing early pregnancy through SRH education, increasing education
opportunities, and economic and social support programmes; increasing the use
of contraception; reducing coerced sex; preventing unsafe abortion; and
increasing the use and the safety of prenatal care, childbirth, and postpartum care
programmes (WHO, 2011a; Chandra-Mouli et al., 2013).

Whilst addressing issues of adolescent pregnancies is a global commitment, the

implementation of the recommendation is variable. Some low-lower and middle-
upper middle income countries have adopted the guideline, such as in South
Africa, by improving access to SRH services including contraception for
adolescents (Hoopes et al., 2015). However, challenges remain in terms of
implementing these guidelines, due to inadequate infrastructure, sociocultural
norms within communities, or resistance from community gate keepers such as
community and religion leaders (MCur et al., 2010; Shung-King, 2013a; Hoopes
et al., 2015). For instance, in South Africa the implementation of the Integrated
School Health Policy has been limited by insufficient financial and human
resources and a lack of training and standard practices for schools (Shung-King,
2013b). In Indonesia, preventing adolescent pregnancy is a national agenda,
such as promoting SRH services and education involving peers, parents and
religious leaders, campaigning for the increase of marriage age and promoting
no sex before marriage (BKKBN, 2013; BKKBN, 2015). However, there is still no
official data or evaluation of the programme to judge its success. In Pakistan,
SRH education, counselling, and contraceptive provision has been provided as a
national health strategy in order to increase sexual knowledge, and contraceptive
 37

use, and to decrease adolescent pregnancy (Salam et al., 2016b). However,

health practitioners face several challenges with adolescents such as difficulties
to invite adolescents to visit SRH services. Therefore health practitioners require
specialised skills for consultation, interpersonal communication, and
interdisciplinary care (Salam et al., 2016a). In Iran, a number of educational SRH
programmes, such as puberty, family life, human immunodeficiency virus
(HIV)/acquired immunodeficiency syndrome (AIDS), and life skills, have been
developed for unmarried adolescents, however, it is not efficient as there is no
sex education in the school curriculum (Vakilian et al., 2011; Mosavi et al., 2014).
From the evidence above, it seems that interventions to reduce adolescent
pregnancy are varied with little formal evaluation to assess their effectiveness
and efficacy.

2.6 Summary

In this chapter, background information related to adolescent pregnancy and

parenthood in low-lower and middle-upper middle was presented. In order to
understand aspects contributing to experiences of adolescent pregnancy and
parenthood in the specific context of low-lower and middle-upper middle, in the
next chapter, the research worldview, methodology, methods of the research and
ethical consideration will be explained.
 38

Chapter 3 Research Worldview, Methodology, Methods and

Ethical Consideration

3.1 Introduction

In this chapter, the research worldview and methodology is presented. An

explanation about qualitative research and a selection of qualitative
methodological approaches are discussed. A brief overview of research designs,
aims and objectives for study 1, 2 and 3 are also provided. Furthermore, ethical
consideration, ethical approval, access to the field and participants are explained
as well as potential researcher effect and bias, and positionality. Rigour of this
research is also presented in this Chapter 3.

3.2 Research worldview

A research worldview is reported to be a set of basic assumptions that informs

methodological decisions and consequently the methods which are used to
investigate research (Crotty, 1998; Creswell and Creswell, 2013). It
fundamentally influences the researchers’ views on how they see the world,
determining their perspectives and developing an understanding of how things
are connected (Denzin and Lincoln, 2003). It is argued that researchers’ personal
philosophical beliefs and principles guide as a general philosophical orientation,
which may influence their actions in terms of how researcher view the world and
how it could be investigated (Crotty, 1998; Creswell and Creswell, 2013). Such
as the choice of research questions, approaches to data collection and
interpretation (Crotty 1998).

The three fundamental philosophical assumptions are: ontology, epistemology

and methodology (Lincoln and Guba, 1985; Crotty, 1998; Creswell and Creswell,
2013). Ontology is about ways of known reality (Lincoln and Guba, 1985;
Creswell and Creswell, 2013). This research therefore follows constructivism.
Constructivism views a world is universal, absolute realities are unknowable and
there is no single reality or truth (Lincoln and Guba, 1985; Crotty, 1998; Creswell
and Creswell, 2013). Epistemology is asking basic beliefs about knowledge and
focuses on the knowing process (Lincoln and Guba, 1985; Silverman, 2011;
 39

Creswell and Creswell, 2013), for example in this research, it is belief that reality
is about the way every individual makes meaning in the events of their lives and
individual develop their subjective meaning of their experiences (Lincoln and
Guba, 1985; Crotty, 1998; Creswell and Creswell, 2013). In terms of
epistemology this research is trying to construct reality from individuals’
perspectives (Crotty, 1998; Denzin and Lincoln, 2000; Creswell and Creswell,
2013). Researcher views that reality is subjective and multiple, as seen by
participants in the research study, and is constructed by those who are involved
in the research situation which is primarily the researcher. To remain grounded
the researcher used quotes and themes in words of participants and provided
evidence of different perspectives. Thus reporting participants realities.
Methodology points to what researchers use to know the reality (Silverman, 2011;
Creswell and Creswell, 2013), for example this research used qualitative
research by applying in-depth qualitative interviews to construct the reality
(Lincoln and Guba, 1985; Creswell and Creswell, 2013). In terms of methodology
this research used an inductive approach which is described as research that
gathered the data from one-to-one interviews to subthemes and themes (Lincoln
and Guba, 1985; Crotty, 1998; Denzin and Lincoln, 2000; Creswell and Creswell,
2013). The methodology applied in this research will be detailed in section 3.3.

3.3 Methodology: qualitative research

Qualitative research is a form of social inquiry that focuses on the way people
interpret and make sense of their experiences (Denzin and Lincoln, 2000) with a
common aim of trying to understand the social reality of individuals, groups and
cultures (Flick et al., 2007; Creswell, 2014). It tends to explore behaviour,
perspectives, feelings and experiences of people’s life (Denzin and Lincoln, 2003;
Flick et al., 2007; Green and Thorogood, 2009). Qualitative research also helps
researchers discover meanings, experiences and views from participants’ words
(Pope and Mays, 2006) and can provide a rich, descriptive, valuable
understanding of individuals' attitudes, beliefs, motivations, opinions, aspirations,
and behaviours (Green and Thorogood, 2009). Qualitative research offers
opportunities for researchers to explore new areas of research using open-ended
question, and therefore it gives a chance for the researcher to build new
 40

evidence, facts or even theories (Denzin and Lincoln, 2003; Flick et al., 2007).
However, the approach is not without limitations, potential research bias in
particular and strategies have been put in place to minimise such bias (see
section 3.6 in this Chapter).

This research used a generic exploratory qualitative research approach which is

adopted from Merriam and Merriam (1998) which Thorne described as non-
categorical qualitative research (Thorne, 2009). This qualitative approach has no
guiding set of specific characteristics (Caelli et al., 2003). Even though a generic
exploratory qualitative approaches does not claim any single established
qualitative methodology approach, it can draw on the strengths of established
methodologies (Kahlke, 2014; Bellamy et al., 2016). Thus enabling researchers
to be flexible to adopt other techniques of qualitative research approaches such
as techniques of ethnography, case study method, grounded theory and the
techniques of action research, but does not claim to ‘be’ any of these in a
methodological sense (Merriam and Merriam, 1998; Caelli et al., 2003).

A generic exploratory qualitative research approach can be used when the

research focuses on descriptions of what people experience and how they
experience what they experience, and it simply seeks to understand a
phenomenon, a process, or the perspectives and worldviews of the people
involved (Patton, 1990). As the study aimed to explore Indonesian adolescents’
reproductive practices and their experiences’ during pregnancy and their early
parenthood, a generic exploratory qualitative approach has been selected as an
appropriate research methodology.

A number of methodological approach were considered. Grounded theory was

not selected as this research aimed to explore adolescents experiences where
little is known about the topic rather than to generate a theory (Denzin and
Lincoln, 2003). Ethnography does not appear to be appropriate to explore the
research questions because this research study is not about culture or pattern
values of a particular cultural nor does it involve tools of extended observation or
even participant observation for data collection that ethnography usually employs
(Denzin and Lincoln, 2003; Creswell and Creswell, 2013). Phenomenology was
considered as it is characteristically used to investigate participants’ lived
experiences (Forrester, 2010; Creswell and Creswell, 2013) and it would be right
 41

to be applied to achieve the overall aim i.e. to exploring adolescents’ reproductive

practices and their experiences during their pregnancy and early parenthood.
However, the objectives of this research led the researcher towards a more
flexible approach. Therefore, generic qualitative research methodology was
deemed suitable to be used in order to explore this research’s questions.

3.3.1 Research design

Exploratory qualitative research was used as a research design to gathered deep
and rich information from personal experiences which was difficult to reach by
measuring or counting numbers, prevalence or impact which quantitative
methodologies usually focus on (Creswell, 2014). Additionally, exploratory
qualitative research allowed the researcher to use open-ended questions and it
also gave the opportunity for participants to respond to the questions by using
their own words rather than forcing them to choose fixed responses (Mack et al.,
2011). Having considered the above reasons for selecting exploratory study, a
qualitative systematic review and two qualitative empirical studies were
employed. Diagram 3-1 outlines the overview of exploratory qualitative research
design:

Figure 3-1: Design of research

 42

3.3.2 Description of the research

This section provides brief descriptions of the three studies. Study 1 is a
qualitative systematic review, study 2 and 3 are empirical studies which were
conducted in Indonesia.

3.3.2.1 Study 1: Qualitative systematic review and its rationale

The first study was a qualitative systematic review to provide comprehensive
insight into the health and social experiences of pregnant adolescents and their
partner in Indonesia and other low-lower and middle-upper middle income
countries. Qualitative systematic reviews are studies that identify, gather,
appraise and synthesise all the available qualitative research evidence of a
particular subject (Davies et al., 2011) and are appropriate where the aim is to
synthesise evidence related to peoples’ experiences (Wilson et al., 2010).
Integrated evidence is expected in a systematic review (Campbell et al., 2003).
For this study, a synthesis was to provide insight into what is known about
adolescents experiences of their pregnancy and postnatally in low-lower and
middle-upper middle income countries to inform and guide the interview
questions of study 2 and 3.

3.3.2.1.1 Aim
The aim of this study was to explore health and social experiences of pregnant
adolescents and their partners in Indonesia and other low-lower and middle-
upper middle income countries in order to inform study 2 and 3.

3.3.2.1.2 Objectives
1. Explore and synthesise health and social experiences of pregnant
adolescents and their partner in Indonesia.
2. Explore and synthesise health and social experiences of pregnant
adolescents and their partner in other low-lower and middle-upper middle
income countries.
3. Compare and contrast the health and social experiences of pregnant
adolescents and their partner between Indonesia and other low-lower and
middle-upper middle income countries.
 43

3.3.2.1.3 Methods
Seven steps were: (1) develop a review questions; (2) state a clear aim and
objectives; (3) carry out a comprehensive literature search strategy; (4) screen
results of the search strategy; (5) critically appraise included studies; (6)
synthesise; and (7) asses heterogeneity of study findings (Walsh and Downe,
2005; Petticrew and Roberts, 2006; University of York. NHS Centre for Reviews
and Dissemination., 2009; Gough et al., 2012). The process of the study 1 are
presented in Chapter 4.

3.3.2.2 Study 2: An In-depth study of pregnant Indonesian adolescents

and their partner during the pregnancy
Study 2 explored the experiences of unmarried (at time of conception) pregnant
Indonesian adolescents’ and their partners during pregnancy, adopting an in-
depth approach to explore participants’ experiences, through detailed, in-depth
data collection (Creswell, 2014). Within this research, in-depth study was
employed to gain information about Indonesian adolescents’ experiences who
are experiencing adolescent pregnancy due to premarital sexual relationships
whilst resident in Indonesia. Data were gathered over three different time points:
early contact, mid-point of the expected date of birth and close to the expected
date of birth. These findings were to provide actual and contextual which also
guided interview questions for study 3

3.3.2.3 Aim
Study 2 aimed to explore Indonesian adolescents’ experiences during pregnancy.

3.3.2.4 Objectives
1. Explore the experiences of pregnant, female Indonesian adolescent
residents in Indonesia.
2. Explore the experiences of male Indonesian adolescents who have a
pregnant Indonesian girlfriend whilst resident in Indonesia.
3. Compare and contrast between female and male Indonesian adolescent
experiences whilst resident in Indonesia.
 44

3.3.2.5 Study 3: An In-depth study of health and social experiences of

young parents in Indonesia
Study 3 explored health and social experiences of young parents in Indonesia
during their early parenthood. Interviews were undertaken to gather data guided
by a topic guide which was developed based on the findings of study 1 and 2.

3.3.2.5.1 Aim
The aim of study 3 was to explore health and social experiences of Indonesian
young parents who had had adolescent pregnancies within their first year as a
parent.

3.3.2.5.2 Objectives
1. Explore young mothers’ health and social experiences after the birth of
their baby.
2. Explore young fathers’ health and social experiences after the birth of their
baby.
3. Compare and contrast health and social experiences and life changes of
young Indonesian mothers and fathers.

3.3.3 Methods for study 2 and 3

Research methods refer to the specific technique or procedure used to gather
and analyse data (Silverman, 2006), namely population, sample technique and
sample size, inclusion and exclusion criteria, participants’ recruitment process,
data collection and data analysis. The following sections summarise the methods
used. How the methods of study 2 and 3 were applied are presented in detail in
Chapter 5 for study 2 and in Chapter 6 for study 3.

3.3.3.1 Study population, sample technique and sample size

Study population refers to a study of a group of individuals taken from the
general population (Flick et al., 2007), whilst sample means representatives of
the study population (Creswell, 2014). This study population in this research was
Indonesian adolescents with premarital pregnancy and their partner (for study 2)
and young parents experienced premarital pregnancy (for study 3). As both
studies 2 and 3 were located in the exploratory qualitative research, a non-
probability sampling technique was selected. A non-probability sampling
 45

technique does not involve random selection (Patton, 1990; Sandelowski, 1995;
Trotter, 2012), and it is appropriate for qualitative research which aims to provide
an in-depth understanding of the world, as seen through the eyes of the people
being studied and not to produce a statistically representative sample or draw
statistical inference. Samples size for qualitative studies are generally much
smaller than those used in quantitative studies (Mason, 2010). Ultimately,
qualitative samples are drawn to reflect the purpose and aims of the study
(O'Reilly and Parker, 2013), therefore the sample of study 2 and 3 was planned,
which also considering gender balance and diversity of the participants. Detail of
how sampling techniques were applied can be seen in Chapter 5 for study 2 and
Chapter 6 for study 3.

3.3.3.2 Inclusion and exclusion criteria

Inclusion criteria are defined as characteristics of the potential participants must
have if they are to be included in the study, whilst exclusion criteria are
characteristics that disqualify potential participants from inclusion in the study
(Trotter, 2012; Creswell and Creswell, 2013). Inclusion and exclusion criteria are
essential to be employed to help the researcher find the most suitable candidates
to participate (Denzin and Lincoln, 2000; Creswell et al., 2007). The details of
inclusion and exclusion criteria and how they were applied for study 2 and 3 can
be found in Chapter 5 and 6 respectively.

3.3.3.3 Recruitment
Participant recruitment involves a number of activities, including identifying
eligible participants, adequately explaining the study to the potential participants,
and recruiting an adequate sample based on study aim and design (Yin, 2009;
Smith et al., 2011; Creswell, 2014). Participants’ recruitment is a vital process
which influence to the success of research study (Seed et al., 2009), to be able
to answer research questions. Literature echoed that research which explores a
sensitive topic of people’s experiences found retention or low recruitment rates,
for example research which explored behavioural problems, alcohol abuse,
adolescent pregnancy and cigarette smoking (Faden et al., 2004; Seed et al.,
2009). Therefore strategies to improve participant recruitment were introduced in
study 2 and 3, which can be found in Chapter 5 and 6 respectively.
 46

3.3.3.4 Data collection

Data collection for qualitative research usually involve direct interaction with
individuals on a one-to-one basis or direct interaction with individuals in a group
setting (Flick et al., 2007). The main methods for collecting qualitative data are
individual interviews, focus groups, observations and action research (Jeanfreau
and Jack, 2010; Trotter, 2012). A one-to-one in-depth interview guide was used
for study 2 and 3 as an appropriate way to collect sensitive data and facilitate
participants to freely express their views privately (Morse et al., 2001; Flick et al.,
2007). This technique enabled exploration of the experiences using topic
guidelines and probing questions to explore important points for individuals and
factual situations (Morse, 1992). Since the topic of this PhD research study is
arguably a sensitive topic in an Indonesian context, a one-to-one in-depth
interview was preferred to gathered data rather than group interviews or a focus
group to probe information from participants. In-depth interview also offers the
potential to obtain in-depth data, and facilitated movement from general to
specific issues. It provided an opportunity to engage in a purposeful way with the
participants, gaining their views, perceptions and thoughts, understanding their
interpretations of the health and social context of Indonesian tabooed culture
where pregnancies occurred outside of marriage. As there was a potential that
when discussing their pregnancy and parenting experiences the participants
might be distressed, a protocol for managing distress was developed informed
by Draucker et al. (2009). The following procedures present the protocol for
managing distress. Should a participant become uncomfortable or distressed
whilst discussing their experience, the following actions would be taken by the
interviewer:

1. Stop the discussion or interview and ask if the participants wants to rest.
2. Assess their feelings and thoughts, for example by asking the participant
a question such as ‘Tell me what thoughts you are having? ‘Tell me what
you are feeling right now?’ ‘Do you feel you are able to go on about your
day’ or ‘Do you feel safe?’
3. Review the condition of the participants, if the participant will continue the
interview or they want to complete it later or offering of the rearrangement
of the interview.
 47

4. If the participant wishes this to complete the interview, the interview will be
completed.
5. Time will be spent with the participant and assistance provided, within the
scope of the interviewers abilities, to discuss their concerns and support
them, if appropriate.
6. The participant will be recommended to speak to a midwifery member of
staff to discuss their concerns.
7. A follow-up phone call will be made by the interviewer the following day to
ensure that the participant is alright. During this time, the information
previously provided regarding to the support and will be, once again,
provided.

3.3.3.5 Data analysis

The process of analysis for qualitative research involves uncovering and/ or
understanding the big picture, by using the data to describe the phenomenon and
what this means (Ritchie and Spencer, 1994; Flick et al., 2007). Thematic
analysis for identifying, analysing and reporting patterns in the data was selected
in study 2 and 3. Additionally, thematic analysis provides a flexible research tool
that can potentially provide a rich and detailed, yet complex account of data in
terms of reporting experiences, the reality of participants and meanings (Pope
and Mays, 2006; Clarke and Braun, 2013). Furthermore it can be used to study
which acknowledges the ways individuals make meanings of their experience,
and, in turn, the ways the broader social context impinges on those meanings
(Green and Thorogood, 2009). As this PhD research aimed to explore Indonesian
adolescents’ experiences and data were gained from participants’ words and
views, thematic analysis was deemed appropriate to be used for data analysis.
Detail how data analysis was applied in study 2 and 3 are presented in Chapter
5 for study 2 and Chapter 6 for study 3.

3.4 Ethical consideration

Research ethics refers to moral principles guiding research from its inception
through to completion and publication of results (Oates et al., 2010). Conducting
research with human participants involves interaction between the researcher
and participants. Such a situation may cause problems as it may lead to
 48

undesirable effects for both the researcher and participants such as physical risks
and emotional harm (WHO, 2011b). As this study involved adolescents as
participants, ethical principles for research were considered in order to minimise
any risks of physical and emotional harm.

Ethical issues included the practical processes of seeking ethical approval and
identifying ethical issues for participants i.e. autonomy and informed consent,
confidentiality and anonymity, assessing the risk of harm, and researcher safety
(Homan, 1991; Pope and Mays, 2006; Porter, 2007; Pannucci and Wilkins, 2010).
Autonomy is described as the acknowledgement of the rights of the individuals to
determine their own course of action in accordance with their own wishes and
plans (Forrester, 2010). In this PhD Research, autonomy of the participants was
also considered, which is explained in Chapter 5 for study 2 and Chapter 6 for
study 3.

Informed consent refers to a voluntary agreement to participate in research which

involves a process, in which the subject has an understanding of
the research and its risks (Babbie, 2001; Bryman, 2004). Informed consent is
essential to be obtained before enrolling participants in a particular type of
research, in which also applied in study 2 and study 3. Furthermore,
confidentiality is a core ethical issue in conducting research (Green and
Thorogood, 2009). Confidentiality involves non-disclosure of personal information
and includes the right of privacy throughout the research process (Thomas and
Magilvy, 2011), for example for study 2 and 3 by removing all details of personal
information of research participants in order to maintain confidentiality, privacy
and respect (Thomas and Magilvy, 2011).

An additional aspect of ethical consideration is assessing the risk of harm which

is described as a process of assessment of any potential risk that could harm
both the researcher and participants (Fife, 2005; Creswell, 2014). A further
consideration of ethics is researcher safety. The literature suggests that a
researcher gathering sensitive data in the field has a potential risk of personal
harm and vulnerability to both psychological and physical threat (Punch, 1994;
Oates et al., 2010). In order to minimise such risks, the researcher needed to
considers personal safety and security (Punch, 1994). Therefore a process called
fieldwork risk assessment had done before data collection started. The
 49

researcher also acknowledged of being an adult female interviewer who had to

make conversation with male interviewees. Although, interviews were conducted
in a private room of public health centres and/ or midwifery private services, the
researcher ensure that these places were appropriate to be used since they
enabled both the researcher and participants to feel more secure. For example,
researcher has lone working colleague during the interviews, interviews were
conducted at working hours, and the researcher also explained to participants
that the place for the interview was selected in order to enabled them to seek help
from midwives in the same building at any time they want. The details of how
study 2 and 3 addressed the potential ethical issues will be discussed in Chapter
5 for study 2 and Chapter 6 for study 3.

3.5 Ethical approval, access to the field and participants

Ethical approval should be obtained through ethical review before conducting
research with human participants (Homan, 1991; Oates et al., 2010; Snowden,
2014). As it helps the researcher to consider ethical issues and how to manage
these. Before conducting research, ethical approval from two institutions was
gained i.e. School of Healthcare Research Ethics Committee (SHREC) and
Indonesian Ministry of Health in Yogyakarta Province Level (Appendix A). In
addition, as part of the ethical process, permission was gained from ‘Aisyiyah
University of Yogyakarta where the researcher is a member of academic staff.
The ‘Aisyiyah University of Yogyakarta was a partner institution as the
organisation was supporting, in part, the PhD study by way of providing study
leave.

The role of the partner institution was influential for profiling the study officially
and as a consequence, influenced social acceptability in the research field in an
Indonesian context. A further step recruitment was to secure a research permit
from the local government (Gunungkidul, Yogyakarta) in order to have access to
research fields i.e. a public health centre and a private midwifery clinic.
Furthermore, permission was gained from the Director of the Public Health Centre
and from a midwifery private clinic. The next step was a brief meeting with staff
in both the Public Health Centre and midwifery private clinic as an introduction
and to present and profile the research aims and design. In each location where
 50

recruitment was to take place, the role of staff was explained and agreement
secured, specifically to give information to potential participants and to share
contact details of potential participants who agreed to be contacted. Additionally,
permission to use a private room for interviewing was secured. There was
positive feedback from both the Public Health Centre and midwifery private clinic
in response to the research since it was a first time experience for both institutions
for being a place for any research related to exploring adolescent pregnancies,
particularly for premarital pregnancy including male adolescent participants.

Procedures for recruitment included access to antenatal records to identify

potential participants for study 2 and postnatal records to identify potential
participants for study 3. Details of recruitment strategies is explained in the
methods section of Chapter 5 for study 2 and the methods section of Chapter 6
for study 3. The researcher was able to access antenatal and postnatal records
of potential participants during the period of research as it is a normal practice in
Indonesia for the researcher to access the medical record of the patients when
they have already obtained ethical approval and official permission from the local
government as well as institutions.

3.6 Researcher effect and researcher bias

Researchers are human beings; they could make mistakes or errors during the
research processes (Najendran, 2001), which may cause potential bias of the
research and need to be minimised. For this research, strategies were adopted
from Pannucci and Wilkins (2010), including limiting bias of pre-study, during data
collection and process of analysis and interpretation (Zapor et al., 2008; Monahan
and Fisher, 2010; Smith, 2011).

Pre-study bias may appear before the study commences such as during
developing a research plan (Pannucci and Wilkins, 2010), for example, potential
bias of research design and research methodologies. Such potential bias was
minimised by developing a clear aim, objectives, purpose and methodology,
research design and methods, and by having frequent meetings with the
supervisory team for confirmation and feedback. Furthermore, a literature review
was conducted to justify the research and oral assessment by internal examiners
 51

from the School of Healthcare prior to the field work helped to raise any potential
bias. There was potential for bias during data collection and analysis (Pannucci
and Wilkins, 2010). Research was conducted in a different culture and cultural
language. There was a risk of potential bias in the translations process as
meanings may change and transparency could not be assured. To minimise such
bias, a sample of transcriptions was checked by an Indonesian fellow i.e. from
audio recording to transcript. Detail of how to minimise potential bias in
translations process addressed for study 2 and 3 can be found in Chapter 5 and
6 respectively.

Furthermore, recall bias that may appear in the interview process was also
minimised by interviewing participants during their pregnancy i.e. in obtaining
data in adolescent pregnancy for study 2 which aimed to explore their antenatal
experiences and excluding young parents who have baby over the aged of one
for study 3 which aimed to explore their early parenting experiences. Meanwhile,
bias of analysis of findings was minimised by using an iterative processes to gain
insight and meaningful data as well as to minimise the missed interpretation.
Finally, with regards to bias of findings, although study 1 was qualitative
systematic review, the synthesise of the findings were transparently provided. In
terms of participants’ recruitment, only those whom met with inclusion criteria
were being recruited in order to provide the data for obtaining the aim of this PhD
research. Training about plagiarism and how to paraphrase were completed.
Training of qualitative systematic review was also completed. These strategies
therefore were employed to minimise the bias of findings.

3.7 Positionality
One of the most important features in researching adolescents is positionality,
that refers to a researcher’s social, cultural and subject position that can
potentially have an effect on how they ask the questions to participants, how they
frame themselves and how they engage in relation to participants (Borbasi et al.,
2005; Pechurina, 2014). Different positions was considered as one of issues of
positionality as the researcher as an adult and the interviewees as adolescents.
There was also different age between the researcher and the interviewees.
Researcher as an adult who is a member of academic staff in a university and
 52

the participants were adolescents who were in high school or just had left school
or quit their job due to adolescent pregnancy. Therefore to ensure that
adolescents were able to express their views freely, the researcher
acknowledged these power imbalances, for example by offering a handshake at
the first meeting, wearing simple clothes (e.g. wearing casual clothes instead of
midwifery uniform clothes or work uniform), using daily language in interviews
(Morrow and Richards, 1996) and providing small snacks as well as drinks as
hospitality. As the research was conducted in a public health centre and a
midwifery private clinic, wearing casual clothes assisted differentiation between
the researcher and midwifery staff and arguably put participants at ease enabling
to explore the experiences of adolescents. It was evident that some participants
assumed that the researcher is a religious person as the researcher was wearing
a hijab during interviews, so when some participants talked about religious values
they keep saying ‘you know more about our religion rule’. Although some
participants were very often saying that, the researcher was still be able to
explore their own views by using probe questions.

From the outset the researcher was able to meet and discuss with staff about the
research including explaining the purpose and details of the research process
and data collection in both the public health centre and midwifery private clinic.
Even though the researcher was familiar with the locations and member of staff
as well as having experience of the midwifery practice network before this
research was conducted, the recruitment process was adhered in order to protect
potential participants. Therefore, the researcher did not take for granted or
advantage of any relationships.

3.8 Rigour of the research

Demonstrating the rigour of the qualitative research is important in order to

ensure the quality of the research (Pope and Mays, 2006) and central of the
research processes are trustworthiness and authenticity (Lincoln and Guba,
1985; Merriam and Merriam, 1998). In qualitative research, there are quality
criteria to describe trustworthiness i.e. credibility, transferability, dependability
and confirmability (Lincoln and Guba, 1985). The following table provides an
 53

explanation of how the researcher addressed the rigour of this research, which
presents in table 3-1 adapted from Miles and Huberman (1994) page 277-279.

Table 3-1: Rigour of the research and application within this PhD research
Criterion Concerned with Application
Credibility The extent to  Discussion meeting with the supervisory
(internal which the team to maintain believability.
validity) observer  Used a digital audio voice recorder to
assesses a real produce high quality audio records.
situation  Verbatim transcription processes were
(Merriam and carried out.
Merriam, 1998;  Transcripts were also checked against
Silverman, their recordings to ensure that the
2006). information obtained from participants
were accurately converted.
 Transcripts were translated from Bahasa
Indonesia to English and back
translations were conducted by using a
fellow whom fluent in Bahasa Indonesia
and English, as well as has experiences
in transcriptions and translations of
qualitative interviews.
 Process of analysis also been recorded to
enable the researcher to do an iterative
process of data analysis
Transferability To what extent  Audit trail by documenting detailed
(external the findings account of research process including the
validity) could be applied research setting, methods and
in other justification, and processes of interviews,
situations data analysis and reporting findings.
(Merriam and  Discussion meeting with the supervisory
Merriam, 1998). team to maintain believability.
Dependability Refers to the  Transparent description of the research
(reliability) stability or steps taken from the start of a research
consistency of project to the development and reporting
the inquiry of findings.
processes usage  Used N-Vivo 10 to store and manage the
over time (Mill data. The data were coded and analysis
and Ogilvie, decisions recorded within this software.
2003; Houghton Labels and descriptions of the codes,
et al., 2013). initial grouping of codes and eventual
theme building were recorded. This
essentially provided a central point
through which the research analysis
process can be tracked.
 54

Criterion Concerned with Application

 Regular meeting with supervisory team to
maintain believability.
 Presentation of the quotes provide a
coherent argument that explains the
experiences of Indonesian adolescents
during their pregnancy and their early
parenthood
Confirmability Refers to the  Audit trail by documenting detailed
(objectivity) neutrality and account of research process including the
accuracy of the research setting, methods and
data (Tobin and justification, and processes of interviews,
Begley, 2004). data analysis and reporting findings.
 Keeping a reflective journal.
 Translations and back translations
 Regular meeting with supervisory team to
maintain believability.
 Seminar and workshop presentations to
gain peers feedback.
 The findings were described in detail and
supporting quotes from participants were
used to enable the readers of this report
to ascertain whether the account
presented reflected the participants’
views

3.9 Summary

In this chapter, the research paradigm along with the methodology of the research
were presented. A brief description about research design was outlined and
introductory overviews of study 1, 2 and 3. Moreover, ethical consideration,
ethical approval, researcher effect and researcher bias, positionality, and rigour
of the research were also demonstrated. The following chapter will present a
detailed account of study 1 i.e. a qualitative systematic review of health and social
experiences of pregnant adolescents and their partner in Indonesia and other
low-lower and middle-upper middle.
 55

Chapter 4 : Study 1: Health and Social Experiences of Pregnant

Adolescents and their Partners in Indonesia and Other Low-
lower and Middle-upper Middle Income Countries: A
Qualitative Systematic Review

4.1 Introduction

Chapter 4 reports on study 1, i.e. a qualitative systematic review which aimed to

explore health and social experiences of pregnant adolescents and their partners
in Indonesia and other low-lower and middle-upper middle countries. Within this
chapter, detail will be provided of the review process, covering the aim and
objectives of the review, and review methods including data synthesise and
findings. The qualitative systematic review provided evidence for developing
interview questions for study 2 and 3. The methods describe the process of the
qualitative systematic review, including defining the study question by using a
framework: Population, Event, Outcomes, Study design (PEOS) (University of
York. NHS Centre for Reviews and Dissemination., 2009). A PRISMA flowchart
presents a transparent search strategy. A data extraction table and a critical
appraisal, followed by data synthesis, findings and discussion are presented as
guided. Strength and limitations of study 1 are involved.

4.2 Aim
The aim of this study was to explore health and social experiences of pregnant
adolescents and their partners in Indonesia and other low-lower and middle-
upper middle income countries in order to inform study 2 and 3.

4.3 Objectives
1. Explore and synthesise health and social experiences of pregnant
adolescents and their partners in Indonesia.
2. Explore and synthesise health and social experiences of pregnant
adolescents and their partners in other low-lower and middle-upper middle
income countries.
 56

3. Compare and contrast the health and social experiences of pregnant

adolescents and their partners between Indonesia and other low-lower
and middle-upper middle income countries.

4.4 Methods

Seven steps were adopted to conduct a qualitative systematic review: develop a

review question, state a clear aim and objectives, carry out a comprehensive
literature search strategy, screen results of the search strategy, critically appraise
included studies, synthesise and asses the heterogeneity of study findings
(Walsh and Downe, 2005; Petticrew and Roberts, 2006; Thomas and Harden,
2008; University of York. NHS Centre for Reviews and Dissemination., 2009;
O'Connell and Downe, 2009; Gough et al., 2012).

4.4.1.1 Define the review question

The PEOS framework was adapted from the Centre of Review and Dissemination
(CRD) handbook 2009 version in order to create a meaningful structure to shape
the review. The research question was ‘What are pregnant adolescents’ and their
partners’ health and social experiences in Indonesia and other low-lower and
middle-upper middle countries?

Table 4-1: PEOS framework and inclusion limits

Elements Inclusion Exclusion Rationale

Population Adolescents Pregnancy It is anticipated that women who
(aged 19 or as became pregnant by way of rape
less). consequenc would hold different
es of rape. perspectives, views and
experiences about their
pregnancy such as trauma which
would not be comparable to non-
rape cases.
Event Pregnancy.
Outcomes Experiences, These are key aims of the
perspectives, systematic review.
and views.
Study Qualitative A range of studies may report
Design studies and these outcomes.
studies
 57

Elements Inclusion Exclusion Rationale

reporting
experiences
e.g. surveys.
Inclusion -Papers - These papers were included
limits published in order to provide a
and data reasonable period whereby
collection adolescents’ views could be
between transferable to a current
2004-2014. context1.
- Researcher speaks English
-Papers
and Bahasa Indonesia.
published in
English or
Bahasa
Indonesia.
There is a requirement for the process of selecting papers to be explicit and
conducted in such a way as to in order to improve clarity and transparency of the
systematic review (Petticrew and Roberts, 2006). The selection process of
papers is important in the process of the systematic review because the inclusion
and exclusion of papers determines the scope and credibility of the systematic
review (Meline, 2006). In relation to that, study 1 applied strategies of selecting
the papers.

4.4.1.2 Literature search strategy

The literature search strategy involved a systematic search by using a range of

methods to identify relevant studies, manage the references retrieved by the
searches, obtain documents and write up the search process (University of York.
NHS Centre for Reviews and Dissemination., 2009). The search strategy of this
systematic review included the following sources: professional databases, grey
literature, key local journals, and reference lists (Walsh and Downe, 2005;
Petticrew and Roberts, 2006; Thomas and Harden, 2008; University of York. NHS
Centre for Reviews and Dissemination., 2009).

Professional databases: professional databases were ASSIA, Medline, Maternity

and Infant Care, ScienceDirect, PsycInfo, EMBASE and CINAHL. These
databases were selected because they potentially included literature related to

1 The process of qualitative systematic review was conducted in 2014.

 58

health and social experiences of adolescents. These professional databases

have been used to search electronic sources of published literature including
journal papers, records of ongoing research, conference proceedings and PhD
theses. Meanwhile, non-research based literature were excluded in order to
maintain credibility of the review (University of York. NHS Centre for Reviews and
Dissemination., 2009). Detail of the search strategy can be seen in Appendix B.

Grey literature and specific websites: grey literature was also searched for by
using Google Schoolar and University of Leeds sites, in order to explore relevant
documents. Grey literature was also searched from the websites of international
organisations such as WHO, UNICEF, Alan Guttcmacher and local Non-
Governmental Organisations (NGOs) as well as local Indonesian government
sites such as the Indonesian Ministry of Health, the Indonesian Family Planning
Board.

Key local journals: online hand searching to specify journal index pages was
applied to explore key journals; Asian Pacific Journal of Reproduction, Asian
Nursing Research, Asian Pacific Journal of Public Health, Pacific Rim
International Journal of Nursing Research, KEMAS, and Indonesian Journal of
Public Health. These key local journals were selected as they also, potentially
included journal papers related to health and social experiences of pregnant
adolescents and their partners in Asian countries, particularly in South East Asian
countries including Indonesia.

Selected papers reference list were screened to identify relevant literature by

using Google Scholar (Petticrew and Roberts, 2006; Higgins et al., 2009).
Contacting authors: it is an appropriate part of a search strategy to contact
authors when additional data may be needed (Petticrew and Roberts, 2006). One
of the selected papers did not provide original quotes from participants. Therefore
authors were contacted by email for additional data. However, there was no
response. In order to provide a transparent process of literature searching, a
PRISMA flow chart was adapted to provide an outline of the search strategy that
was had completed. The PRISMA flowchart can be seen in Figure 4-1.
 59

Database searching Records Records identified from Key

yielded 10,130 results identified journals:
with following detail; through
• Asian Pacific Journal of

Identification
websites of
• ASSIA: (n: 418) Reproduction: (n: 1)
Indonesian
• Medline: (n: 886) • Pacific Rim International
government (n:
Journal of Nursing Research
• Maternity and infant 2) and
(n:1)
care: (n:430) International
• Asian Nursing Research: (n: 2)
• ScienceDirect : (n: NGOs (n: 5)
• Asian Pacific Journal of Public
2,835) Health: (n: 5)
• PsycInfo: (n: 1,361) • KEMAS: (n:2)
• EMBASE: (n: 4,115) • Indonesian Journal of Public
• CINAHL: (n:85) Health: (n:3)

5,445 were excluded

Remove duplication using EndNote (n: 6,924) based on title and
abstract.
Screening

Record screened (n: 1,479)

1,452 were excluded as
Low-lower and middle-upper middle income countries: a
they did not meet the
total of 1,479 with following details (ASSIA: 107; Medline:
inclusion criteria.
120; Maternity and Infant Care: 95; ScienceDirect: 321;
PsycInfo: 223; EMBASE: 514 and CINAHL: 85 and Key
journals: 14)

Full-text articles excluded,

with reasons
(n = 18 ), with following
detail:
-Primary data was a mixture
from adolescents and others
(n:8);
Full-text articles assessed for eligibility (n: 29)
-Data collected before 2004
Eligibility

(database search n: 23; website of Indonesian but published in 2004 and

government and NGOs n: 0; Key journals n: 4) (reference after (n: 5);
list n:2) (3 studies conducted in Indonesia) (full text
-Abstract in English but full
accessed and reference list screened by using Google
text reported in different
Scholar)
language (n:4)
- Primary data was not
reported and contacting
authors was resulting no
feedback (n:1)
Included

Studies included in qualitative synthesis

(n = 11 )

Figure 4-1: Search strategies for the systematic review

 60

The combined search strategy from the databases yielded 10,130 results by
using key terms (see Appendix D for search outline). Furthermore, a total of
seven articles were identified from specialist websites i.e.: Indonesian Ministry of
Health, Indonesian Family Planning Board, Alan Guttmacher Institute, UNICEF
and WHO. 14 papers were also identified manually from key journals, i.e.: Asian
Pacific Journal of Reproduction, Asian Nursing Research, Pacific Rim
International Journal of Nursing Research, Asian Pacific Journal of Public Health,
KEMAS and Indonesian Journal of Public Health. All identified papers have been
imported and stored in Endnote and then the process of removing all the duplicate
references resulted 6,924 papers. At this stage this appeared to be a very
sensitive searching process. The next stage was to undertake manual screening.
Manual screening was employed by reading the title and abstract in order to
select research conducted in low-lower and middle-upper middle income
countries and the process resulted in 1,479 papers. A manual screening was
needed because when potential papers were searched using the World Bank
Classification list of low-lower and middle-upper middle income countries (see
Appendix C) as key terms, a large number of papers were missed as they were
not indexed using those keywords. Hence, the coverage was poor. Therefore,
manual screening was applied by reading the title and abstract in order to select
papers from low-lower and middle-upper middle income countries. All potential
papers were screened by their title and abstract for a second time in order to
double check for any missed data. In this process, a screen tool was also
employed. Following the application of the inclusion and exclusion criteria, 29
papers were selected based on their title and abstract, of these 3 papers were
conducted in Indonesia.

The second phase of selecting papers was accessing the full text of the 29
included papers. A pre-screening tool was utilised and the reading of 29 included
papers was conducted, and example of pre-screening tool used can be seen in
Appendix D. Following the process of reading of the full text of 29 selected
papers, 18 papers were discarded because data was a mixture of adolescents
and others i.e. healthcare providers (n: 3), parents and family (n: 3), teachers
religious leaders and community (n: 2), therefore data cannot be identified
whether from adolescents or others. Data collected before 2004 but published
 61

after 2004 (n: 5), paper abstract was in English but full text reported in another
language (n:4) and the paper did not provide quotes (n:1), whilst contacting the
author received no responses. The 18 papers that were discarded from the
process were used for the background of this PhD thesis. The reference lists of
29 papers were also screened manually and relevant papers’ titles screened
which resulted in two additional papers. Finally, the nine remaining papers were
included and two additional papers from the reference list were selected. A total
11 papers were extracted and assessed for quality assessment, including 9
journals papers and two conference papers.

4.4.1.3 Result of search and study selection

It became apparent that several selected papers were indexed in more than 1
professional databases. The table 4-2 explains where papers were indexed.

Table 4-2: Included studies and indexed sources

Title/ Author/ Year Indexed sources

Relationships, perceptions and the socio-cultural ScienceDirect
environment of pregnant teenagers in Soshanguve
Secondary School/ (Maholo et al., 2009)
Experiences of pregnancy and motherhood among ASSIA, ScienceDirect
teenage mothers in a suburb of Accra Ghana: a
qualitative study/ (Gyesaw and Ankomah, 2013)
Psychological Health and Life Experiences of ScienceDirect, PsycInfo
Pregnant Adolescent Mothers in Jamaica/ (Wilson-
Mitchell et al., 2014)
Northeastern Thai Adolescents’ Perceptions of Key journal: Pacific Rim
Being Unmarried and Pregnant/ (Muangpin et al., International Journal of
2010) Nursing Research
Lived experiences of early pregnancy among Reference list from a
teenagers: A phenomenological study/ (Pogoy et paper: The Scholastic
al., 2014b) Performance of
Adolescent Pregnant
Learners (Mutshaeni et
al., 2014)
One foot wet and one foot dry: transition into ASSIA, Maternity and
motherhood among married adolescent women in Infant Care,
rural Vietnam/ (Klingberg-Allvin et al., 2008) ScienceDiret, Medline,
CINAHL
 62

Title/ Author/ Year Indexed sources

Becoming a mother: teenage mothers’ experience Medline
of first pregnancy (Maputle, 2006)
Experiences of teenage pregnancy among Xhosa ASSIA, Maternity and
families in South Africa/ (Sindiwe James et al., Infant Care,
2012) ScienceDiret, Medline,
CINAHL
Existential phenomenology as a possibly to Reference list from a
understand pregnancy experiences teenagers/ paper: Conflicts
(Jorge et al., 2006) experienced by female
adolescents with the
discovery of pregnancy
(Moreira et al., 2008)
A descriptive study of the reasons and Medline
consequences of pregnancy among single
adolescent mothers in Lesotho (Yako and Yako,
2007)
Pregnancy stigmatization and coping strategies of CINAHL
adolescent mothers in two Yoruba Communities,
South-western Nigeria/ (Melvin et al., 2009)
Adolescent pregnancies in the Amazon Basin of CINAHL
Ecuador: A right and gender approach to girls’
sexual and reproductive health/ (Goicolea, 2009)
Table 4-2 shows the data that the most frequent database that indexed the
included papers was ScienceDirect, which indexed five papers. CINAHL indexed
four papers, ASSIA and Medline indexed three papers each, Maternity and Infant
Care and the reference list indexed 2 papers each, PsycInfo and Key journals
indexed a paper each. EMBASE database did not index any of included papers.
ScienceDirect indexed the highest number of selected papers because this
database focuses a health and social sciences which was compatible with the
aim of this qualitative systematic review. It is acknowledged that a possible
limitation of every systematic review is a potential that relevant studies could have
been missed (London, 2014). However, combining multiple sources had been
completed to minimise such potentially missing studies (Viswanathan et al.,
2012). The pre-screening tool was useful to clarify whether papers should be
included, kept for background in the study or rejected (University of York. NHS
Centre for Reviews and Dissemination., 2009). The tool provided a clear inclusion
and exclusion criteria with a PEOS framework. Application of the tool enabled
consistency.
 63

4.4.1.4 Data extraction

Data extraction was the process by which researchers obtain the necessary
information about study characteristics and findings from the included papers
(Thomas and Harden, 2008; Elamin et al., 2009). Standardised data extraction
formed from Munro et al (2007) quoted from Higgins et al. (2009) was employed
to quote data. (Sample of data extraction can be seen in Appendix E). Data
extraction was used to enhance consistency in this systematic review and
potentially to reduce reviewer bias (University of York. NHS Centre for Reviews
and Dissemination., 2009). Whilst, the main characteristics of included papers
can be seen in Table 4-3.
 64

Table 4-3: Main characteristics of the included papers

No Title/ Author/ Country Aim Type of Data Collection Participants/ Findings

Year Research Sample Size
1 Relationships, South To determine A qualitative Semi-structured interview 30 Teenagers lacked knowledge about
perceptions and Africa teenagers’ exploratory with specific themes to adolescent menarche and menstruation, leaving
the socio- patterns of study. explored and audio mothers them unprepared for their
cultural relationships, recorded. The one to one pregnancy. Participants did not
environment of perceptions interviews were in a realise the consequences of their
pregnant towards their private room at the love and sexual relationships.
teenagers in pregnancy Primary Healthcare Clinic. Circumstances around their lives
Soshanguve and lives and There is no specific and the socio-cultural environments
Secondary describe the information related to the contributed to their pregnancy,
School/ (Maholo role of their duration of the interviews. resulting in teenagers showing
et al., 2009) socio-cultural There is inclusion of regret, shame, denial and some
environments criteria to be participants. accepting their pregnancy.
in their However, the author did Communication about sexuality was
pregnancies. not mention how they lacking and teenagers had no risk
were selected and why perceptions regarding their
they were selected. Author pregnancy.
also did not explain how
many participants were
excluded and criteria for
exclusion.
The role of the author was
as a main researcher.
Recruitment process was
not in detail explained by
author as well as how the
 65

No Title/ Author/ Country Aim Type of Data Collection Participants/ Findings

Year Research Sample Size
participants were
approached. There is no
information related
participants’ withdraw’.
2 Experiences of Ghana To explore A qualitative Focus group discussions 54 Some of the participants became
pregnancy and experiences exploratory (FGD) consisted of 6-9 adolescent pregnant as a result of transactional
motherhood of adolescent study. participants each group for mothers sex in order to meet their basic
among teenage mothers about an hour and were needs. A few others wanted to
mothers in a during audio recorded. A become pregnant to command
suburb of Accra pregnancy, moderator was a nurse respect from people in society. In
Ghana: a childbirth and who previously had nearly all cases, parents and
qualitative study/ care of their experience of working with guardians of the adolescent mothers
(Gyesaw and new-borns. adolescents and a note were upset in the initial stages when
Ankomah, 2013) taker was also employed they heard the news of the
in every session of FGD. pregnancy. One key finding, quite
Six respondents were different from in other societies, was
recruited from the health how often teenage pregnancies were
facility during special clinic eventually accepted, by both the
days set aside for young women and their families.
mothers, whilst three Also observed was a rarity of
respondents were willingness to resort to induced
recruited from the abortion.
community to reflect
mothers who do not have
access to health facilities.
An interview guide, based
on topics similar to the
FGDs, was used to
 66

No Title/ Author/ Country Aim Type of Data Collection Participants/ Findings

Year Research Sample Size
conduct the in depth
interviews. There is no
specific information related
to participants withdrawn.
3 Psychological Jamaica To explore Mixed method Semi structured interview 30 pregnant The following themes were
Health and Life the study. and focus group adolescents identified: decision-making,
Experiences of experiences discussions in order to resilience, social support, community
Pregnant and the explore psychosocial support system, distress, and
Adolescent impact of outcome of adolescent perceptions of service. Participants
Mothers in pregnancy on pregnancy. Interview reported positively on the specific
Jamaica/ pregnant appointments were made interventions tailored to their needs
(Wilson-Mitchell adolescent immediately prior to or at the Teen Clinic. Although
et al., 2014) psychological following regularly motherhood is valued, none of the
health. scheduled clinic visits so pregnancies in this study were
as not to be disruptive. planned by the mother.
Participants were free to
decline an answer, to stop
or to leave individual or
focus group interviews at
any time if there was a
feeling of discomfort with
the process or questions.
Audio recording of
interviews and group
discussion was optional.
All of the participants
recruited for the study
consented to audio
 67

No Title/ Author/ Country Aim Type of Data Collection Participants/ Findings

Year Research Sample Size
recording. One of the
respondents declined
audio recording and was
excluded from interviews.
None of the participants
requested an early exit
from interviews or focus
groups
4 Northeastern Thailand To glean Descriptive Each participant was 16 unmarried Results revealed “Being Devalued”
Thai further qualitative interviewed 2 – 4 times, pregnant and “Ending Adolescent Life” were
Adolescents’ understandin study for 60 - 90 minutes each adolescents the thematic meanings of being an
Perceptions of g of the time, in an attempt to unmarried pregnant adolescent.
Being Unmarried meaning of gather rich information “Being Devalued” was the
and Pregnant/ being an regarding being an adolescents’ perception that they
(Muangpin et al., unmarried unmarried pregnant were seen as a “bad girl” and had
2010) pregnant adolescent. Field notes lost their sense of self-worth.
adolescent in and reflective journal “Ending Adolescent Life” was the
northeastern comments were written adolescents’ perceptions that their
Thailand. after each interview, and adolescence ended because of:
used as supplementary being isolated from their peers;
data in interpreting the being unable to engage in teen
information and context in activities; and, dropping out of
which it was obtained. school.
Interviews were located in
a private room of antenatal
care clinics, audio
recorder and the author is
the primary researcher for
 68

No Title/ Author/ Country Aim Type of Data Collection Participants/ Findings

Year Research Sample Size
data collection. Eighteen
of 28 unmarried pregnant
adolescents approached
were deemed eligible to
participate. However, two
were excluded because
their parents did not give
verbal consent for them to
participate. Consequently,
16 unmarried pregnant
adolescents who were 13
to 17 years of age and had
a gestational age of 32 to
36 weeks participated.
These participants were
purposively selected from
antenatal care clinics from
their antenatal visiting
appointment and primary
researcher (author)
contact nursing staff to
make name list of potential
participants with their
details. After have list of
name primary researcher
contact adolescents
directly.
 69

No Title/ Author/ Country Aim Type of Data Collection Participants/ Findings

Year Research Sample Size
5 Lived Philippin To determine Phenomenolog Interviews were conducted 10 Results show that curiosity, lack of
experiences of es the lived ical study by the researcher in the adolescent sexual knowledge, financial and
early pregnancy experiences houses’ of participants. mothers family problems and uncontrolled
among of early There is no information emotions led to sexual activity and
teenagers: A pregnancy related to participants’ pregnancy among teenagers.
phenomenologic among high recruitment, access to the Teenage mothers faced a lot of
al study/ (Pogoy and low fieldwork, participants challenges after pregnancy like
et al., 2014b) performing withdrawn as well as the providing proper care and needs of
students in duration of interview. their child. High performing teenage
terms of the Author also did not provide mothers were at college levels and
causes, duration of interview. work for a living to support the needs
effects, of their child. Low performing
challenges teenage mothers ended up as
and their housewives. Teenage mothers have
coping fewer opportunities to finish their
mechanisms. studies after engaging in early
pregnancy. Taking care of the baby
and providing financial assistance
were challenges they encountered
and tried to cope with. The academic
performance, the financial status and
support of the family of teenage
mothers determine if they can
pursue their studies and achieve
their dreams in life.
 70

No Title/ Author/ Country Aim Type of Data Collection Participants/ Findings

Year Research Sample Size
6 One foot wet Vietnam To explore Qualitative Open-ended qualitative 22 It emerged from the narratives that
and one foot dry: married study interviews, were applied. A adolescent young women experienced
transition into Vietnamese semi structured guideline mothers ambivalence in the transition to
motherhood adolescents’ was employed in the motherhood in that they felt too
among married perceptions interview process. The young but also happy to be able to
adolescent and interviews lasted between please their husband and the
women in rural experiences 45 and 90 minutes extended family. Patterns were
Vietnam/ related to Participants were recruited shown indicating that the participants
(Klingberg-Allvin transition into from 3 of the 25 experienced little power with regard
et al., 2008) motherhood communes in the district. to decisions in relation to pregnancy,
and their Women were selected delivery, and contraceptive usage.
encounter from lists provided by the Feelings of being patronized and
with staff at the CHC in each ignored in the encounter with
healthcare commune. There was no healthcare providers were seen in
service. information related to the narratives.
venue of interview, and
participants’ withdrawn as
well as access to field
work.
7 Becoming a South To explore Qualitative Unstructured in depth 14 Five themes emerged from studies
mother: teenage Africa and describe study interviews by using open adolescent i.e. inadequate information/
mothers’ the ended questions, all the mothers knowledge, unplanned/planned
experience of experiences interviews were recorded pregnancy, ineffective
first pregnancy of adolescent and notes had also been communication, under-utilisation of
(Maputle, 2006) mothers of taken during interview health resources and adequate/
first process. Participants inadequate social support.
pregnancy identified from antenatal
and to visits of clinics in
 71

No Title/ Author/ Country Aim Type of Data Collection Participants/ Findings

Year Research Sample Size
develop Capricorn District,
guidelines of Limpopo Province.
a support Fourteen (14) teenage
programme mothers who were
that is pregnant for the first time
contextual were purposively selected.
and relevant There is no information
to the needs related to duration of
of adolescent interview, place of
mothers. interview, and
participants’ withdrawn.
Author also did not explain
how many participants
were excluded and criteria
for exclusion.
8 Experiences of South To explore Qualitative Data were collected by 10 Pregnant adolescents experienced
teenage Africa and describe study means of audio-taped, adolescents overwhelming emotions, breakdown
pregnancy the one-on-one, semi- who had in relationships with parents, families
among Xhosa experiences structured interviews and experienced and peers but had positive
families in South of teenage by taking field notes. Most premarital relationship with their boyfriend.
Africa/ (Sindiwe pregnancy participants chose to have pregnancies,
Parents of adolescents who had
James et al., among the interviews at home but 10 parents
premarital pregnancy experienced
2012) Xhosa on different days. The and 10
their children’s pregnancy as
families. researcher asked to use grandparents
disappointing, embarrassing and
an outside room with a of
failures in their parental role.
closing door to conduct adolescents
the interviews. If no who Grandparents of adolescents who
outside room was experienced had premarital pregnancy
 72

No Title/ Author/ Country Aim Type of Data Collection Participants/ Findings

Year Research Sample Size
available, any other room premarital experienced that the pregnancy as a
in the house with a closing pregnancies. family disturbance and
door was used. Pregnant acknowledged that healing should
teenagers were identified take place in the family.
from antenatal care clinic
registers. There is no
information related to
duration of interview, and
participants’ withdrawn.
9 Existential Brazil To Phenomenolog An In-depth interview was 4 pregnant Pregnant adolescents have 3 steps
phenomenology understand y study conducted on the day adolescents regarding their pregnancy.
as a possibly to the meaning when they had ANC visit
-Being there: discovery of pregnancy
understand of pregnancy appointment. Four female
was surprised, contradictory feeling,
pregnancy for pregnant pregnant adolescents
wanted to flee from pregnancy.
experiences adolescents, identified from antenatal
teenagers/ trying to care visits record and -Being in the world: lack supports,
(Jorge et al., capture their further they contacted and shameful and being alone.
2006) way of being were invited to participate. -Being with the others: fear with
and new There is no exclusion delivery, trying to gain supports from
being in the criteria for this study. partners and parents.
world as a There is no information
pregnant girl. related to duration of
interview, place of
interview, as well as
participants’ withdrawn.
There is no information
related where interview
held , author’s role and
 73

No Title/ Author/ Country Aim Type of Data Collection Participants/ Findings

Year Research Sample Size
there is no information
related whether the
interview recorded or not,
other sources such as field
notes were considered or
not.
10 Pregnancy Nigeria To Phenomenolog In-depth interviews were 48 pregnant Findings showed that adolescents’
stigmatization understand y study conducted with adolescent adolescents sexual debut was through coercion
and coping how mothers who had with later sexual life. Pregnant
strategies of adolescent unintended pregnancies. adolescents were stigmatised by
adolescent mothers cope All interviews were held in fellow adolescents, neighbours and
mothers in two with this type preferred locations their significant others. Prior to their
Yoruba of pregnancy suggested by the delivery, almost all of the
Communities, participants. adolescent adolescents attempted abortion but
South-western mothers in two selected failed. There were gender biases
Nigeria/ (Melvin Yoruba communities. The blames on the adolescent mothers;
et al., 2009) inclusion criteria was the little or no antenatal care was sought
presence of one or more from the hospitals. Were such
adolescents’ mothers attempts were made; faith healers
between the ages of 12 and traditional birth attendants were
and 21 who had most preferred. Adolescent mothers
unintended pregnancy and were able to destigmatised their
a 13 life birth within the pregnancy through religious and
last 3 years preceding this personal resolutions coupled with
study in a household. informal support from their mothers
There is no information and a few significant others.
related to duration of
 74

No Title/ Author/ Country Aim Type of Data Collection Participants/ Findings

Year Research Sample Size
interview, and participants’
withdrawn.

11 Adolescent Ecuador To explore Qualitative In depth interviews were 11 Girls´ decision making regarding
pregnancies in experiences study conducted. There is no adolescent sexuality was limited by the need for
the Amazon and emotions information related to girls either secrecy, misinformation, and gender
Basin of around duration of interview, pregnant or structures that reinforced girls’
Ecuador: A right pregnancy participants’ recruitment, already subordination. Pregnancy was
and gender and as well as participants’ mothers conceptualised as stressful whilst
approach to motherhood withdrawn. Author also did motherhood had positive
girls’ sexual and among not provide access of connotations alongside personal
reproductive adolescent research field. sacrifices, and increased
health/ girls, using responsibility with little support from
(Goicolea, 2009) content partners or welfare policies and
analysis. programs. A mechanism of
resistance emerged from girls’
defiance of external criticisms and
from girls’ interest in continuing
education as a means for economic
independence.
 75

4.4.1.5 Appraisal of the quality of included papers

Critical appraisal is an important part of systematic review to assess quality of

included papers in order to evaluate papers’ strength and weaknesses (University
of York. NHS Centre for Reviews and Dissemination., 2009). In this systematic
review, appraising the quality of papers also has been conducted before the
synthesise of the data. A tool called Critical Appraisal Skill Programme (CASP)
for qualitative study (See in Appendix F) was applied to assess the
trustworthiness of a range of qualitative studies (Burls, 2006). Furthermore, the
overall quality of papers was assessed using an approach modified from CASP
and McInnes and Chambers (2008). 11 included papers have been appraised
with 10 screening questions of CASP and the following grades were used:

4: When any hint questions can be answered specifically.

3: When any hint questions can be answered but are not specifically mentioned.

2: When there is information provided but there are also some of hint questions
that cannot be answered.

1: When there is little information provided;

0: When there is no information provided of any hint questions.

Furthermore, the grades adapted from (McDermott et al., 2004) were used to
judge the included papers into four criteria i.e.:

A: scored 31 and above;

B: scored (21-30);

C: scored (11-20);

D: scored (bellow 10)

The table 4-4 presents the grading process of appraising the included papers.
 76

Table 4-4: Grading process for appraising the included papers

Study 1 2 3 4 5 6 7 8 9 10 11
Clear aim and 4 3 3 3 3 3 4 4 4 3 3
objectives
Appropriateness 3 3 3 3 3 4 3 4 4 2 2
of methodology
Research design 3 3 3 3 3 4 3 4 4 2 2
Recruitment 2 3 3 3 2 3 3 3 2 3 1
Data collection 3 2 2 3 2 3 2 3 2 3 1
Relationships 0 4 0 0 0 0 0 0 0 0 0
between
researcher and
participants
Ethical issues 4 4 1 4 1 4 1 1 4 1 1
consideration
Data analysis 4 4 2 4 3 4 3 4 1 4 1
Finding and 3 3 3 1 3 4 3 4 3 4 2
reporting
Research value 2 3 4 4 1 3 4 3 3 1 4
Total 28 32 24 28 21 32 26 30 28 23 17
Overall B A B B B A B A B B C
10 of the included papers [1,2,4,5,6,7,8,9,10and 11] were qualitative studies and
only one article [3] was a mixed method study. The following sections critically
appraises the included papers based on item criteria and hint questions adapted
from CASP.

a. Aim and objectives of the research

Aim and objectives of the research need to state the overall purpose of the
papers; they should be clearly and concisely defined (Bryman, 2001;
Burls, 2006). All the papers [1,2,3,4,5,6,7,8,9,10,11] stated a clear aim of
their research. However, only four papers [1,7,8,9] implicitly mentioned
objectives and the relevancy between aim, objectives and outcome. A
clear desired outcome of the research is an important aspect on defining
the objectives of the study (Chalmers and Altman, 1995). Burls (2006)
suggested that appraising the aim and objectives of included papers such
an omission threatens of the trustworthiness of the included papers.
Therefore in this quality appraisal of included papers, they were only
 77

scored 4 when they clearly mentioned aim and objectives of the study, in
which could addressed all the hint questions of CASP in regards to the aim
and objectives section.
b. Appropriateness of methodology
There were clear statements of the type of methodological approach in
every included papers. All included papers also attempted to determine
[1,5,9] understand [2,3,6,7,8] or explore [4,10] research participants’

experiences. However, only papers [6,8,9] explained and defended why

the methodology was selected. Reporting on how the author addressed
the aim of the research by using specific methodology was indicates
whether the methodology suited or not with the aim (Mulrow and Cook,
1998; Higgins et al., 2009; Gough et al., 2012), therefore researcher
should provide justification on selecting methodology. This CASP
appraising list assisted the researcher to judge the papers as they
provided hint questions, including whether selected methodology was
appropriated to reached the aim of the research.
c. Appropriateness of research design
The research design of the research have been clearly mentioned in
papers [1,2,3,4,5,6,7,8,9,11]. However, only two papers [6,8,9] with give a
sense of why and how the research designs have been employed. An
explanation of research design is necessary to be assessed in order to
gain an understanding if the research design addressed the aim and
objectives or whether it meets with the research outcome or not (Creswell,
2014). Research design is an important aspect in the research process
because it carries an important influence on the trustworthiness of the
findings (Jeanfreau and Jack, 2010; Creswell, 2014). It needs to be
highlighted that paper 10 had lack information related to research design,
therefore it made lack of clarity and transparency of how the research
design selected and implemented.
d. Recruitment
There were papers which explained in detail the recruitment selection
process, particularly providing research information when approaching
potential participants [1,2,3,4,6,8,9] and by providing explicit inclusion and
 78

exclusion criteria [3,4,5,6,8,10]. The transparency of the process of

researching participants’ recruitment can be assessed by providing
detailed description of participants’ recruitment and selection process
including inclusion and exclusion criteria, in which assures ethical
processes and indicates trustworthiness (Chalmers and Altman, 1995;
Dixon-Woods et al., 2007). There were five papers [4,6,7,8,10] explaining
the number of participants excluded from the research study. Ten papers
used a purposive sampling technique [1,2,3,4,5,7,8,9,10,11] and study [6]
used a convenience sampling technique, in which appropriate to be used
for qualitative research (Trotter, 2012; Marshall et al., 2013). A flaw was
found from study [11] as the research included participants with three
years after they experienced adolescent pregnancy, therefore risks of
recall bias were considered as high. Recall bias represents a major threat
to the credibility of studies using self-reported data (Hassan, 2005).
e. Data collection
All papers describe specific methods of data collection; the majority used
in-depth interview [1,3,4,5,6,7,8,9] and a few used focus group
discussions [2,3,10]. Eight papers [1,2,3,4,5,6,8,9] provided detail
explanations of interview process i.e. employing audio recording, taking
field notes after the interview was completed and putting memos for
specific information. Not all papers made reference to the interview setting.
Five papers provided this information; interviews were conducted in a
private room of health centres [1,2,3,4,5] and in participants’ house [8],
participants’ preference [10], other papers did not [6,9,11]. There are no
included papers which discussed about reason for choosing methods of
data collection. Data collection is an important aspect to be appraised
because it involves activities of securing the information needed from
participants as well as how the researcher maintain participants’ and
researcher’s safety Therefore, how transparently the author explains the
process of data collection will affect the credibility of the research papers
(Jeanfreau and Jack, 2010).
 79

f. Relationships between researcher and participants

In terms of relationships between the researcher and participants, paper
[2] was the only study that explicitly explained the author’s role, potential
bias and influence during the research process i.e. formulation of research
question, choice of location and sample recruitment. Such transparent
methods of reporting qualitative research help to minimise the subjectivity
of the researcher (Burls, 2006). However, unusually all participants
identified had agreed to be included in the paper 2 which suggests an
influence of a research assistant whom also a midwife for recruiting
participants. Relationships may affect the context and content the inquiry,
and equally by the institutional context in which the studies are carried out
as well as the researcher and participants’ personal motivations (Karnieli-
Miller et al., 2009). For paper 2, there was a potential relationship effect
although difficult to judge if coercion occurred. Apart from some reporting
form, paper 2, one of the included papers provided sufficient evidence of
these aspect of the research. Therefore only paper 2 scored 4, whilst
others have 0 score.
g. Ethical issues consideration
There were sufficient details of how ethical standards were maintained in
most papers [1,2,3,4,6,7,8,9,10,11] by gaining consent before interviews
[1,2,4,6,7,8,9,10,11], explaining anonymity [1,2,4,6,7,8,9,10] and
confidentiality [1,2,3,4,6,7,8,9,10] and participants’ right to withdraw
[1,2,4,6,7,8,9,10]. Most of the studies of included papers have gained
ethical approval from ethical board institutions [1,2,4,6,8,9,11]. Whilst,
other papers [3,5,7,10] instead of gaining ethical approval they gained
official permission from their local governments which seemed to be a local
requirement. It appeared that ethical considerations were met for local
requirements in order to assure the reader that included participants were
not harmed, privacy was maintained, and participants provided informed
consent , therefore participants were participating voluntarily without any
coercion (Jeanfreau and Jack, 2010; JBI, 2014). It is evident that there
were variation of how the ethical issues considerations were maintained
 80

by the author and only 5 papers which explained comprehensively on how

the ethical issues were addressed within research process.
h. Data analysis
Six of the included papers [1,2,4,6,8,10] provided in depth description of
the analysis, presenting clear categories, themes derived from data,
demonstrating analysis data, and independent coder usage as well as
original data. Four included papers [3,5,7,9] did not provide adequate
information of how data were analysed. Therefore, assessing credibility of
data analysis was unclear. For example, how the researcher considered
any framework used to analyse the data, if there is any software for data
management, if transcriptions were translated into English as the data
collection was conducted in their home language. Research papers should
be able to demonstrate a clear account of how early, simple systems of
categories evolved into more sophisticated coding structures and finally
into defined concepts for the data (Jeanfreau and Jack, 2010). Judging
analysis process in a systematic review process is important in order to
maintain rigour of the findings (Mulrow and Cook, 1998; Petticrew and
Roberts, 2006).
i. Finding and reporting
Trustworthiness of study is one dimension to be considered when
assessing studies as it influences credibility, dependability, transferability
and confirmability (Petticrew and Roberts, 2006; Porter, 2007). All papers
[1,2,3,4,5,6,7,8,9,10,11] have discussion findings and are supported by
original data i.e. participants’ quotations. Evidence shows that participants’
quotes from interviews are effective to demonstrate how the discussion,
conclusion and recommendations related to verbal data were conducted
by the researcher during the process of research (Wilson et al., 2010;
Goldblatt et al., 2011). This enables other researchers to assess how
comprehensive the report is and how data has been produced, analysed
and concluded (Booth and University of Sheffield. School of Health and
Related Research., 1997; Dixon-Woods et al., 2007). Stating how to
maintain the trustworthiness of research is also presented in papers
[1,2,3,5,6,7,8,9,10]. However, these papers do not address in detail why
 81

they selected and employed the methods. Furthermore, paper [4,11] had
not clearly pointing trustworthiness as there was no further explanations
on how and why trustworthiness has been addressed. Therefore, compare
to other papers, those two papers gained less scores.
j. Research value
Papers [1,3,4,6,8,9,10] clearly describe information related to how the
findings can be valuable, specific further research needed and how to
transfer the findings. Meanwhile, papers [2,5,7,11]have no explanation
about specific further research needed and recommendation for policy or
public. Research value is how qualitative research impacts on a particular
groups of people and it is should be demonstrated by the researcher
explicitly including whether they provide knowledge, facts, understanding,
identified new area and where further research may be necessary and how
the findings can be transferred to other populations (Burls, 2006). In
regards to that, within appraisal process research value explanation was
one of the component which have to be judged in order to improve
transferability of the research (Pechurina, 2014).

4.4.1.5.1 Result of critical appraisal

The quality assessment resulted in papers with the following different

grades: A:3; B: 7; C: 1 D: 0). Paper number 11 was rejected from data
synthesis because it has a C grade. Such rejection was applied in order to
maintain the credibility and trustworthiness of the systematic review.
Finally, the number of included papers was 10 papers.

4.5 Data synthesis

The process of qualitative systematic review resulted in 10 papers included for

data synthesis. The research was conducted from different parts of low-lower and
middle-upper middle income countries including South Africa, Ghana, Jamaica,
Thailand, the Philippines, Vietnam, and Brazil. All included papers recruited
female adolescents. There were two types of participants which were pregnant
adolescents and adolescent mothers who have children, included both married
and unmarried participants. It is evident that there were no included papers
 82

conducted in Indonesia which met inclusion criteria and no male adolescents

were recruited in the included papers. As a consequence, specific health and
social experiences of pregnant adolescents in Indonesia and male adolescents’
health and social experiences cannot be explored. However, a systematic
process was maintained in undertaking synthesise of the included papers to
explore health and social experiences of pregnant adolescents in low-lower and
middle-upper middle income countries in order to provide information that was
beneficial on developing research questions of study 2 and 3 as well as
discussion for overall.

In terms of data synthesis a thematic synthesis adapted from Thomas and

Harden (2008) was used because it provided practical guide which assisted the
researcher to synthesise. There were three stages of synthesise process (see
Table 4-5). During the first phase, each line of text was coded, before comparing
initial codes and then continuing with the second phase which was organising
free codes into descriptive themes. After that, the third phase was employed
which was the development of analytical themes. A chart adapted from (Ritchie
and Spencer, 1994; Ritchie, 1999) was used during this process. Example of
coding, organising and development of analytical themes can be seen in
Appendix H.

Table 4-5: Phases of thematic synthesis adapted from Thomas and Harden
(2008)

Phase Process Involved

Free line by a. The findings section from each study was entered
line coding verbatim into word document.
findings. b. Descriptive code was created inductively to capture
meaning and content of each sentences.
c. Translation of concept from one study to another and
initial synthesis of study findings.
Organising a. All texts allocated a code were examined.
free codes b. Similarities and differences between codes were
into identified and grouped.
descriptive
themes
Development a. The descriptive themes from phase 2 were used to
of analytical answer the questions of systematic review.
themes b. Each themes that emerged was compared to previous
themes.
 83

4.6 Findings

The original review question was ‘What are pregnant adolescents’ and their
partners’ health and social experiences in Indonesia and other low-lower and
middle-upper middle income countries?’ The aim of the qualitative systematic
review was to explore health and social experiences of pregnant adolescents and
their partner in Indonesia and other low-lower and middle-upper middle. Findings
report a qualitative synthesise of health and social experiences of pregnant and
recently pregnant adolescents in low-lower and middle-upper middle income
countries. Four themes emerged from data synthesis of 10 included papers i.e.;
‘I am pregnant’; ‘Support;, ‘Consequences of adolescent pregnancy’, and
‘Experiences after the birth of the baby’. The ‘I am pregnant’ theme describes the
adolescents’ experiences on their period of discovering pregnancy. Some of
adolescents were experiencing shocked as it was unplanned but some of them
expressed that they wanted the baby. The experience of conception, pregnancy
and physiological changing are also discussed in this I am pregnant theme, as
well as their experience about intention to preserve or terminate their pregnancy.
During their pregnancy, adolescents also acquired ‘Support’ which described in
‘Support’ theme. Additionally, adolescents also experienced consequences of
their pregnancy which is presented under the ‘Consequences of the adolescent
pregnancy’. The ‘After the birth of the baby’ theme presents adolescents’
experience on their period when the baby is born and after the birth. The Figure
4-2 outlined the themes emerged from qualitative systematic review.
 84

1. I am Pregnant
- Unplanned pregnancy
-I wanted a baby
-Conception, pregnancy and
physiological changing
-Preserve or terminate
pregnancy
2. Support
4. After the birth of -Parents
the baby -Partner/ husband
-Experiences during -Wider family members
labour and when baby Experiences
-Community and
is born religious leaders
-Resilience -Healthcare providers

3. Consequences of the Adolescent Pregnancy

-Stigmatisation and shame
-Education and work
-Symptoms of complications
-Distress and regret
-Lack of confidence to be young mother

Figure 4-2: Themes and subthemes of study 1

4.6.1 Theme 1: I am Pregnant

Within this theme, the experiences of pregnant adolescents from the onset of
becoming aware of their pregnancy are presented. There are four sub-themes,
led by ‘Unplanned pregnancy’ which describes experiences of some pregnant
adolescents about their unplanned pregnancy, whilst ‘I wanted a baby’ sub-theme
explained experiences of some pregnant adolescents about their desire for
having a baby. Within the ‘I am pregnant’ theme, there is also experiences of
pregnant adolescents related to ‘Conception, pregnancy and physiological
changing’ including pregnant adolescents’ knowledge related to their pregnancy.
Additionally, a conflict occurred whether to ‘preserve or terminate pregnancy’ was
occurred amongst some pregnant adolescents as their pregnancy was
unplanned.
 85

4.6.2 Unplanned
An unplanned pregnancy is a pregnancy that is either unwanted (i.e., they
occurred when no children, or no more children, were desired) or miss-timed (i.e.,
they occurred earlier than desired) (John Santelli et al., 2003; Brunner Huber et
al., 2013). This ‘unplanned’ subtheme describes experiences of adolescents
related to their first discovery of their unplanned pregnancy. The majority of
included papers highlighted that the pregnancies were not planned [1,2,3,7,9,10].
For some adolescents, the pregnancy was not expected or even realised until the
pregnancy discovery. Adolescents spoke about experimenting in sexual
relationships with a lack of awareness of consequences. The following examples
of quotes from included papers highlight of adolescents women’s experience of
unplanned pregnancy:

Table 4-6: Examples of quotes about ‘unplanned pregnancy’

Quotes Previous
themes
“My pregnancy was not planned, at this age especially that I’m still at Unplanned
school, it was a mistake” (Study 7, App A) pregnancy
“It was a surprised, I never expected it, no way. And I only used a condom Discovery
sometimes, when it was close, so I only used a condom at the exact pregnancy was
moment, sometimes. I didn’t even think about that, I just wanted to spend surprised
time with my boyfriend, go out with my friends, have fun, but I didn’t think
about pregnancy then....” (Statement B, study 9, p. 910)

It is apparent that most pregnant adolescents of the included papers did not plan
their pregnancy as most attended school or work. Therefore, most of them viewed
that their pregnancy as their mistake which seemed to lead their self-blame.
Findings also show that lack of awareness of sexual relationship’s consequences
were experienced by some pregnant adolescents as well as they were
experimenting sexual relationship with only occasionally using contraception,
which led to an unplanned pregnancy occurring.

4.6.3 I wanted a baby

Whilst, some participants explained that their pregnancies were not planned,
others reported that they wanted a baby [1,2,3,6,7,9]. This ‘I wanted a baby’
subtheme describes adolescents’ experiences related to their wishing of having
a baby. Some examples are:
 86

Table 4-7: Examples of quotes about ‘I wanted a baby’

Quotes Previous themes

“ I am now happy as I wanted a baby desperately. My Socio-cultural norms and
boyfriend is 28 years and is working and supports me and teenagers’ environment/
my baby.”(study 1, p.55) individual beliefs
“I was very happy; I didn’t believe that I will fall pregnant.” Planned/ unplanned
(study 7, app 1) pregnancy

Some adolescents desired to have a child and some of them also anticipated
long-term futures with their partners, who would be involved in childrearing and
would financially support them. It is evident that adolescents whom obtained
supports from their partner, they expressed readiness for having baby.
Additionally, since study 7 included some married participants, having a baby for
some pregnant adolescents therefore was also become one goal of their
marriage relationship.

4.6.4 Conception, pregnancy and physiological changes

Under this subtheme, the experiences of adolescents related to the conception,
pregnancy and physiological changes are described, including their knowledge
and response of their pregnancy and physiological changes. A lack of knowledge
related to pregnancy and conception was identified from most participants
[1,2,3,4,6,7,9]. Adolescents had little or no knowledge related to conception,
pregnancy and physiological changes. This is because adolescent women were
less likely to access education and information about sexual health, reproduction
and signs of pregnancy. Such conditions therefore, may trigger adolescents to
have challenges through their pregnancy. The following table describes this topic.

Table 4-8: Examples of quotes about ‘conception, pregnancy and physical

changes’

Quotes Previous themes

“I don’t know anything about pregnancy. I just got to know Knowledge and perceptions
that I am pregnant after telling my friend that I have missed about their pregnancies/
my period. I even took some purgatives to cleanse my Knowledge related to
stomach as I was feeling sick”(Study 1, p.53) pregnancy and information
received during antenatal-care
“ I was not expecting anything. I did not know I was pregnant. I am pregnant
It was my mother who realized I was pregnant because I was
vomiting all the times but still menstruating” (study 2, 16
years old)(p.777)
 87

A lack of understanding and knowledge meant that some adolescents did not
realise that they were pregnant nor did they expect that to become pregnant. It is
also evident that some adolescents also explained that their pregnancy was
discovered by others which seemed to be due to adolescents’ lack of knowledge
related to pregnancy. It also appears that some adolescents experienced red
vaginal discharge which they thought it was menstruation, in fact red vaginal
discharge can be considered as a sign of pregnancy complication (Azevedo et
al., 2015).

4.6.5 Preserve or terminate pregnancy

Preserve and terminate pregnancy subtheme describes adolescents’
experiences in regards to their response of pregnancy including their intention of
whether to preserve or terminate their pregnancy. Finding shows that there were
some adolescents who attempted to terminate their pregnancy [2,3,11]. It also
appears that some adolescents were not ready for their pregnancy.

Table 4-9: Examples of quotes about ‘preserve or terminate’

Quotes Previous
themes
“At first no I wasn’t sure because I wanted to abort it at first …. Actually my Decision
boyfriend stop me say that it was his first child and he is not sure if he is making
going to get a next one or I am going to be able to get pregnant in the future.
So I just decided to bring it.” (study 3, A-R5)” (p.4737)
I told my partner and he asked me what I wanted to do. He brought me some Options for
medicine for an abortion, but the pregnancy, wouldn’t abort. He even went to abortion
the extent of giving me akpeteshie (local gin), but still no abortion.” (Study 2,
19 years old) (p.778)
It is evident that some adolescents made attempts to terminate their pregnancy
by either taking medicines or other lay concoctions without success. Whilst, some
others also felt that carrying a pregnancy was not their own decision. It appears
to be that in some contexts, adolescents were having control over their pregnancy
and in some others they did not. For example, some of them explained that their
decision to carry the pregnancy was their decision or pregnancy was continued
because terminating pregnancy was not ‘success’, and some others explained
that pregnancy was carried out because of the decision of their partner or parent.
Additionally, there is also evidence of the need to highlight that some of
adolescents also have no control in regards to whether to preserve or terminate
their pregnancy.
 88

Summary of theme I am Pregnant

The theme of ‘I am Pregnant’, confirms that whilst some adolescent pregnancies

were unplanned, some others showed readiness and wanted a baby. However,
most of the included papers highlight that pregnant adolescents have a lack of
information related to their pregnancy including conception and physiological
changes. Furthermore, the findings suggest that some adolescents experienced
having control over the pregnancy and some of others did not in regards to
preserving or terminating their pregnancy. Giving the findings within ‘I am
pregnant’’ theme, these informed the topic guideline of study 2, particularly
related to initial period of pregnancy discovery.

4.6.6 Theme 2: Support

Within the ‘Support’ theme, experiences of how adolescents gained help from
others i.e. parents, partners, communities and healthcare providers are
described. Previous literature described that support refers to the availability of
helps or assistance such as material, emotional, informational, and/or companion
(Logsdon et al., 2005a; Xie et al., 2009; Kim et al., 2014). It is evident that some
adolescents gained support from a variety of sources of support such as parents,
partner, family, community and healthcare providers. The following sub themes
present source of supports that gained by some adolescents.

4.6.7 Parents
Within this ‘Parent’ subtheme, experiences of adolescents on gaining support
from parents are described. Parent/ parents were identified as one source of
support for adolescents during their pregnancy and once their baby was born
including acceptance of pregnancy and helping to care for the baby. The quotes
in table 4-10 as examples of quotes regarding to the support from parents:

Table 4-10: Examples of quotes about ‘support from parents’

Quotes Previous themes

I was not feeling well after delivery so it was my mother who Caring for the baby
did everything for us. She only brought her to me to suckle
(14 years old, study 2, p. 778)
No she (Mom) didn’t say anything I expect her to cuss, she Social support
always told me that if I got pregnant she would put me out
 89

Quotes Previous themes

and she wouldn’t be there for me she would be gone, So I am
just surprise she is actually there right now…… (A-R5, study
3, p.4737)

Findings show that some adolescents sought support from their parents for taking
care of their child, whilst some others also obtained emotional support from their
pregnancy such as acceptance. It was also evident that some of adolescents
were surprised by their parents’ support because their pregnancy was out with
their parents’ expectation. It was evident that when pregnancy occurred their
parents still provided support to them.

4.6.8 Partner/ husband

The ‘partner/ husband’ subtheme describes adolescents experiences related to
their partner/ husband’s support in regards to their pregnancy and motherhood.
Some adolescents felt supported from their husband [2,5,8,9,11], for example in
terms of taking care their child and financial support. The following quotes in table
4-11 provides examples of adolescents’ quotes related to their partner support.

Table 4-11: Example of quotes about ‘support from partner’

Quotes Previous themes

My partner was and continues to be supportive in the care of the child Caring for the
(19 years old, study 2, 778) baby
“I am just a housewife. Only my husband supported us financially. The Challenges and
only support that I could give my child is to rear him in a right way so that Coping
he could not experience the things I experienced” (study 5,p 250) mechanism

It is evident that some adolescents shared the responsibility of taking care of their
children with their partner, whilst some others gained financial support from their
husband. It was also interesting to highlight from some adolescents’ experiences
that division on responsibility within their family were appeared. For example, the
wife took responsibility for taking care children and husband provided financial
support for their family.

4.6.9 Wider family members

For some adolescents, support from their family members [2,8,11] was evident.
Within the ‘wider family member’ subtheme, experiences of adolescents on
gaining support from their wider family member are presented, this included
caring for the baby, getting involved throughout pregnancy and caring for the
 90

adolescent women themselves. The following examples of quotes indicate the

type of support:

Table 4-12: Examples of quotes about ‘support from wider family members’

Quotes Previous themes

My aunty has been so good to my child and myself. She Caring for the baby
bought the baby’s clothes and all that the baby needed, she
got them (16 years old, study 2, p. 778)
I had to stay with my father In law who took care of me during Coping with unintended
the period. (adolescent mother, 18 years old, study 11, p. 25) pregnancy and available
network of supports
It is evident that the family member became a source of support for some
adolescents, which seemed to be a positive influence for some adolescents in
their transition to be motherhood. Some adolescents also explained that the
availability of their family member on providing support was important for their
development of coping skill management.

4.6.10 Community and religious leaders

Community and religious leaders also had been identified as one of the factors
who provided support experienced by adolescents. For example support came
from church community. Such experiences are described within the ‘community
and religious leaders’ subtheme. This including emotional support which had
been given by showing acceptance for pregnant adolescents. The following
quotes are examples of adolescent’s experiences:

Table 4-13: Examples of quotes about ‘community support’

Quotes Previous themes

I deviated from the Christian way I was brought up. After my Coping with unintended
ordeal, I rededicated my life back and some members of my pregnancy and available
church supported me and volunteered to care for me and my network of supports
child. I now assist in providing domestic services on weekend
basis at three of our members’ residence. They have also
supported my education and I am now running a Diploma
programme in the Polytechnic Ile-Ife (adolescent mother, 19
years old, study 3, p. 26)
I stopped going to the church when I noticed that I was Pregnancy Stigma
pregnant. I was suspended from engaging in church activities Experiences
and my partner was invited for questioning. We were both
sober and asked for forgiveness. We served some
punishments and our pastor later encouraged us to live holy. I
have learnt my lesson. However, there are still some of our
church members who don’t believe in us because of our past.
(study 11, p.25)
 91

It appears that some pregnant adolescents were gaining emotional support from
their community which therefore led them to their return to their community, which
seemed to be positive way for adolescents to continue their life including
education and employment.

4.6.11 Healthcare providers

Within this subtheme, adolescents’ experiences of gaining support from
healthcare providers are described. For example about how they accessed health
education and information. It also appears that some adolescents could access
healthcare services such as midwives and general practitioners. The following
quotes are the examples of adolescents’ experiences related to support from
healthcare providers:

Table 4-14: Examples of quotes about ‘support of healthcare provider’

Quotes Previous themes

I like the fact that as you start coming to the clinic as a Perception of services
teenager, yes they introduce you to go back to school... and
they always make sure they talk to you (about) what to eat just
to keep your baby all of that stuff, to take care of the baby,
don’t be stress about it (A-R1, study 3, p. 4735)
“If I’m having problems I consult the general practitioner.” Under-utilization of health
(study 7, app 1) resources

It is evident that some adolescents accessed healthcare services and gained

information related to caring the baby from healthcare providers. It appears that
some adolescents could access support from healthcare providers.

Summary of theme Support

Evidence showed that adolescents were gaining support from several sources,
which were parents, partner/ husband, wider family members, community and
religion leaders and healthcare providers. This theme therefore provided
evidence from low-lower and middle and upper middle income countries that
although many of pregnant adolescents were being excluded from society, some
pregnant adolescents were not being left. This evidence therefore guided the
topic questions for study 2 and 3.
 92

4.6.12 Theme 3: Consequences of the adolescent pregnancy

The consequences of adolescent pregnancy theme describes experiences of

adolescents relating to health-psycho-social consequences in regards to their
pregnancy. It is evident that adolescents experienced stigmatisation and they felt
shame of their pregnancy which is described under ‘Stigmatisation and shame’
subthemes. Adolescents also experienced school termination and also work as
consequence of their pregnancy which is presented in ‘consequences to
education and work’ subtheme. Additionally, the pregnancy also consequently
brought complications or symptoms due to the complication for some
adolescents, and such experience is described under the ‘symptom and
complication’ subtheme. As pregnancy for some adolescents was unplanned,
distress and regret appeared and such experiences are presented under ‘distress
and regret’ subtheme. Literature showed that adolescents pregnancy has
potential risk of negative consequences in terms of health-psycho-and social,
particularly when pregnancy occurred in a place where there is lack of support
and accessibility to healthcare (WHO, 2014b).

4.6.13 Stigmatisation and shame

Stigma refers to attitudes and beliefs that lead people to reject, avoid, or fear
those they perceive as being different (Whitley and Kirmayer, 2008). In this
subtheme, stigmatisation and shame refers to adolescents’ experiences
regarding stigmatisation from society and shamefulness due to their pregnancy.
Stigmatisation and shame were experienced by adolescents [see papers:
3,4,6,7,8,9]. The following quotes in table 4-15 describe the experiences.

Table 4-15: Example of quotes about ‘stigmatisation and shame’

Quotes Previous themes

“I think so because it wasn’t expected, they fret I mean not fretting but it Distress versus
is going to be on your mind whether you like it or not. It is going to be onpsychosocial health
the back of your head, it is going to be right there in front of you. (Have
you ever had any of those feelings – bad or sad or depressed or fret a
lot when you found out you were pregnant?)…Yes, I said oh my God is
this for real? You would be touching it…do you think it is something in
there?” (study 3, A-R1, p.4738)
“I feel shy and sad to get married early; I am still young, and none in this Ambivalence
village get married this early. My body is small, too. I don’t know how it Toward Becoming a
happened, but when I got back from work, my parents said that there Young Mother/
was a person who asked if I wanted to get married. I could not eat for
 93

Quotes Previous themes

several days. At night I thought about it, and then I didn’t know why I being to young to be
decided. . . . But then after marriage, I felt sad, shy and regret that I got a young mother
married early.” (study 6, pregnant woman, age 17)(p.432)

It is evident that stigma has become one of the social pressures that are
experienced by pregnant adolescents, which potentially result in their
experiences of feeling shame, low self-esteem and regret. This social
stigmatisation seemed to be an additional burden for adolescents which
developed their distress. Additionally, it is apparent that some of adolescents also
described that marriage in early age was initially from their parents and it created
sadness and regret as they were not ready. It is explained that in some context
adolescents were likely have no control over their own life.

4.6.14 Education and work

Education and work subtheme describes consequences of adolescent pregnancy
in terms of education and work, which was experienced by adolescents. It is
evident that adolescent pregnancy was also having negative consequences for
adolescents [see papers 1,2,6,7]. For example, they had dropped out and were
not be able to continue their education as a result of their pregnancies. The
following table involves examples of quotes of participants from the included
papers which describes the condition.

Table 4-16: Examples of quotes about ‘education and work’

Quotes Previous themes

“But until then I was kicked out of school because the school found Meso/ macro
out about it. So I had to stop.” (study 3, A-R5) (p.4738) community support
system
“My life definitely changed within a second or a minute when I knew I Dropping out from
was pregnant. I couldn’t continue my study. It’s like a half of my life is school
dead.” (study 4 p.156)

It is evident that some adolescents experienced a life change after they had
dropped out from school due to their pregnancy. Some adolescents were not be
able to access education in the school as well as having no access for vocational
course due to pregnancy and motherhood, which seemed resulted in them having
fewer skills and opportunities to obtaining jobs.
 94

4.6.15 Symptoms of complications

Symptoms of complications in this study refers to experiences of women
adolescents related to signs of having pregnancy problems that led to pregnancy
complications. Symptoms of complications was identified as one of the
experiences faced by adolescents [2,6,7], including bleeding and hyperemesis.
This is in line with evidence from previous studies which mentioned that
adolescent pregnancy has a higher risk of pregnancy and childbirth complications
(Azevedo et al., 2015). The following table includes expressions of adolescent
women in the included papers.

Table 4-17: Examples of quotes about ‘symptoms and complication’

Quotes Previous themes

“...... I also told her that I was bleeding and felt like couldn’t stop Being Ignored and
urinating, but she just said, “That’s no problem.” You know, they Patronized by the
care very much about those who have money. Really, I am telling Healthcare Providers/
the truth. They do not care about us if we don’t have money; it is Lacking confidence
always like that at the hospital.” (study 6, new mother, age
18)( p.343)
“I was always wet and my mother said I have premature rupture Inadequate information/
of membranes (motse o thobegile) (study7, app 1) knowledge related
physiological changing
during pregnancy

Some adolescents explained that during their pregnancy they experienced

bleeding, some others also explained they felt that there were vaginal discharge
and wetness, in which can be considered as symptom of complication. It is also
evident that some adolescents attempted to seek help in healthcare services,
however, there was a lack of care provided. For example, they were being
ignored. It seemed that some adolescents were more likely to be vulnerable as
they had a lack of accessible and appropriate healthcare services

4.6.16 Distress and regret

It is evident that adolescents experienced distress and regret with their pregnancy
[1,3,8,9,11]. Under this ‘distress and regret’ subtheme, adolescents’ experiences
related to their feeling of distress and regret due to their pregnancy are explained.
Distress and regret was can be considered as psychological consequences of
adolescent pregnancy (Pudrovska, 2009; East et al., 2012; Lang et al., 2012;
Siegel and Brandon, 2014). The quotes from the included papers that are shown
in table 4-18 are examples which illustrate the situation.
 95

Table 4-18: Examples of quotes about ‘distress and regret’

Quotes Previous themes

“Basically teenage pregnancy is very difficult and become The emotional turmoil
painful and stressful.” (Study 8, T2, p.193) experienced by the pregnant
teenagers was caused by the
overwhelming emotions they
experienced in relation to their
pregnancies
“Well I try to kill myself two times….I take up a knife and I distress versus psychosocial
put it like this…(To your stomach two times?)…Yes health
Miss….(How long ago was that?)…. When I find out…. I
never want to continue (living) Miss…I can’t manage the
baby!” (study 3, B-R2) (p.4738)

It is evident that most of the adolescents experienced distress due to their

pregnancy. There were two quotes from adolescents explaining that they had
attempted to commit suicide. It seemed that adolescent pregnancy was not
bearable for some adolescents from the included papers. Additionally, regret was
also a common feeling from many of the adolescents.

Summary of theme consequences of the adolescent pregnancy

Under the theme of consequences of adolescent pregnancy, it was suggested

that adolescent pregnancy brings adverse consequences and burdens in both
the health and social aspects of adolescents’ lives. For example, stigmatisation
and shame from their community; education interruption and quitting their job;
experiencing symptom of complication; and distress.

4.6.17 Theme 4: After the birth of the baby

‘Experiences during labour and after the birth of the baby’ theme describes
experiences during the process of delivery, just after the birth of the baby and
when they engage in motherhood that were faced by adolescent women. For
example, experience in the labour process and baby born and transition to
engaging in motherhood. This theme included two subthemes which are
experiences during labour and when the baby born; and resilience.

4.6.18 Experiences during labour and when the baby is born

Under this subtheme, experiences during labour and when the baby is born
amongst adolescents are described. Evidence from the included papers suggests
that many adolescent women had negative perceptions related to their delivery
 96

process [2,11]. The examples of quotes provided in table 4-20, describe their
experiences.

Table 4-19: Examples of quotes about ‘experiences of labour and when

baby is born’

Quotes Previous themes

“ I toileted too much during labor. So when I delivered, I said Oh Thank Adolescent in labor
god and no more.” (study 2, 19 years old) (p.778)
“(Is this your first pregnancy?)….Yes and last!... No more I am not Distress versus
even sure if I am going to survive this first one! That is no way on my psychosocial health
agenda no, time soon! When I am set and ready in life maybe; or
adoption but no never again. I am positive and I am certain of that! ….
It is true, Lord Jesus, people usual say one “pickney a nuh pickney” but
this have to be the one, one, one. When I am ready and set in life
when I am about thirty when I should have certain assets and things
going for me, if I am marry or something or I am in a committed
relationship maybe I will consider going again, especially if the person
doesn’t have a child.” (study 3, p.4738)

It is evident that many adolescents had negative experiences related to their

delivery process and it seemed to lead to their traumatised feeling of having
another baby.

4.6.19 Resilience
Resilience refers to the process of recovering from difficulties or toughness
(Powley, 2009; Cramer et al., 2015). Other literature echoed that resilience is a
period when individual recover from a crisis (Romo and Segura, 2010; Daniele
and Yann, 2014). It is evident that adolescent were experiencing life difficulties
as a consequence of their pregnancy. The ‘resilience’ sub theme describes the
experiences of adolescent women in putting in efforts to recover from difficulties
resulting from the pregnancy. Adolescents experienced resilience after their
pregnancy [1,3,4,5,11]. The quotes in table 4-21 are examples of the participants’
expression of being resilient.

Table 4-20: Example of quotes about ‘resilience’

Quotes Previous themes

“Whenever something knocks you down you have just to get back up Resilience
on your feet, and that is what I am planning to do…Yes something
knocks me down just stand to rise and I am going to arise even
stronger (Interviewer: You think so?)…I know so! I am going to achieve
them (goals that you have set)…. I like to finish school, I tell myself say
I want to be either a doctor or a midwife, so I am going to work very
hard.” (study 3, A-R5) (p.4736)
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Quotes Previous themes

I was in JSS 3 when I became pregnant. After giving birth, with the Coping with
support of my parents I went back to learn hair dressing (study 11, p. unintended
25) pregnancy and
available network of
supports
It is evident that some adolescents explained that they tried to manage their life
after the pregnancy and baby born. Some of them tried to plan to continue their
education or vocational skill, in which seemed to be good for them for their future
employments.

Summary of the theme of experiences after the birth of the baby

It is evident that adolescent women were traumatised with their delivery process.
This likely has an influence on adolescent women’s perspectives related to the
view of being pregnant in the adolescent age as some of the pregnant
adolescents suggested that others avoid adolescent pregnancy. There was also
further evidence that whilst some of the pregnant adolescents experienced
difficulties and felt stuck, some of them transferred into a period of resilience. This
evidence also guided the question topic for study 2 and 3.

4.7 Discussion

Four main findings emerged from study 1 which aimed to explore pregnant
adolescents’ and their partners’ health and social experiences in low-lower and
middle-upper middle income countries. The main themes are ‘I am Pregnant,
‘Supports’, ‘Consequences of adolescent pregnancy’ and ‘After the birth of the
baby’.

Under the theme of ‘I am pregnant’, both unplanned pregnancy and wanting to

have a baby emerged. Most of the research evidence shows that adolescent
pregnancy is mostly unplanned and associated with a lack of education and
awareness about contraception and pregnancy, or partner violence and abuse
(Butt and Munro, 2007; Tatum et al., 2012; Panova et al., 2016). As access to
legal abortion was unavailable for adolescents due to healthcare policy and
practice in some countries where data were collected therefore it is evident that
some of them attempted abortion by using their own methods. Despite this having
a high risk of mortality and morbidity of both young pregnant women as well as
 98

for their baby. According to Shirodkar (2010) it is evident that in the condition of
unplanned pregnancy with limited access to legal abortion, there are groups of
women who tend to attempt to terminate their pregnancy with their own methods,
for example attempting self-induced abortion by using concoctions, which was
also experienced by one of pregnant adolescents in this included papers.
Additionally, there were also adolescents whom attempted to terminate their
pregnancy by taking potassium which was also poison. Although, there were also
some of adolescents who wanted their babies, it seems that they were having
adequate support from their partner or family. For example their partner was
mature and in full time-employment. The findings are in line with previous
research that pregnant adolescents who wanted a baby usually have long-term
futures with their partners such as those partners who would be involved in
childrearing and financially support the pregnant adolescent (Edirne et al., 2010;
Osaikhuwuomwan and Osemwenkha, 2013; Fenn et al., 2015).

Furthermore, the theme ‘Support’ provides findings related to support sources

around pregnant adolescents. Support in this qualitative systematic review is
defined as providing encouragement such as financials, foods, house or health
services (Sauls, 2004; Logsdon et al., 2005a; Madkour et al., 2013). Findings
suggest that some pregnant adolescents obtained support from partners,
parents, family, communities and healthcare providers. Supports systems have
a direct influence on how pregnancy consequences affect pregnant adolescents
for example decreasing the risk of depression during pregnancy (Benson, 2004;
Loaiza and Liang, 2013). It is evident that some adolescents experienced
difficulties in managing and adjusting to their new life as a young pregnant. For
those who obtained support, they tend to adjust to their life faster and be more
resilience than others who have limited supports. Pregnant adolescents with
supportive healthcare providers will have better knowledge of managing their
pregnancy because they can access the information and support which they need
from healthcare providers (Logsdon et al., 2005b). Additionally, it is normal when
women experience physical and emotional changes during their pregnancy,
however, when women have no adequate information related to that, it may
cause anxiety which may lead to depression (Rini et al., 2006; Letourneau et al.,
2007). Support sources therefore should be accessible for pregnant adolescents
 99

both from the community and healthcare providers. Support is not only focusing
on pregnant adolescents, but, the support also needs to be accessible for their
partners as well (Lehti et al., 2012; Barton et al., 2015; Ibrahim et al., 2016).
Findings showed that community acceptance and healthcare providers supports
were important on adolescents re-engagement in society, in which support them
to re involved in their community and develop their self-esteem of being young
parents.

The third theme is ‘Consequences of Adolescent Pregnancy. The findings show

that adolescent pregnancy brings negative health and social consequences for
example in health matters, pregnant adolescents in the included papers
experienced symptoms of complications and also symptoms of depression.
Meanwhile, in social consequences pregnant adolescents experienced stigma
and judgement, education or job termination and also they experienced a lack of
confidence to be a young mother. The findings are similar to previous research
which has been documented that adolescent pregnancy has directly given
negative outcomes in terms of health and social aspects (Gogna et al., 2008;
Areemit et al., 2012; Corcoran, 2016). Evidence from previous research reveals
that adolescent pregnancy has a higher risk of maternal morbidity and has an
indirect influence on maternal mortality (Omar et al., 2010; Rasheed et al., 2011;
Sekharan et al., 2015). Adolescent pregnancy increases the risk of anaemia,
post-partum depression, post-partum haemorrhage, and miscarriage (Azevedo
et al., 2015). It also increases the risk of low birth weight, intra uterine foetal death,
and intra uterine growth retardation (Balaha et al., 2009; Casey, 2010; Edirne et
al., 2010). In terms of social outcomes, evidence shows that adolescent
pregnancy links with financial difficulties, limited opportunity on school and works,
limited financial outcome, stigmatisation and single parenting (Benson, 2004;
Logsdon et al., 2005b; Mushwana et al., 2015; Osaikhuwuomwan and
Osemwenkha, 2013). Although, much research documented that adolescent
pregnancy brought negative health and social outcomes for both the mother and
the baby, there is a research conducted in the UK about the positive experience
of adolescent pregnancy as the pregnancy changes adolescents’ direction of life
for considering careers because they had someone else for whom they were
responsible (Seamark and Lings, 2004). Therefore, further research exploring
 100

adolescents’ experiences needs to be considered to obtain wider research

evidence related to adolescent pregnancy experiences in lower, middle, or even
high income countries.

The last theme of the systematic review is ‘After the birth of the baby’. The main
finding was that pregnant adolescents were experiencing financial difficulties,
feeling exhausted, dropping out from school and depression. The finding is in line
with previous research evidence that the negative consequences of adolescent
pregnancy does not only occur in the period of pregnancy but also in the period
after the birth of their baby for example delays in education, emotional crises,
financial difficulties and depression (Hillis et al., 2010; Mollborn, 2010). Although,
some pregnant adolescents in the included papers initially wanted their baby,
they still found difficulties in adjusting to their motherhood. Findings also suggest
that some pregnant adolescents were expressing resilience and put their efforts
into managing their life by making attempts to gain vocational training, come back
to their education and also to work. They also tended to give advice for people to
learn from their experiences that being a mother is a challenge and it needs
adequate preparation. Additionally, evidence from previous research shows that
resilient mothers who experienced early pregnancy are influenced by positive
adaptation in their transition into motherhood (Lévesque and Chamberland,
2016). There is also evidence which shows that young mothers who obtained
adequate support experience resilience faster than those who lack support
sources (Hess et al., 2002; Romo and Segura, 2010). Therefore, it can be
concluded that although adolescent pregnancies bring negative experiences
among almost all pregnant adolescents in the included papers, some of them
also could be resilient when support and opportunities are accessible to them.

4.8 Strengths and limitations noted within this study 1

A comprehensive search protocol was prepared for the review that incorporated
the searching of a range of professional databases, grey literature and specific
websites, key local journals, reference lists and contacting authors. In addition,
this qualitative systematic review transparently provides the methods that have
been utilised to synthesise the data. There were only papers with grade A and B
 101

that resulted from the critical appraisal included in the systematic review. This
was to maintain the quality of the systematic review.

Confirmation and audit trail have also been maintained by discussing every step
of the systematic review with the supervisory team and feedback was also
obtained from peers from seminars as well as conferences. A framework adapted
from Thomas and Harden (2008) was used for systematically synthesising the
data. Furthermore, variety was also obtained from the included papers i.e. a
variety of countries where the research was conducted, methodology and
methods and status of participants. However, there were also limitations noted in
the process of the qualitative systematic review. This qualitative systematic
review has only included studies in English and Bahasa Indonesia. Furthermore,
due to the systematic process there is no included research conducted in
Indonesia and also all perspectives are from only adolescent women.

4.9 Conclusion

The findings of this qualitative systematic review emphasise that adolescent

women’s experiences of pregnancy vary as they journey through their pregnancy
and early motherhood. Crucially, the findings highlighted that there are no male
adolescents involved in the included papers and no included papers were
conducted in Indonesia. Therefore, the exploration was only for pregnant
adolescents experiences in low-lower and middle-upper middle income countries.

4.10 Summary

In this chapter, a qualitative systematic review process and its findings have been
explained. Following a systematic search of literature, 11 papers were identified
for inclusion in the review. A quality assessment was conducted and one paper
was rejected on the grounds of poor quality, therefore findings of 10 papers were
included in the data synthesis. There were 10 included studies generated and it
is evident that no studies conducted in Indonesia and no male participants were
included for the systematic reviews. Therefore, the researcher was not be able to
compare and contrast experiences in Indonesia and other low-lower and middle-
upper middle income countries as well as being unable to explore male
 102

adolescents’ health and social experiences. Initially, there were studies

conducted in Indonesia, however, during the process of the systematic review
they were excluded due to not meeting the inclusion criteria. The 10 included
papers’ findings highlight the diverse adolescent women’s experiences in terms
of health and social experiences in low-lower and middle-upper middle income
countries.

Four key themes emerged which are ‘I am pregnant’, ‘Support’, ‘Consequences

of Adolescent Pregnancy’ and ‘After the birth of the baby’. The systematic review
provided the information that whilst some of the adolescents planned their
pregnancy, others did not. Whist, some of the adolescent women had positive
pregnancy experiences such as having adequate support from their partner,
parent and healthcare provider, most of them explained that adolescent
pregnancy had adverse consequences in health and social experiences. Some
adolescent women tended to experience resilience, whilst the others experiences
struggle with pregnancy complication, financial matters, jobs, education,
depression and regret, exclusions, single parenting, shamefulness and
stigmatisation as well as difficulties of raising the babies.

Having the evidence that there were no included papers conducted in Indonesia
and no papers which included male participants, conducting research exploring
adolescent pregnancies experiences in Indonesia including exploring female and
as participants is needed. The findings of study 1 were used to inform and
construct topic guideline of study 2 and study 3 that were conducted in Indonesia.
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Chapter 5 : Study 2 An In-depth Study of Pregnant Adolescents

and their Partners during the Pregnancy

5.1 Introduction
Chapter 5 presents a detailed account of study 2. This study focuses on
Indonesian adolescents’ experiences during pregnancy. The aim and objectives
are presented along with the methods used, including study population, sampling
technique and size, inclusion and exclusion criteria, recruitment, process of data
collection, and data analysis. Participants’ quotations are provided to add depth
to the themes generated. A summary of each theme and a discussion drawing
on the wider literature is provided. An overarching summary at the end of this
chapter is provided in order to conclude what Chapter 5 is about.

5.2 Aim and objectives for study 2

The aim of the study was to explore Indonesian adolescents’ experiences during
their pregnancy with the following objectives:
1. Explore the experiences of pregnant, female Indonesian adolescents
residents in Indonesia.
2. Explore the experiences of male Indonesian adolescents who have a
pregnant Indonesian girlfriend whilst resident in Indonesia.
3. Compare and contrast between female and male Indonesian adolescents’
experiences whilst resident in Indonesia.

5.3 Methods
This section explains the methods used to meet the above aim.

5.3.1 Study population, sampling technique and sample size

The population of this study was Indonesian pregnant adolescents and their
partners who were resident in Indonesia. Non-probability sampling technique was
selected to be used in study 2 i.e. convenience and snowballing sampling
technique in order to reach the number of potential participants. It was considered
appropriate to employ two sampling strategies as it was to anticipated that it may
be challenging to recruit participants because of the sensitive nature of the topic.
 104

There was no literature to help estimate recruitment patterns in this context to the
best of researcher’s knowledge. Theoretically, when difficulty in recruiting
participants is anticipated, using more than one technique to improve recruitment
is recommended (Luborsky and Rubinstein, 1995; Marshall, 1996; Flick et al.,
2007; Mason, 2010). The researcher expected four couples would be included in
study 2 due to considering challenges of participants’ recruitment. Recruiting a
small sample in qualitative studies or even only an individual, is reasonable where
gathering narrative data via in-depth interviewing is the methods of choice
(Crouch and McKenzie, 2006).

5.3.2 Inclusion and exclusion criteria

The table 5-2 presents inclusion and exclusion criteria for study 2. These were
developed and applied in order to select participants which could meet with the
aim of this study.

Table 5-1: Inclusion and exclusion criteria

Gender Inclusion Exclusion
Female 1. Rape cases.
1. Indonesian resident.
2. Learning
2. Pregnant.
disabilities.
3. Aged 19 or less (at the time of
recruitment).
4. Premarital pregnant case or married
during pregnancy.
Male 1. Learning
1. Indonesian resident.
disabilities.
2. Has a pregnant girlfriend or wife.
3. Aged 19 or less (at the time of
recruitment).
4. Premarital pregnant case or married
during pregnancy.
As study 2 aimed to explore Indonesian adolescents’ experiences during
pregnancy due to premarital sexual relationships, women who were pregnant due
to rape were excluded. This was because pregnant women as a consequence of
rape, would not be stigmatised as they did not behave out with cultural and
religious values. Women who become pregnant as a result of rape cases may
have access to a legal abortion or have the choice to place their child in public
foster care. Consequently their experiences different to adolescents who chose
a relationship. Adolescents with learning disabilities were also excluded as it was
considered unjust to approach them as they were less likely to understand what
 105

was required from them and why. They may be less likely to provide informed
consent to be involved in this study (McClimens and Allmark, 2011).

5.3.3 Recruitment
The researcher identified potential participants by reviewing antenatal care
records in both a public health centre and a midwifery private clinic. It is a normal
practice to access patients’ medical records by a researcher in Indonesia when
ethical approval and permission have been obtained. Furthermore, posters about
the study were displayed in the waiting rooms of the public health centre and
midwifery private clinic. The poster displayed brief information to attract
adolescents to participate and contact number for the researcher, if there were
any queries related to study. The antenatal records were identified potential
participants because they provided history of the pregnancy, partner or husband,
and age of participants as well as a contact number and address. Two different
procedures were used to gained the consent of married and unmarried
participants, as required by local legislation (Subekti and Sudibyo, 1995). Details
of how participants were recruited is explained in the following section:

1. Married participants
a. Female and male potential participants were identified from antenatal
care (ANC) record by the researcher.
b. At the antenatal clinic appointment a midwife offered potential
participants an information sheet and a consent form and asked if they
would like the researcher to contact them within 3 days to ascertain
whether they wished to take part in the study.
c. Within three days, potential participants were contacted by mobile
phone. A brief introduction was given including who the researcher
was, the purpose of contacting them and then checked whether
potential participants had received an information sheet and consent
form from their midwife.
d. A brief explanation of the study related to the information sheet was
also given. Potential participants had the opportunity to seek
clarification and ask questions. When the researcher was assured that
they understood the information, they were asked if they were
interested to take part in the study or not.
 106

e. When potential participants expressed interest verbally to participate

in the study, an appointment was made for a face to face interview
session.
f. An informed consent was gained by signing the informed consent
sheet, before the interview was conducted.
Adolescents who were married are legally permitted to give consent to participate
in any research. According to Indonesian Civil Law Code (Kitab Undang Undang
Hukum Perdata) (KUHP) article 330, in Indonesia adulthood (age of consent) is
considered when people are aged 20 or above or under 20 years of age and
married. Furthermore, in Indonesia, it is common for a woman’s partner or
husband to accompany their wife to an antenatal care visit. Therefore the similar
procedure for recruiting married male participants were employed.

2. Unmarried participants
a. Stage a, b, c and d were followed as above.
b. When potential participants expressed an interest verbally, to take
part, it was explained that the researcher needed their permission to
gain consent from the adolescents’ parents.
c. In this situation, before the first interview session, informed consent
was gained from adolescents’ parents.
There were a couple (two participants under aged of 20) in study 2 who needed
to gain consent from their parents as they were not married, whilst the rest of the
participants were married at the time of interview and gave individual personal
consent before the interviews were conducted. Details of participants information
sheets, and consent form (in English version) can be seen in the appendix I.

5.3.4 Data collection

In-depth interviews were undertaken in order to gain verbal information about
participants’ experiences. In addition, field notes were written soon after the
interview in order to capture context such as participant behaviours during
interviews and/ or the researcher’s thoughts and feelings in relation to the
interview process. For example, body language of participants and gestures, or
specific tensions which were expressed when participants described their
experiences. Field notes were beneficial, particularly in helping the researcher in
 107

terms of data interpretation. A sample of field note written can be seen under data
analysis section 5.3.5.

In terms of tools for interviews, a topic guide was developed based on the findings
of study 1. Generally, in-depth interview topic questions often only involve one or
two questions and then during the interview, the researcher develops questioning
and probing based on the answers of participants (Liao and Xie, 2009; Brouneus,
2011; Fetscher, 2013). In study 2, the guide included more than two questions
and used probes to explore adolescents’ experiences dependent upon the
adolescents’ answers. The interview questions helped the researcher explore
topics and themes informed by findings of study 1 (Brouneus, 2011; Trower,
2012). Details of interview questions can be seen in the table 5-2.

Table 5-2: Interview questions of study 2

Interview Questions of Study 2
Female Male

1. Theme 1 : Initial contact during 1. Theme 1 : Initial contact during

pregnancy
pregnancy
 Can you tell me what it is like
 Can you tell me what it is like
having a pregnant girlfriend or
being pregnant?
wife?
 And can you tell me how you first
 And can you tell me how you first
knew you were pregnant….and
knew that your girlfriend or wife
how you found help…who
was pregnant….and how did you
helped you the most?
respond to it?
 Is this a good time to be
 Is this a good time to have a
pregnant for you?
pregnant girlfriend or wife for
2. Theme 2: Mid-point before term
you?
 Can you tell me how you have
2. Theme 2: Mid-point before term
been feeling about this
 Can you tell me how you have
pregnancy?
been feeling about your
 And can you tell me about any
girlfriend’s or wife’s pregnancy?
changes you have made to your
life so far?  And can you tell me about any
changes you have made to your
 Can you tell me about who has
life so far?
helped you and what help you
 Can you tell me about who has
have needed so far
helped you and your girlfriend or
3. Theme 3: Late pregnancy
wife and what help you have
 Can you tell me how you feel
needed so far?
about this pregnancy now?
3. Theme 3: Late pregnancy
 And can you tell me about your
 Can you tell me how you feel
plans for the birth and after your
about your girlfriend’s or wife’s
baby is born?
pregnancy now?
 108

Interview Questions of Study 2

Female Male
 Can you tell me about who has  And can you tell me about your
helped you and what help you plans for the birth and after your
have needed so far? baby is born?
 And after your baby is born, who  Can you tell me about who has
do you think will help you and helped you and what help you
what do you think you will need? have needed so far?
 And can you tell me about any  And after your baby is born, who
changes you have made to your do you think will help you and
life so far? what do you think you will need?
 And can you tell me about any
changes you have made to your
life so far?
The process of recruitment, consent and interview questions were piloted. A
pregnant adolescent and her partner participated in the pilot, which helped
researcher to assess if the process of recruitment, consent and the questions
were understood, applicable and if they yielded pertinent answers. The pilot
interview was conducted individually. It was found that:

 Pilot participants understood the information sheets, informed consent form

and voluntarily agreed to be interviewed by signing the informed consent
form.
 When using a friendly conversational approach duration of interview was
between 30 to 40 minutes without any significant interruption.
 Participants responded and seemed enthusiastic about describing their story
which suggested that they had a clear understanding of the questions and
were willing to participate voluntarily.
 Neither participant asked for an appointment with the midwife after their
interviews, suggesting that neither needed additional support from her
 Probing questions were used to gain further insightful perspectives such as
‘tell me more about your feelings on…..’ ; ’you said……..tell me a bit more
about that…….’ ; ‘you said…… expand on that if you can…..’ and ‘how do
you feel about that’.
Since the pilot process of research appeared feasible to be run and interview
questions showed gathered data appropriately, there were no amendments
required to the participant information sheet, informed consent form, procedure
 109

of recruitment or interview schedule. The pilot data were not included in data
analysis. Although it was evidence that separating data from pilot interview of
qualitative research are not necessary (Holloway, 1997), from the initial plan
researcher had no intention to use the pilot data to be further analysed.
Researcher also found that there were no new information emerged from the
pilot.

In terms of real data collection, interviews were recorded in Bahasa Indonesia.

There were three times of interviews with each participant at different time points,
with an expected maximum of 60 minutes per interview and pre decided range of
topics was prepared. The first interview was conducted soon after first contact
was made during the pregnancy, the second interview was between the time after
contact and the expected date of birth and the last interview was in the late
pregnancy (before expected birth dates). However, participants were free to
withdraw at any time before, during the interview and up to 24 hours after the
interview without giving a reason. Participants had the choice whether or not to
complete three interviews in order to maintain the autonomy of participants.
During the interview, verbal and non-verbal communication were used by
researcher to provide appropriate feedback (Silverman, 2006; Onwuegbuzie and
Denham, 2013). For example, if the interviewee was on track, head nodding or
verbal acknowledgement was used to encourage participants to give more
information. In an Indonesian cultural context head nodding is considered as sign
to encourage people in communication. By contrast if the interviewee was not on
track, the probing questions were used to help guide the interview such as by
using ‘lets talk about…..’.

Probing questions were also used to encourage participants to explore more

topics related to their experiences. However, consideration was given should any
participants express anxiety, discomfort or distress during the interview, a rest
would be offered and consent to continue or to withdraw from the study would be
sought. Arrangements were also in place should participants get upset and/ or
require help after the interview, participants could also see a midwife. There is
evidence that employing probing questions helps the researcher to probe the
participant’s thinking and re-framing their thinking. In order to maintain
consistency of the topics explored, the researcher used the topic guide.
 110

5.3.5 Data analysis

Thematic analysis was conducted by using a framework from Colaizzi (1978) in
extracting, organising, and analysing the narrative dataset with systematic steps
in study 2. The key stages of qualitative data analysis adapted from Colaizzi
(1978), are:

1. Transcription by using a protocol from audio recording, read and re read

transcriptions to getting familiar and acquire a feeling them.
2. Extracting significant statement by reading transcription and pull out
statements or phrases that directly pertain to the investigated phenomenon.
3. Formulated meaning by spelling out meaning of each significant statement.
4. Clusters of themes by integrating ideas of meaningful ideas into sub themes
and themes.
5. Exhaustive description of the phenomenon by integrating results so far of
phenomenon being investigated.
6. Formulate exhaustive description of the phenomena being investigated as
unequivocal a statement of identification of its fundamental structure as
possible.
7. A final validating by returning to the participants.

The application of Colaizzi (1978) framework in practice can be seen in Table 5-

3.

Table 5-3: Data analysis process

No Data analysis Application of the study Quality assurance
step of
Colaizzi
(1978)

1 Transcription a. Interview audio record a. Peer checking was

transcribed verbatim in employed to
Bahasa Indonesia. validate interview
b. Six examples of audio records and
transcriptions translated transcriptions.
into English. Blocking audio that
c. Transparently providing involved names
statements and phrases and personal
that cannot be directly details was
translated into word by conducted to
word, so meanings were improve
confidentiality.
 111

No Data analysis Application of the study Quality assurance

step of
Colaizzi
(1978)

priority in the translation b. Pseudonyms have

process. been used to
d. Transcripts were read improve
and re-read to make the confidentiality.
researcher familiar with c. All the
the data and acquire a transcriptions were
feeling of them. done by the
e. Conversational gap researcher and the
fillers, expressions of examples of
feelings of doubt, English translations
confirmation, insecurity, provided in order to
thoughtfulness; were also minimise
presented in misinterpretation
transcriptions, pauses and loss of
were indicated; and meaning.
incomplete words were d. An experienced
written verbatim. These person fluent in
techniques were both Bahasa
beneficial in line by line Indonesia and
analysis. English as well as
had experiences in
qualitative
interview
transcriptions was
used to check the
transcriptions
against audio
records and back
translation to
minimise error in
transcriptions and
translation.
e. Six examples of
transcriptions
translated into
English were
reviewed by
supervisors.
f. Presenting design
of research
including data
analysis was also
conducted to gain
feedbacks from
peers in local
 112

No Data analysis Application of the study Quality assurance

step of
Colaizzi
(1978)

seminars and
conferences as
well as
international
conferences.

2 Extracting a. Identify significant or a. N Vivo training was

significant meaningful statements or attended before
statement phrases related to data analysis.
adolescent experiences b. Qualitative data
by highlighting them. analysis training
b. Using N-Vivo tool to course was
highlighted them. attended before
data analysis
process.

3 Formulating a. Explain the meaning of Review of initial

meaning each significant or analysis by supervisors
meaningful statement or to assure believability.
phrases by considering
Indonesian context.
b. Draw out the
experiences,
perspectives, views,
feelings, and opinions
c. Using N Vivo to create
nodes as coding step

4 Clusters of a. Integrating the resulting Review of initial

themes ideas that came from analysis by supervisors
formulating meaning by to assure believability.
categorising them into
sub themes and themes
b. Return to the
transcriptions and audio
recording to double check
and reminding of the
context
c. N Vivo was used to
manage the process

5 Exhaustive a. Subthemes and themes a. Quality check of

description were checked whilst translation by
revisiting significant or experienced
 113

No Data analysis Application of the study Quality assurance

step of
Colaizzi
(1978)

meaningful statements or person whom

phrases fluent in both
b. Recognising the languages, in
possibility of new order to check the
phenomena emerged, transcriptions from
converting and merging Bahasa Indonesia
of subthemes or themes to English and
was also conducted. English to Bahasa
c. Narratively build Indonesia
dimension of female and b. Review by
male experiences supervisors to
d. N-Vivo was used to assure
manage the process believability.

6 Formulate a. Exhaustive descriptions Review by supervisors

fundamental were integrated into the
structure fundamental structure in
order to provide a clear
structure of adolescents’
experiences
b. Experiences presented
narratively by using
quotes and distinguishing
fonts and narratively
building the experiences
of females and males that
can be related each other

7 Final validation The researcher did not

conduct member checking.
However, quality assurance
was maintained during the
process of analysis to
enhance credibility,
dependability, believability
and trustworthiness.

The data analysis began with data preparation which involved activities such as
the transcription of interviews into Bahasa Indonesia and the data were
anonymised, all details that potentially pointed to participants were removed and
pseudonyms have been used to improve confidentiality. All the transcriptions
were transcribed by the researcher in order to minimise misinterpretation and
 114

losing meaning (Easton et al., 2000). The similar background of the researcher
and experiences in midwifery practices as well as research in a similar context
was also beneficial in data interpretation. Field notes that were taken after each
interview ended also helped the researcher on data interpretation. An example of
field notes can be seen in the following box.

Title: Field note of Interview of Participant 4 (Devi) (1st Interview)

Date: 29th April 2015
Length of interview: 25 minutes
Descriptions:
Devi came to public health centre with her mother. At the time of first meeting/
interview she was unmarried. During pre-interview session, she did not talked
much. She also asked her mother to accompany her during pre-session interview.
Pre session interview includes informal conversation and in this session I used the
opportunity to tell more about myself as a researcher. The pre session interview
was about 20 minutes long.
During the first interview, Devi still did not want to talk much. She answered the
questions briefly and I could see that she was avoiding to describe her current
condition in detail. She also said that she was not ready to tell the story at some
points of the topics, such as when I asked her plan about marriage. Devi mostly
talked about her experiences or concern about judgement from societies, when
I asked about responses of boyfriend and family, she said wanting to talk about
it in the next interview after she married.
When she described about her family, she appeared to describe carefully;
without making herself appeared to have disappointed her family, but still
maintaining honesty. I could see that she was trying to explain that her family
was doing fine, whilst she put herself as the person who did a mistake.

In terms of transcriptions, they took about 6 to 7 hours to complete, this is in line

with suggestion by Carpenter (2008) and Speziale and Carpenter (2011) that
each interview with about 60 minutes length will take about 6-8 hours to
transcribe. An audit check was also used to compare transcriptions against
interview records by an Indonesian fellow who was capable and experienced in
qualitative data transcriptions and English translations. There was a high level of
agreement that transcriptions were accurate with the audio record. Furthermore,
four sample transcripts were translated into English by the researcher and then
checked by an Indonesian fellow who is fluent in both Bahasa Indonesia and
 115

English, and translated back from English to Bahasa Indonesia. The back
translation was used to ensure that there was no change in meaning in the
process of translation. This approach was to minimise missed interpretation in
some phrases, expressions and/ or language. Factors which affect the quality of
translation in research include the linguistic competence of the translator and the
translator’s knowledge of the people under study, therefore it is important that the
translation is conducted by a translator who is truly bilingual (Chen and Boore,
2010). The PhD researcher is bilingual in Bahasa Indonesia and English, is
familiar with the socio-cultural context in this research, and has experience in
research and practice in similar contexts. Overall there was no different opinion
regarding to the participants narrative in Bahasa Indonesia and English text,
which reflect high level of agreement in terms of terminology and meaning
between PhD researcher and the co-researcher (an Indonesian fellow). These
strategies were conducted to improve the accuracy of the transcripts translation.

Furthermore, an iterative process in order to gain meaningful insight was

employed to find data from a different angle and to minimise missed information
that might be occurred. The iterative process of data analysis was useful for
researcher in terms of understanding the meanings and allowed researcher to
worked form different angel of views. QSR N Vivo 10 has been used for data
management of transcripts, scanned field notes, soft file related data and audio
recording. The following figure illustrates the sample of N-Vivo used on managing
sources of data:
 116

Figure 5-1: Example of N Vivo on managing sources

Familiarisation was conducted by reading and re-reading through the data,
listening and re-listening to the audio recordings of interviews and identifying
emergent themes as well as considering the applicability of predefined themes.
The process was employed in order to get familiar with and get a general senses
of the data, as well as to remind the researcher during the process of interviews
which is in line with aspects to consider in qualitative interview transcriptions
suggested by Speziale and Carpenter (2011). The next step was coding by using
an inductive approach where themes were developed directly from the data.
Coding was in English language in order to start analysing further processes
which were looking for patterns, comparing and contrasting; abstraction and
synthesis; production of thematic account; development of typologies and looking
for deviant cases (if any) to refine the analysis. QSR N Vivo 10 was used to
organise codes, subthemes and themes. During data analysis, an iterative
process was applied and discussion with the supervisory team was also
conducted to maintain believability. The following figure illustrates the sample of
N-Vivo used on coding and creating sub themes and themes:
 117

Figure 5-2: Example of the use of N Vivo for analysis

5.4 Findings

This section provides findings from study 2 including recruitment outcomes,

characteristics of participants, and emerging themes.
5.4.1 Characteristics
In study 2, eight Indonesian adolescents (four couples) including females and
males were recruited (plus two participants for the pilot). All participants were
identified from antenatal records from both the public health centre and midwifery
private clinic. The profile of the participants can be seen in the table 5-4.
 118

Table 5-4: Profile of participant

Couple Participants/ Interviews Descriptions
Age (minutes)/
gestations
1 Siska (18) 42”/ 32 Siska was in high school and married
weeks her boyfriend. She married when she
was in her 3rd trimester of her
30”/ 36
pregnancy.
weeks
27”/ 39
weeks
Ahmad (19) 30”; 37”; 27” Ahmad is Siska’s husband. He left
school and at the time of interview, he
was working part time with only earns
minimum wage per month.
2 Aprilia (18) 46”/ 24 Aprilia has not completed secondary
weeks school due to her economic situation.
She was in her 2nd trimester of her
43”/ 29
pregnancy at the time of marriage.
weeks
30”/ 36
weeks
Arif (18) 40”; 27”; 25” Arif was Aprilia’s husband. He
completed secondary school. He
worked in a city with minimum monthly
wages.
3 Dwi (19) 39”/ 16 Dwi completed primary, secondary and
weeks high schools education. She married
her boyfriend in the 3rd trimester of her
30”/ 20
pregnancy.
weeks
51”/ 35
weeks

Junianto (19) 25”; 35”; 45” Junianto was Dwi’s husband. He

completed secondary school and then
worked with minimum monthly wages.
4 Devi (18) 25”/ 24 Devi was aged 18. She left school in
weeks due to being pregnant. She married her
boyfriend in the 2nd trimester of her
51”/ 28
pregnancy.
weeks
35”/ 36
weeks
 119

Couple Participants/ Interviews Descriptions

Age (minutes)/
gestations
Rahmad (19) 20”; 25”; 41” Rahmad was Devi’s husband. He left
school due to his girlfriend’s pregnancy
and he was looking for job at the times
of the interviews.

5.4.2 Process of participant recruitment

The process of recruitment can be seen in Figure 5.3.

Eight couples were identified and approached from antenatal records and
invited to participate in study 2.

Five couples (10

Three couples (Six adolescents)
adolescents) agreed.
declined due to several reasons):
 One couple moved away to other
island.
 One couple declined to
participate in the study 2 and not One couple Four couples
provide a reason.
(Two (Eight
 One couple could not be
contacted. adolescents adolescents
participated in participated in
pilot interviews).
interview).
Data not
including in the
analysis .

Figure 5-3: Process of approaching adolescent participants for recruitment

to study 2
There were eight couples identified as potential participants and all of them were
approached to participate in the study 2. However, of these 8 couples, one couple
moved to another island therefore they decided for not to participate due to limited
time. One couple declined to participate without giving a reason. One couple
could not be contacted, because their mobile number was not active and a letter
was sent but no response was received. For both couples this may have been
 120

due to nature of this sensitive topic. In total five couples agreed to participate, in
which one couple participated in pilot process and interview questions and four
couples participated for the main interviews.

Displaying posters did not result in any participants or queries. However, the
posters may have contributed to participants’ decision to take part in this study,
because the posters provided brief information and they were displayed in the
waiting rooms of the public health centre and midwifery private clinic which
enabled people to read easily. Furthermore, the snowballing sampling technique
did not work, none of the participants provided information or pointed to further
potential participants. Both female and male adolescents were also more likely to
be reluctant to answer when the researcher asked if they have any friends or
know people that potentially could be involved in this study 2. This was most
probably because adolescents pregnancy due to premarital pregnancy is
considered as opposition to cultural and religion expectations in an Indonesia.
Additionally, in terms of the data collection process, one participant in study 2
asked for a break about 10 minutes during the interview due to feeling high
tension with the story. An opportunity to stop the interview was offered, but, the
participant decided to continue after a 10 minute break. None of the participants
contacted the midwife after the interviews, which suggests that participants were
not experiencing negative feelings and were voluntarily telling their experiences.

5.4.3 Emerging themes

The data and emerging themes explains female and male adolescents’
experiences before the pregnancy occurred, when pregnancy occurred and when
they engaged in marriage. The themes represents the experiences of
adolescents’ journey through their pregnancy. Four themes emerged from the
data which are ‘sexual debut’, ‘it shouldn’t have happened’, ‘ending adolescent
life’ and ‘journey into new life’. It starts with the experience of engaging in
premarital sexual relationship and sexual debut amongst adolescents, which led
to the pregnancy occurring; such experiences are categorised in the ‘Sexual
Debut’ theme. Followed by adolescents’ experiences when they discovered their
pregnancy and when others such as family, peers, school and community
responded their pregnancy, themed ‘It shouldn’t have happened’. The ‘ending
adolescent life’ theme presents adolescent experiences of how they engaged in
 121

marriage, life changing after marriage and how others responded to their
marriage. The last theme is the ‘Journey into New Life’ which describes
adolescents’ experiences in their marriage including how they manage their life
and how they sought support. The four themes which emerged from the data
presents adolescents’ journey into an unplanned pregnancy and marriage. The
diagram 5-4 presents the themes.

1. Sexual Debut
- Reasons of engaging in sexual intercourses
- Preventing the pregnancy: trial and error

2. It shouldn't have
4. Journey into
happened
new life
- It shocked me: it
- Allah and I Experiences needed to be ended
- Practical, during - Being judged and
emotional and pregnancy shameful
financial support
- Lack of knowledge
- What I hope and
related to pregnancy
need
matters

3. Ending adolescent life

- I am not ready but married is the only choice
- Left by peers, isolated and lack of freedom
- Powerlessness and helplessness

Figure 5-4: Themes and subthemes that emerged from study 2

5.4.3.1 Theme 1:Sexual debut

The theme of ‘Sexual debut’ represents adolescents’ experiences of their
premarital sexual relationships before their pregnancy occurred and their
experiences related to SRH education. Previous research defined that sexual
debut among adolescents refers to the first sexual relationship and then sexual
activities being practiced by adolescents subsequent to the first encounter
 122

(Cavazos-Rehg et al., 2009; Chiao and Ksobiech, 2015; Ding et al., 2015).
Adolescents’ sexual debut has been explored in low-lower and middle-upper
middle income countries, in study 2, sexual debut refers to both female and male
adolescents’ experiences of their first time of engaging in premarital sexual
relationship. The participants also highlighted their reasons for engaging in
sexual relationships and of the ways in which they attempted to prevent
pregnancy.

5.4.3.1.1 Reasons of engaging in sexual relationships

Both female and male adolescents described their experiences of their
willingness and reason for engaging in sexual relationship for the first time and of
their sexual activities subsequently. There are several reasons cited in literature
which most often influence adolescents’ decision making on engaging in sexual
relationship which are peer influences, desire for loving and intimacy
development with their partners, partner coercion and adolescent marriage
(Bergamim and Borges, 2009; Tavares et al., 2009; Finer and Philbin, 2013).
Findings from study 2 concur that some of reasons adolescents engage in sexual
relationship were similar with previous literature such as desire for loving each
other. It appears that loving each other was a common reason which influenced
both female and male adolescents in this study to engaging in premarital sexual
relationship. For example, this was articulated by Rahmad:

“We love each other (pause) we did (sex) and I never forced her to do that
(pause) I know her since long time ago and our relationship is not for fun only
(pause) we also support each other…” (Rahmad, male, 19 years old)
Similarly, some female adolescents’ accounts also confirmed that loving each
other brought them into engagement in premarital sexual relationship, for
example Aprilia reported:

“It (sex) was unplanned before but I have never been forced by him for doing it
(sex)(pause) it was because we love each other I think (pause) I love him that is
why I gave it (sex) to him (pause) that is for my first time and will never give it
for somebody else….” (Aprilia, female, 18 years old, 24 weeks gestation)
Aprilia’s quote represents all female participants. The quotations of Rahmad and
Aprilia indicate that relationships were developing between both female and male
adolescents into their intimacy which was driving them to their engagement in
premarital sexual relationship. Such sexual relationship therefore consequently
 123

led to the pregnancy occurring. It is evident that individual intention for loving
each other drove adolescents into premarital sexual relationship, which reflects
their intimacy development. Further discussion about why the sexual relationship
and intimacy development amongst adolescent occurred can be seen in section
5.5. Additionally, there will be also further discussion and explanation related
power of individual including desire to loving each other which played an
important role in adolescents’ sexual debut, which can be seen in Chapter 7.

All female participants also stated that initially they were approached by their
boyfriend to engaged in premarital sexual relationship. As reported by female
adolescents, Devi and Siska:

‘…..honestly at first time it (sexual intercourse) was unplanned (pause) I also

realised that sex could led pregnancy, but, I remember at first time he was
trying to convinced me and said to believe him that it (pregnancy) wouldn’t
happened since he knew the way to prevent the pregnancy…..(Devi, female, 18
years old, 28 weeks gestation)
“He asked for the first time and he also always said what we did (sexual
relationship) would be no problem (pause) just safe (pause) would not make me
pregnant (pause) he convinced me.” (Siska, female, 18 years old, 32 weeks
gestation)
It appeared that female adolescents had been influenced by their boyfriends to
engage in a premarital sexual relationship and they confirmed that initial
willingness for engaging in sexual relationship came from their boyfriends. It can
be seen that both Devi and Siska were anxious about becoming pregnant and
they were passive and agreed to engage in sexual relationship as their boyfriend
asked. Such experience, most probably happened most probably because there
was a culture value in Indonesian society that placed men as decision maker and
women as followers. Further discussion about the potential reasons on why
female adolescents appeared to be passive and agreed to what their boyfriends
requested can be seen in discussion section 5-5.

However, none of the male participants stated who initiated or wished to engage
in sexual relationship. The male participants had the tendency to focus on the
reasons for engaging in sexual activities, for example as Ahmad reported:

“…….it (sex) was not for fun only for us (pause) so is that wrong if then I did (sex)
with the one that I love? (pause) and also we did it (sex) without any forces
(pause) we love each other (Ahmad, male, 19 years old)
 124

Like Ahmad, many male adolescent participants reported that feeling in love
influenced them to engage in premarital sexual relationship. Whilst, loving each
other was highlighted by both some female and male adolescent participants in
this study 2 as a precursor to their initial premarital sexual relationship, this was
not the case for female adolescent participants subsequently after the initial
sexual debut.

Some female adolescent participants reported that they continued with their
premarital sexual relationship in order to avoid anger from their boyfriends. Some
female adolescent participants were reluctant to fulfil their boyfriend’s request to
having subsequent premarital sexual intercourse but they were afraid to reject it.
The fear of female adolescents to reject premarital sexual intercourse as
requested by their boyfriend appeared was because of boyfriend’s coercion, as
explained by Siska and Dwi:

“I just forgot when I did for first time but it was months ago and then it was
becoming important thing for him when we had dates (pause). When I refused
then he started to get angry and told me that I wanted another guy.” (Siska,
female, 18 years old, 32 weeks gestation)
“He was always taking an opportunity for having it (sex) and then when I
refused (pause) he kept said that I do not love him anymore…...” (Dwi, female,
19 years old, 16 weeks gestation)
Some of the female adolescent participants elucidated that their boyfriends
desired to have subsequent premarital sexual intercourse at their meetings after
their sexual debut. Majority of female adolescents’ accounts suggested that they
made attempts to refuse sexual intercourse, however, they were fearful of their
boyfriend angriness. It is apparent that their boyfriends did sexual coercion to
continue to engage in premarital sexual relationship. According to Stadler et al.
(2007) sexual coercion is defined as an aggressive behaviour such as pressure,
trickery or emotional force which is used in order to get someone to agree to sex.

A minority of male participants also showed that they wanted to exert control on
their girlfriend. For example, there was one male adolescent participant who
reported his intention to make his girlfriend becomes pregnant in order to control
her, as Junianto reported:

“First time we did it (sex) was about long time ago (pause) and it was never
plan but then since she was being hard to be controlled and try to avoid me I
 125

then did it again on purpose to make her pregnant, why? (pause) It is because I
love her and I want to marry her……” (Junianto, male, 19 years old)
It is evident that some male adolescent participants used coercive behaviour yet
some female adolescent participants were aware of such coercive behaviour but
were helpless and gave in (further discussion will be presented in section 5-5).
For example Junianto’s girlfriend (Dwi) acknowledged that there was a hidden
intention in Junianto’s behaviour stating that:

“Sometimes I feel that he trapped me (pause) for made me pregnant (pause) I

feel that he did on purpose because he wanted to marry me” (Dwi, female, 19
years old, 16 weeks gestation)
Dwi’s statement clearly indicates that her boyfriend tried to control her by making
her pregnant and then marrying her. Initially couples engaged in a sexual
relationship driven by love, initiated by males, demanded by males and the
responsibility to prevent the pregnancy seemed to be that of the male and female
adolescents passively agreeing and appearing helpless.

5.4.3.1.2 Preventing the pregnancy: trial and error

According to WHO (2016) preventing pregnancy refers to birth control (also
known as fertility control), which is a method or device used to prevent pregnancy,
such as sexual practices, chemicals, drugs, or surgical procedures (Jain and
Muralidhar, 2011; Will, 2014; Rafie et al., 2016). In this study both female and
male adolescents explained the ways in which they attempted to prevent
pregnancy. They discussed availability of contraception, contraceptive advice
and their understanding of SRH as well as how they gained information about
sexual matters. Clearly all participants were aware that sexual intercourse might
result in pregnancy. They realised that there were ways to prevent a pregnancy
and they experimented with their own traditional methods of contraception. It
appears that adolescents were experimenting to prevent pregnancy with several
methods but at the end they found errors as pregnancy occurred. The
experiences of how adolescents were experimenting with their own method of
contraception that ended on their pregnancy is explained under ‘preventing the
pregnancy: trial and error’.

All female and male adolescent participants described that they used different
types of birth control methods such as coitus interruptus, avoiding sexual
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relationship within ovulation period and counting menstruation cycle. Both female
and male provided examples of ways in which they attempted to prevent
pregnancy, for example:

“We were counting my menstruation cycle and then when it was around 14
days of my cycle he put sperm outside.” (Dwi, female, 19 years old, 16 weeks
gestation)
“....... for first time I did it (put sperm inside before 7 days of next menstruation)
I was worried but after having sex for many times and safe then we thought
that what we did was right…..(Rahmad, male, 19 years old)
Participants were unaware of the effectiveness of traditional methods and did not
use any modern contraception methods such as contraceptive pills, injections,
condoms and other contraceptive devices. According to Polis et al. (2016) of the
74 million unintended pregnancies each year in the low-lower and middle-upper
middle, a significant proportion (30%) were due to contraceptive failure including
withdrawal, periodic abstinence and calendar rhythm.

Findings suggest that the majority of participants did not have adequate and
relevant knowledge and information about contraception. This was in the main
because contraception services in Indonesia were provided only for married
couples. Although condoms were available in general convenience stores and
easily accessible, mostly adolescents in this study were reluctant to access them
because they were ashamed and feared being judge as premarital sexual
relationship is prohibited. Many male participants highlighted these feelings in
their account:

“...there were condoms in Alfa mart (convenience stores), but it’s very shameful
for me to buy, I know everybody there (pause) I was a student, had not married
yet (pause) so what would people say if I buy some condoms?”(Rahmad, male,
19 years old)
“I was just worried if people know (accessing condom) and it would be very
shameful if my friends know as I had not married yet at that moment……”
(Junianto, male, 19 years old)
All female participants explained that they did not use any effective contraception
and some were not aware of contraception, as Siska and Aprilia explained:

“He had formulae from his friend (pause) he said it is safe when having sex
seven days before my next menstruation and it would be no problem without
any pills or condoms” (Siska, female, 18 years old, 32 weeks gestation)
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“I was not quite sure actually about what we did to avoid pregnancy, but since
I don’t know anything about that I then let him ask his friend” (Aprilia, female,
18 years old, 29 weeks gestation)
These findings suggest that both female and male adolescents in this study were
experimenting preventions of pregnancy which had potential risk of pregnancy
occurring. The statements of Siska and Aprilia also point that they had limited
knowledge or information related to SRH as well as lack of access to
contraception due to cultural and policy practice in Indonesian context. Many
Indonesian adolescents’ testimonies also indicated that they were unaware of
SRH services, for example Devi and Siska reported:

“I have never heard about it (SRH clinic) (pause) but if I knew this sort of place I
might not go there, as people will start to talk about reasons of why I visit such
a clinic…” (Devi, female, 18 years old, 24 weeks gestation)
“There was a session with our teacher about how a woman becomes pregnant,
I remember she talked about how sperm and egg meet and how it grows up in
the uterus that’s all (pause) I also never knew about sexual reproduction
consultation, I think she didn’t provide that kind of services…..” (Siska, female,
18 years old, 32 weeks gestation)
Although SRH services were provided, adolescents views regarding to SRH were
based on the social belief that SRH services are for married couples. Findings
suggested that whilst SRH information was provided in schools the focus of the
information tends to be on biological and anatomic rather than on relationships
and behaviour which have risk of pregnancy or preventing pregnancy. The
information provided therefore was more likely did not meet with adolescents’
need and seemed to have less impact on preventing adolescent pregnancy.

Given adolescents had limited SRH information about preventing pregnancy, the
majority of male participants reported accessing the internet as one of the
sources from which they gained information to construct their knowledge about
sexuality and prevention of pregnancy. However, many reported low levels of
knowledge of contraception and believed they did not have enough information
on which to base decisions. Although this was the case for male participants,
female participants did not elude how they gained information related to sexual
matters. For example, Arif and Rahmad reported:

“There are a lots of sources you can find on the internet and they mentioned
about how to make woman enjoy sex and some of them also provide
information about how to prevent pregnancy but what I did was wrong (pause)
maybe (pause) I don’t know, I am not sure about it…(Arif, male, 18 years old)
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“…by using doctor online in website I got them (information about sexual
matters) but I pretended to be a mature man, no one would know as it was just
only online chat.” (Rahmad, male, 19 years old)
Use of internet for gaining information about sexual matters was of concern for
public because some resources from the internet might not be appropriate, as it
is possible for it to be inaccurate and not based on current evidence (Bleakley et
al., 2009; González-Ortega et al., 2015). It was apparent that access to the
internet was easy as all participants brought at least one smart phone with them
to the interview and access for internet in Indonesia is general very good (further
discussion about internet in regards to adolescents’ sexual and reproductive
practice can be seen in section 5-5).

Summary of Sexual Debut theme

The findings of study 2 indicate that adolescent participants engaged in premarital

sexual relationship initially due to loving each other and then subsequently due
to male adolescents’ coercion to continue. One male adolescent participant
reported that he intentionally wanted his girlfriend pregnant in order for it to be
easier to control her which was also acknowledged by her girlfriend. Lack of
information and knowledge related to SRH and contraception, limited access to
contraception and SRH services due to cultural and policy practices were also
experienced by adolescents which led to experimenting of their own methods of
preventing pregnancy. It was also evident that the internet was a key source of
information about sexual matters amongst male adolescents participants, which
constructed their knowledge about sexuality and pregnancy prevention.

5.4.3.2 Theme 2: It shouldn’t have happened

Adolescent pregnancies are most often unplanned and occurred amongst
couples with lack of preparation (WHO, 2014a). Unplanned pregnancy usually
has high risk of adverse outcome in maternal mental health such as anxiety,
depression, self-harms and suicide behaviour (Barton et al., 2017b). It is because
usually an unplanned pregnancy precludes pre-conception counselling, and pre-
conception care, it is often delays initiation of prenatal care (Boden et al., 2015;
McKeating et al., 2016; Herd et al., 2016). In fact, pre-conception counselling and
care as well as early initial antenatal care are of benefit for women in order to be
ready for their pregnancy period. Prenatal care and counselling provide education
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and ways of alternative problem solving about pregnancy matters, for instance
through managing psychological and physical changing during pregnancy and
detecting pregnancy complication early (Kiwuwa and Mufubenga, 2008; Gross et
al., 2011; Gross et al., 2012)

Findings of this study highlight that participants asserted that ‘It shouldn’t have
happened’ and did not expect it to happen. Participants’ reactions to the
pregnancy was that ‘It shocked me: it needed to be ended’, they were ‘being
judged and felt shameful’, and had a ‘lack of knowledge of pregnancy matters’.
The theme ‘It shouldn’t have happened’ therefore describes adolescents
experiences when they discovered their pregnancy, their responses, how others
responded their pregnancy as well as their knowledge related to the pregnancy.

5.4.3.2.1 It shocked me: it needed to be ended

Wider literature has reported that feeling of shock commonly happen in
adolescent pregnancy, particularly when the pregnancy was unplanned (Siegel
and Brandon, 2014; Corcoran, 2016). Feeling shocked usually happened when
people find unexpected event in their life (Bammann, 2007). The ‘it shocked me:
it needed to be ended’ subtheme shows adolescents responses when they
discovered their pregnancy and their attempts to terminate their pregnancy.
Feeling shocked was experienced by the majority of participants when they first
knew of the pregnancy, as reported by Devi and Arif:

“I was really shocked (pause) I did not expect anything until my menses was
late (pause) then I started to get worried that I may become pregnant (pause) I
was waiting for my menses and when it got late by 14 days and then I knew
that I was pregnant (Devi, female, 18 years old, 24 weeks gestation)
“…it shocked me really because we were safe (experimenting preventing
pregnancy) for quite long time, I didn’t expect her to get pregnant…” (Arif, male,
18 years old)
Literature echoed that unplanned pregnancy associated with psychological
distress such as depression and anxiety (Barton et al., 2017b). It was evident
from both female and male participants that the pregnancy was unplanned and
many participants experienced an anxious time whilst waiting for their menstrual
period to occur. It appears that at the beginning of their pregnancy discovery,
almost all female and male participants experienced shocked, followed by
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distress and anxious, which could be symptom of psychological distress (Bener

et al., 2012). Aprilia and Ahmad’s comments were similar to others:

“I was very upset, confused, didn’t know what to do, I cried all day long as I
was frightened if my boyfriend would run away and not want to take
responsibility for the pregnancy” (Aprilia, female, 18 years old, 24 weeks
gestation)
“I was fearful to hear that she got pregnant but at the same time I was also
feeling blessed since I am going to have a baby (pause) I felt that I am becoming
a real man…. (Ahmad, male, 19 years old)
Whilst, the male participants were concerned once they found that their girlfriend
were pregnant, some of them felt blessed based on the cultural beliefs in an
Indonesian context that a man is viewed as a real man when the couple gets
pregnant. However, all female participants responded negatively to the
pregnancy. Some female participants talked about their reactions and the ways
in which they wanted to terminate their pregnancy.

“I did take a concoction several times (pause) I mixed unripe pineapple and
coca cola and took it three times a day but nothing happened with this
(pregnancy) (Devi, female, 18 years old, 24 weeks gestation)
“I had some pills that I bought from a drug store for make my menses come
because I intended to abort my pregnancy (pause) I took it for ages until my
pregnancy became obvious then I stopped doing that” (Siska, female, 18 years
old, 32 weeks gestation)
All female participants suggested that they attempted to terminate their
pregnancy by using traditional methods of abortion such as consuming
concoctions. Conversely, the majority of male participants reported that they had
no autonomy over the destiny of the pregnancy or girlfriend’s decision to
terminate the pregnancy. For example, Rahmad and Ahmad wanted their
girlfriends to continue their pregnancy, however, they were pressured by their
girlfriends to support them with their decisions to attempt termination:

“…I was in battle of still keeping my belief that abortion is killing my baby while
she asked me very hard to send her to a clinic for abortion (pause) that was
really a bad moment for me (pause) luckily the baby is still inside until today, I
also feel so worried if people know or a policeman knows as I might be send
into jail……” (Rahmad, male, 19 years old)
“After giving some pills that I bought from a drug store I couldn’t sleep at all
(pause) I have been stressed, since to be honest, I didn’t want to kill my baby,
but she forced me to buy that pill (pause) I was the of kind of person who did a
sin and was adding more and more sin because I was supporting her to abort”
(Ahmad, male, 19 years old)
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This reflects that female adolescents exerted their own control on their
pregnancy. It is apparent that male adolescents were anxious about the life of
their baby and also concerned about their moral obligation not to terminate the
pregnancy based on their cultural and religious belief. Conversely, female
participants’ behaviour was influenced by perceived shame as they wanted to
terminated the pregnancy. Further explanation about the potential reason of why
female adolescents appeared to hold more control than male in their temptation
to terminate unplanned pregnancy are discussed in Chapter 7.

5.4.3.2.2 Being judged and shameful

As premarital pregnancy contravenes cultural and religion expectations, many
participants were concerned about being labelled and feared social
consequences which consequently led to participants’ distress. Adolescents’
experiences are presented within the subtheme of ‘being judged and shameful.’
Social judgement is usually based on expectations which is often influenced by
cultural norm or religion values within society (Skinner et al., 2007; Weed and
Nicholson, 2015). Negative social judgement is often experienced by members
of a community who behave out of their society expectation, for example
premarital adolescent pregnancy (Whitley and Kirmayer, 2008; Melvin et al.,
2009). Both female and male participants reported experiences of negative
responses when the family first heard about the pregnancy. As Rahmad reported:

“My dad was very angry and then slapped me once I entered home, and my
uncle tried to hold his hand for not doing for second one (pause) my mother was
crying, I was really upset as well, I know my parent side, I made a
mistake…..”(Rahmad, male, 19 years old)
Rahmad experienced physical abuse from his father mainly because premarital
pregnancy was prohibited in his family and was not expected to infringe on his
family’s cultural values. His father responded negatively by showing anger. All
male participants acknowledged that they felt that the pregnancy was due to their
mistake, which reflect their self-blame. Some male participants reported
experiencing verbal abuse. Whilst, physical abuse was not experienced by all
female adolescent participants, many of them experienced exclusion from their
community, for example Devi explained:

“My friend’s parents might ask them to leave me or they might decide just to
leave me and put me away as their ex friend (pause) not sure really (pause) they
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are now treating me like someone who could spread the disease.” (Devi, female,
18 years old, 24 weeks gestation)
Social exclusion is defined as a relational process that leads to the exclusion of
particular groups of people from engaging fully in community or social life (Popay
et al., 2008). Almost all participants indicated that they experienced social
exclusion based on the social and religion expectations as consequence of their
premarital pregnancy. As premarital sexual relationship and pregnancy is
prohibited, both female and male adolescent participants experienced negative
social judgement. Aprilia and Rahmad reported:

“…..we are now struggling really hard to ignore what people say (pause) we
also think we would like to live in different city to make less contact with my
current neighbour (pause) but we do not enough money to rent a house in the
city area…..” (Aprilia, female, 18 years old,29 weeks gestation)
“People who don’t like me and my family are always spreading bad news
(pregnancy of his girlfriend) in every corner of the world (pause) they said that
I am still very young and even don’t know how to feed myself and now
impregnate a girl…” (Rahmad, male, 19 years old)
All female and male participants experienced negative labelling from their
community. Some participants intended to leave their community as a result of
negative labelling, in order to minimise contact with them. This was most likely as
a manifestation of their frustration of being judged.

Participants had a lack of opportunity to defend themselves and respond to

negative social judgement. In addition many participants found difficulties in
finding a person to share their experiences with. For example, Devi and Ahmad
explained:

“….but I could not find the right person to share with (pause) I often feel lonely
(pause) they (friends/ peers) left me and never give me any chance to express
what I really feel. “(Devi, female, 18 years old, 24 weeks gestation)
“…… I was really hurt (pause) they judged me like they have never done any
mistakes (pause) they didn’t even give me any chances to explain what actually
happened (pause) they didn’t understand my side really (pause) if they could
hear a little bit……..” (Ahmad, male, 19 years old)
Findings show that community members where they live viewed them without
respect as they were seen to breach society’s moral values. Many participants
gave their accounts of such experiences:

“………this kind of most shameful part of my life when people know that I got
pregnant before marriage (pause) and whenever I met people I felt like they
observed me from my head up to my feet (pause) so now I just make less contact
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with them by staying at home….” (Siska, female, 18 years old, 32 weeks

gestation)
“…..that is really shameful and also bring a very big consequences (pause) well
in this aged it should not happened but yes it happened to me (pause) and
people outside there are looking me down (pause) well I didn’t hear it directly
but my friend told me….” (Arif, male, 18 years old)
Both female and male adolescents in this study reported that they perceived
shame in their community which caused distress to many adolescent participants,
one of the female adolescent participant reported attempting suicide:

“I did something stupid as well because I felt so scared of my parents’ reaction

and feared of what people might say (pause) I was trying to kill myself by using
potassium. I tasted for a bit and when I swallowed it (pause) it made it hard to
breath and was painful in my chest (pause) then I grabbed a bottle of water
then I didn’t remember after that until I opened my eyes on the following
day.”(Siska, female, 18 years old, 32 weeks gestation)
Self-harm and suicide behaviour are often a reflection of a combination of poor
mental health and difficult life event (Draper, 2014; Turecki and Brent, 2016). In
addition, a suicide attempts may be an early of sign of mental illness developing
(Kaslow et al., 2006). Negative judgement and shame were difficult live events
for all participants which led them to their distress and depression. It was more
likely that participants in a helpless situation to took over their life difficulties. Thus
suicide was more likely became the only choice to avoid negative social
judgement and felt ashamed for Siska. In addition, Siska attempted suicide
because she was unable to bear with the premarital pregnancy and its
consequences. She was worried by her family’s reactions when they found out
that she was pregnant because her pregnancy was unexpected by their parents.
It was evident that many participants were also experiencing distress which was
reflected by a difficult life event. For example Rahmad and Arif reported:

“……it was really a nightmare, every minute I was like crazy (pause) that was
stressful (pause) I don’t know what to do (pause) whether to keep this (to
myself) or let my parents know directly (pause) I wished I had magic and could
twist my life back (pause) I then would not doing something stupid which
resulted to her pregnancy….. (Rahmad, male, 19 years old)
“I am so stressful even until today I still cannot imagine life after marriage
(pause) because it just happened without any proper planning (pause) like a big
rain and storm without any cloud (pause) I wished it was only a nightmare”
(Arif, male, 18 years old)
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Similarly, many male adolescent participants reported carrying psychological

burden as a result of premarital pregnancy which resulted in the feelings of guilt
and self-blame. For example, Ahmad reported:

“What I was thinking most was about her parent’s reaction because I knew
that her parent wanted her to continue her education until university but then
I kind of damaged their plan” (Ahmad, male, 19 years old)
Literature echoed that guilt and self-blames associated with depression which
consequently increases risk of psychological distress (Tilghman-Osborne et al.,
2008; Duncan and Cacciatore, 2015). It is evident that participants experienced
negative social judgement, shame, feeling guilty, self-blames, depression and
suicide temptation as a reflection of their live event difficulties as consequences
of premarital unplanned pregnancy. This finding is linier with findings reported
from study 1 (Chapter 4).

5.4.3.2.3 Lack of knowledge related to pregnancy matters

A lack of knowledge related to pregnancy matters are often experienced by
adolescents, particularly when the pregnancy was unplanned (Edirne et al.,
2010). The ‘lack of knowledge related to pregnancy matters’ subtheme refers to
adolescents’ recent experiences regarding their pregnancy, particularly their
knowledge related to physiological and pathological changes during pregnancy.
Female adolescent participants explained their experiences:

“….my breast are becoming large and bigger than previously (pause) I don’t
like it (pause) there are also some black dots in my breast (pause) I also urinate
more frequent (pause) it may be because I got pregnant young? (pause) if I get
pregnant when older I might not find them…” (Devi, female, 18 years old, 24
weeks gestation)
“I remember in the beginning of my pregnancy I started to vomit when I smelt
something boiling like rice and I feel so weak particularly when I stand or walk
for long time…” (Dwi, female, 19 years old, 16 weeks gestation)
Many female participants experienced discomfort as result of physiological
changes during pregnancy. However, they had limited knowledge and
understanding of the way in which to manage such discomfort. For instance, Devi
mentioned that she guessed her discomfort was because of pregnancy as an
adolescent. Other female participants experienced pregnancy complications for
example Aprilia and Siska reported:
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“…. I was hospitalised for about a month, it was because there was liquid
coming from inside and I got contractions very frequently, I then went to the
emergency hospital by myself because my husband was working in a different
city then the doctor said that I needed to be observed and stayed in the hospital
because I might have premature delivery but then I stayed there for 5 days and
the doctor let me to go back home.” (Aprilia, female, 18 years old, 39 weeks
gestation)
“….. she said I had anaemia that’s why I should consume iron tablets and I need
to take it once a day, these taste and smell very fishy, when I smelt it I got
poorly…”(Siska, female, 18 years old, 38 weeks gestation)
Others have reported that adolescent pregnancy increases risk of adverse
outcome for both mothers and children (detail of risks associated with adolescent
pregnancy are reported in the Background Chapter 2) (WHO, 2014a). Therefore
the findings appear to reflect the previous literature. This may have been due to
coincidence as the study design did not set out to measure this outcome.

Summary

The second theme of study 2 is ‘It shouldn’t have happened’ describes both
female and male experiences in their reaction at the beginning of their unplanned
pregnancy discovery. There were different responses regarding attempts to
terminate or preserve the pregnancy. All male participants intended to preserve
the pregnancy, on the other hand all female participants were attempting to
terminate their pregnancy. Negative judgement and shame, guilty self-blames,
and depression were experienced by both female and male adolescents due to
their premarital pregnancy, which led them to emotional distress and
psychological burden. Even one of female adolescent reported made attempt
suicide because of her worriedness of her parents’ reaction. Many female
adolescents had limited knowledge of pregnancy which led to their
misunderstanding of physiological and pathological changing of pregnancy.

5.4.3.3 Theme 3: Ending adolescent life

The theme of ‘ending adolescent life’ refers to adolescents’ experiences when
they were entering married life. When premarital pregnancy occurs in Indonesian
context, it subsequently bring couples into marriage because having children
without being married is not accepted by Indonesian society, therefore single
motherhood outside of marriage is uncommon. According to UNFPA (2013) when
a female adolescent becomes pregnant, her life can change radically because
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her education may be ended, her job prospects diminish, which in some cases
also includes social exclusion and isolation. Within the ‘ending adolescent life’
theme, the participants’ experiences related to how they engaged in marriage,
how they experienced married life, how others responded to their marriage are
described. Adolescents had no choice except to marry as consequences of their
premarital pregnancy. From which this subtheme emerged ‘I am not ready yet but
marriage is the only choice’. When married participants were expected to behave
like their adult counterparts which consequently led to them feeling ‘left by peers,
isolated and lack of freedom’; and it appeared that adolescents felt no control
over what happens in their life which is presented within the ‘powerless and
hopelessness’ subtheme.

5.4.3.3.1 I am not ready yet but marriage is the only choice

Marriage for most people needs to be prepared physically, mentally and
financially because it brings rights and obligations for the couple, which require
skills and abilities for couples to manage their married life (Story and Bradbury,
2004; Asoodeh et al., 2010). The subtheme ‘I am not ready yet but marriage is
the only choice’ reflects the adolescent participants’ experiences of having no
choice except marriage as a consequence of the premarital pregnancy. Both
female and male participants described their experiences:

“I do really understand that marriage should be prepared before (pause) I also

realise that it has not prepared properly yet (pause), like me for instance it
might be a bad outcome (pause) but then I have no choice.” (Dwi, female, 19
years old, 16 weeks gestation)
“…my Dad said that we need to respect her family (pause) that’s why we should
show our responsibility (pause) by sending a delegation to meet her family for
purposing marriage….” (Rahmad, male, 19 years old)
All of the female and male participants were required to get married and had no
control against cultural and family values. Only one male adolescent expressed
that he was ready for marriage, whilst the rest explained that marriage was not
prepared for. For instance, Devi and Rahmad reported:

“Since this pregnancy was unplanned (pause) so there is no preparation at all

on how to deal with married life (pause) as a young wife and soon I will be a
young mother (pause) it is kind of overwhelming positions I have to deal with
(pause) honestly I am not ready for these (pause) I miss my single life….” (Devi,
female, 18 years old, 36 weeks gestation)
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“I feel I got trapped in between different periods of life (pause) I am still young
but forced to have a real mature man’s life (pause) it may be no problem for
some people who are financially settled and ready but for me it is hard really…”
(Rahmad, male, 19 years old)
The majority of female and male participants were not ready for married life, they
felt overwhelmed and consequently experienced difficulties in managing their
married life. Other literature echoed that engaging married life is found hard for
many couples, particularly when marriage was unplanned because married life
requires strong commitment and consequently brings responsibilities as a wife
and a husband (Pande et al., 2011). For example, in this study 2, some
participants were always mentioning that they found it hard in financial matters
and to manage the responsibility as a wife or husband. Further discussion related
to role and responsibility in marriage life in an Indonesian context can be seen in
section 5-5.

5.4.3.3.2 Left by peers, isolated and lack of freedom

Social exclusion refers to disapproval or the act of making certain individuals or
groups within the society feel isolated and unimportant (Stillman et al., 2009;
Saunders, 2015). Social exclusion was experienced by many participants
following their premarital pregnancy. Within the ‘left by peers, isolated and lack
of freedom’ subtheme, the experiences of adolescents related to their married life
and how others responded their marriage are presented. All adolescent
participants experienced social exclusion as a consequences of their marriage.
This experience were articulated by Ahmad and Arif:

“My friends who used to be going out with me (pause) they behave different
they never asked me to join them anymore, maybe they consider my condition
now as a married man and having family responsibilities means I have to stay
with my family.” (Ahmad, male, 19 years old)
“…..after that (marriage) mostly I just stay at home, sometimes I still want to
join them (pause) but now things are different (pause) I have to consider my
parents as well, my status and my wife.” (Arif, male, 18 years old)
Social exclusion appeared to be an additional burden for many male adolescent
participants’ accounts as being married in Indonesian context requires them to
behave like an adult, therefore it is apparent that many male adolescent
participants in this study explained that their married status isolated them from
their adolescents’ peers. For example, instead of going out with adolescent peers,
they were expected to stay at home and take care of their family. Similarly, many
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female participants also explained that marriage isolated their life, as explained
by Devi:

“…..previously I used to go out anytime, anywhere with my friends whenever I

wanted, but now I can’t do it anymore (pause) ….. soon I will be a mother
(pause) so I think it is not proper if I still keep doing what I used to do before I
got pregnant.” (Devi, female, 18 years old, 28 weeks gestation)
It appeared that many adolescents experienced a changing life and needed to
consider their married status which some accepted and brought about a positive
response, as reported by Arif:

“My adolescent life will be ending soon (pause) I am accepting my life changing
(pause) and I will be engaging a family life where I will be a leader of my family
(pause) that means I need to control myself (pause) I think it will not
appropriate anymore if I still become a person who are doing whatever I
do………… it is a man responsibility to do the best for their wife and child.” (Arif,
male, 18 years old)
Findings showed that some participants were appearing to put their efforts to
managing their current role as part of their marriage responsibility as their society
expected. However, many struggled and were powerless which can be seen
within the ‘powerlessness and hopelessness’ subtheme.

5.4.3.3.3 Powerlessness and hopelessness

Powerlessness is defined as a situation when people feel there is a lack of power,
abilities, influence or even control over whatever is considered to be necessary
or that needs to be done (Lundqvist et al., 2002; Tew, 2006). Whilst,
hopelessness means a condition when people think there is no support, no
solutions or feel neglected (Kostak and Avci, 2013; Huen et al., 2015).
Powerlessness and helplessness are often experienced by an individual or a
group of people in a situation when they feel stuck and cannot do anything and
with limited support to take over the problem. Powerlessness and hopelessness
feelings have association with mental health illness such as depression which in
some cases lead to suicide ideation (Bayat et al., 2008; van Laarhoven et al.,
2011; Sahin et al., 2013), in which also happened to one of the participants in this
study which discussed within ‘being judged and shameful’ subtheme.

The ‘Powerlessness and hopelessness’ subtheme explains about experiences of

participants’ limited autonomy for decision making, lack of opportunity to defend
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their condition, lack of support sources and having no control over what happens
with their life. For example the following quotations describe such experiences:

“…..I can’t take any decision because my husband is always controlling me, I
have to follow whatever he wants, I can say sometime he ignores me (pause)
he doesn’t consider that I am his pregnant wife (pause) I feel powerless
sometimes (pause) I want to tell what I feel but I feel worried if he will get angry
and leave me…..….” (Devi, female, 18 years old,36 weeks gestation)
“…I feel hopeless really (pause) I am a woman (pause) still young (pause)
pregnant and having a husband like him, who always get angry and have no
intention to positively change himself (pause) he should reflect back and have
to understand his position (pause) he should try his best to be a real husband
(Siska, female, 18 years old, 39 weeks gestation).
“I am still feeling confused to make a decision (pause) if I still keep this
(marriage) it is really hurtful and burdens me really but if I decide to divorce I
am still not brave enough for a life as a single mother (pause) without a
husband beside me (pause) particularly for my baby I consider my baby (pause)
how hard it will be….” (Dwi, female, 19 years old, 35 weeks gestation)
“When I remember my life before such things happened (pause) what a
beautiful life (pause) have no problem at all (pause) have no conflict at all but
what I feel now (pause) everybody is being so rude when looking at me (pause)
even my wife sometimes she kind of ignore me (Rahmad, male, 19 years old)
It was more likely that patriarchal values influence adolescents’ perspectives,
which is that as a woman they were not be able to take any decision. It is also
apparent that some female participants experienced difficulties in managing their
marriage relationship due to having problems with their husband, however they
had no control as they were expected to be followers of their husband, based on
cultural values (patriarchy). Both female and male participants expressed that
their partner’s behaviours were not meeting with their expectations which resulted
in blaming each other and feeling abandoned. Marriage that was expected to
solve the problem did not happen for adolescents. Role differences based on
patriarchy cultural values also influenced the views of many male adolescents,
for instance pregnancy is not usually to be discussed by men as Junianto
explained:

“She never talks about the pregnancy with me (pause) it is not common for
discussing things with me as a man (pause) so she usually discuss it with her
mom or my mom” (Junianto, male, 19 years old)
His view was confirmed by many female adolescent participants, for instance Dwi
articulated:
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“He doesn’t want to know more about my pregnancy and my health (pause) he
is not expressing exciting for having a pregnant wife that will deliver his baby
soon (pause) he always said that he is not good about pregnancy matters and
he also said that pregnancy is woman matters.” (Dwi, female, 19 years old, 35
weeks gestation)
According to Oakley (2005) social construction refers to idea or meanings that
are assigned to objects or events within society which usually influence people’s
notions in their interactions with societies. For example within this study findings,
there were social constructions about role differences between women and men.
Many female and male adolescent participants explained that pregnancy is a
woman’s matter. Culturally, men are not expected to feel excited about the
pregnancy. In many cases, the social construction of roles categorised pregnancy
as woman’s matter which led to powerlessness amongst many adolescents
participants. Furthermore, many male adolescents also expressed their feelings
of hopelessness as consequence of unplanned pregnancy and marriage. As
Rahmad reported:

I feel that there is no light in my life now (pause) particularly to continue my

education and build my career as I planned before (pause) my bright future is
only a dream now (pause) I have no idea about what I am going to do (Rahmad,
19 years old, male)
Many participants were concerned about their education and career as they were
excluded from education, job and they also explained that they had no control to
continue education due to the feeling of being financially dependent on their
parents. For example, Devi and Rahmad describes his powerlessness:.

“This is the bitter thing that I have now, I had to leave from the school and you
know I had a dream to continue my school until university (pause) this
pregnancy really ends my future (pause) I am still not sure whether I could still
have a chance or not to continue my education after give birth”(Devi, female,
18 years old, 24 weeks gestation)
“…. actually there is a choice to move to another school that has lower grade
than my previous school (pause) but my parent asked me to leave and find a
job as my parents pay for my school (pause) so I just follow them…..” (Rahmad,
male, 19 years old)
Meanwhile, as a consequences of being excluded from education, adolescents
were trying to find a job, which is described by Ahmad:

“… I look vacancies from newspaper and I was also going doing door to door
asking for vacancies in the stores and restaurants around city but still haven’t
got anything yet…..” (Ahmad, male, 19 years old)
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Financial dependence and financial difficulties were therefore experienced by

adolescents as described in the following quotes.

“People reach their life achievement first become settled and marry so they will
have no problem with financial matters (pause) whilst my condition now is 360
degree different… (Dwi, female, 19 years old, 35 weeks gestation)
“…I have not got any job (pause) so I rely on my parents financially which is
really bad since I am a man with a pregnant wife now (pause) it is embarrassing
really (Rahmad, male, 19 years old)
All female and male participants experienced financial problems since they were
married with limited financial source, needed the support of their parents, whilst
such situation did not meet their individual expectations. This financial burden
was exacerbated as they needed to live with their parents as described in the
following quotes:

“……I live with my parents in-law (pause) and it is kind of challenging for me
(pause) I am a wife but at the same time I also need to be a child or even
sometimes I am just like a maid (pause) my parents in-law also show negative
behaviour towards me (pause) she (mother in-law) is always observing me and
looking for my mistakes.” (Dwi, female, 19 years old, 35 weeks gestation)
“I am feeling guilty when I look at myself (pause) I am a husband and I will soon
to be a father of my child (pause) but until today I am still struggling with the
way to earn money (pause) it is hard to find a job (pause) then living with my
parents in-law is the only choice because I don’t have enough money (pause)
which honestly it also burden for me as a man (pause) I am a husband but I also
need to act like a child in front of my parents in-law….” (Ahmad, male, 19 years
old)
Many female and male participants experienced having to change their role as
they were living with their parents in-law. This often led to an additional burden,
such as a felling being observed all the time and a loss of independent life. As
they lived in their parent or parent in-law’s house, they were expected to behave
as children who followed their parent’s rule and at the same time being a young
married couple, soon to be parents which created conflicts. This is evidence that
cultural values and custom play a significant role in adolescent’s perspectives as
normally in Indonesia married people live independently from their parents. A
further discussion explains how the conflict happened is discussed in Chapter 7.

Summary

The third theme is ‘Ending adolescent life’ which presents adolescents’

experiences as they had to be married due to their premarital pregnancy.
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Marriage was initiated by their parents to fulfil society expectations, however, it

also brings problems for participants. For example education termination,
financial difficulties, exclusion by their peers and feeling isolated, and
judgements. Findings showed that as adolescents engaged in marriage, they
were expected to behave as adult counterparts which led to their psychological
stress and burdens as they had lack of preparation for engaging in marriage.
Participants experienced struggling in their marriage relationship and they also
felt burdened due to their responsibility of being wife and husband.

5.4.3.4 Theme 4: Journey into new life

The tittle for theme ‘Journey into new life’ is a phrase that has often been used to
describe transition into a new phase of life (Burns et al., 2012; Riini, 2013). For
example, when people engage in a marriage, graduate from school and then start
works et cetera. In relation to the study 2,‘Journey into new life’ refers to
adolescents’ experiences in their transition from being single into in marriage and
how they experienced their married relationship before their baby was born. This
theme was developed from three subthemes which are; Allah and I; ‘practical,
emotional and financial supports; and what I hope and need.

5.4.3.4.1 Allah and I

A relationship with God, for some people has an important influence on their life
(Tanyi, 2002; Peteet, 2007). For example many people view that God is their life
goal therefore they need to build a close relationship by praying. In this study,
‘Allah and I’ describes adolescents’ experience in their relationship with God
including their spirituality, beliefs, confession, optimism and aspirations which
were influenced by their religious values. For instance Devi and Dwi articulated:

“….Allah could forgive our mistake (pause) you know a marriage is also one of
the things that we as a Moslem should do (pause) although I am getting
married from the way that Allah does not like but I just believe that Allah is the
one who will always hug us in sorrow and happiness (pause) Allah will help
us......” (Devi, female, 18 years old, 28 weeks gestation)
“When I feel so weak then I pray and talk to the God until I feel very close with
Him and then I always cry and ask Him to show me the light (pause) to see the
way I should go (pause) then I feel relief somehow ….”(Dwi, female, 19 years
old, 35 weeks)
Some adolescent participants’ accounts pointed towards acceptance of their
condition in order to gain respect from God. It was also apparent that participants
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built their relationship with God by praying. Findings show that their efforts to build
relationship with the God became a media for them for seeking help from God. It
was also evident that they were in a period of confession about their mistake.
Meanwhile, many male adolescents expressed that their recent situation
happened as punishment from God as previously they broke religious values.
Arif and Rahmad explained:

“….Allah may be getting angry with me (pause) so then gives me kind of

punishment for me to consider (pause) so in the future I can learn from my
mistakes.” (Arif, male, 18 years old)
“I made mistakes and I was wallowing in a dirty valley (pause) so then now Allah
sent the pregnancy to remind me that there is Allah the Greatest that I need to
remember…..” (Rahmad, male, 19 years old)
Both Arif and Rahmad’s views suggest that they were trying to associate their
current life with their past life. It is more likely that moral thought influenced their
perspectives about their life which seemed to be adopted from cultural and
religious values. Further discussion about how cultural and religious values
influenced individual’s perspectives is presented in Chapter 7. Some participants
explained their optimism for their future, they considered their mistakes as a
learning process yet held deep. Deep regret for what recently had occurred as
Dwi and Arif reported:

“So far there is more sorrow than happiness given from this (marriage) I don’t
know if it is normal or not or if it is because of my pregnancy that makes me
feel mellow (pause) well yes (pause) regret is always on my mind (Dwi, female,
19 years old, 35 weeks gestation)
“I feel so regret for making my parents sad (pause) it also puts me in a hard life
because I have not enough preparation for this marriage situation….”(Arif,
male, 18 years old)
Dwi’s and Arif’s views above are representative of other adolescents since almost
all participants expressed regret towards their pregnancy. Mostly, they regretted
having to commit to marriage. On the other hand, some participants described
that their life after married as being better since negative judgement and
stigmatisation from community were less. Aprilia and Junianto reported:

“I feel relieved somehow, at least one problem is solved (pause) I get married
and I will do my best to start my new life with him” (Aprilia, female, 18 years
old, 29 weeks gestation)
“….at least we are being a couple now (pause) less people will talk negatively
when we are together (pause) in my religion marriage is a worship so with this
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worship I then I will feel relived somehow (pause) since I believe that Allah will
help us…..”(Junianto, male, 19 years old)
Statements from Aprilia and Junianto described feeling better after their marriage
for having less social negative judgement as well as being optimistic in asking for
Allah’s help. The discussion about such situation can be found in section 5-5.

5.4.3.4.2 Practical, emotional and financial support

‘Support’ is a generic term which in this context incorporates the different
dimensions of practical, emotional and financial support (Elsenbruch et al., 2007;
Cust, 2016). Support in this sub themes refers to adolescents’ experiences
related to available sources which obtained by adolescents and encourage them
to be survive and continue their life through their unplanned pregnancy and
married for instance emotional encouragement, helping behaviour, financial,
accommodation and healthcare services. The following quotations described
both female and male experiences.

“… I know he also tries to give the best support for me (pause) we are both still
young but we are being supportive to each other (pause) he is also the man who
listens to what I ask (pause) he told me not to worry because he will be always
with me….” (Devi, female, 18 years old, 28 weeks gestation)
“I am doing my best to always support her because I think her burden is bigger
than mine (pause) particularly physically and health matters (pause) as she get
dizzy and she has to carry the pregnancy (Arif, male, 18 years old)
Many female and male participants’ accounts suggest that they were supporting
and being supportive to each other through the pregnancy. However, they
considered that the pregnancy gave burdens and some participants were
expressing positive attitude to as an effort to comfort their partners, which can be
categorised as emotional support (Xie et al., 2009; Stapleton et al., 2012).

A source of support which accessed by all participants was parents. Findings

show that although their premarital pregnancy was out with cultural and family
values, participants were not being left alone. They still can access at least one
of the support sources such as parents, midwives and also the community. The
quotations bellow describe the situation of being supported by their parents, Siska
and Rahmad reported:

“…my father is helping me a lot (pause) he is my hero really (pause) he is the

one who made me strong during my bad time and he still accepts me even
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though I am showering him with shameful things……..” (Siska, female, 18 years

old, 39 weeks gestation)
“ ….now I have a chance to meet my parents in- law frequently and try to get
along with them (pause) they support me and are being so nice with me even
though I am still jobless and lack on financial ability.” (Rahmad, male, 19 years
old)
Overall, adolescents’ parents provided support in terms of emotional, financial,
nutrition, and accommodation. Many female and male adolescents also gained
support from the midwife, which was explained by Dwi and Junianto:

“The one who supports me the most (pause) particularly when I feel so stressful
during my pregnancy is her (midwife) (pause) she always listened to what I
talked about (pause) being good advisor for giving many alternative ways to
solve the problem…” (Dwi, female, 19 years old, 35 weeks gestation)
“The midwife shows empathy to what we are experiencing now and what she
said was giving us kind of light because she said there is still hope in the future
which is a cute baby (pause) it is kind of new motivation for me….” (Junianto,
male, 19 years old)
All adolescent participants expressed that they were supported by midwives such
as encouragement and care services. Few female and male adolescents also
sought support from a teacher and peer. For example, Siska and Junianto
reported:

“……one of my teacher in my school was really helpful (pause) she supported

me and let me to take the final exam and she also said she will keep in secret
about my pregnancy (pause) so I can have my high school certificate (pause) it
is different with other schools as they usually do not allow students to continue
their school when somebody get pregnant like me (Siska, female, 18 years old,
32 weeks gestation)
“Most friends that I know well are expressing empathy with me (pause) they
said life must go on (pause) no need to feel upset all the time, sometimes they
visit me at home, ask me to join them to go to our favourite place where we
usually hangout, drinking, smoking, or sometimes just only chat and telling
jokes (pause) but then I choose to stay at home with my wife to minimise
negative judgement from my neighbours….. (Junianto, male, 19 years old)
Findings show that one of participant experienced compassion from the teacher
which led her to obtain her school certificate, whilst other participants had to leave
school or a job when pregnancy occurred. It was apparent that the teacher
considered that Siska had only few months left to finish her school therefore the
teacher gave her the opportunity to finish. There was also evidence that few
participants sought emotional support from their peers, for example they were not
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socially excluded, however, since a married person is expected to stay at home

with their family then participants chose to stay at home.

5.4.3.4.3 What I hope and need

Hope is defined as a feeling of expectation and desire for a particular thing to
happen (Downman, 2008; Martin, 2014). Hope comes into its own when crisis
looms, opening people to new creative possibilities (Davis, 1990; Downman,
2008). In regards to this study , participants were expressing hope of their future
life which is described within subtheme of ‘What I hope and need’, the
experiences of adolescent participants related to their expectations for the future
and their immediate needs are also presented. Devi and Rahmad reported:

“… I need money and you know that my husband still has not found any jobs yet
(pause) and myself (pause) what kind of job could I get? I did not complete my
high school (pause) so that is a problem as well…” (Devi, female, 18 years old,
24 weeks gestation)
“Honestly that (continue education) is still in my wish list (pause) but I haven’t
been brave enough yet to discuss it with my parents (pause) they may still feel
upset and not have enough money to pay for my school (pause) the wedding
party was really expensive and my parents spent a lot for that.” (Rahmad, male,
19 years old)
It appeared that in many female and male participants’ account, education and
work were required. It seemed that giving opportunity for education was one of
their expectations in order to have wider opportunity for employments. Some
participants explained that school termination limiting them for employment as
Devi reported:

“….my parents already paid for one year full tuition fees (pause) and the
pregnancy happened only a month after my parent paid these fees (pause)
school didn’t give money back (pause) so then I am not sure if I could have a
chance to have any training for skills to give me opportunity for job (pause)
because the training skill is also required fees (pause) it would be hard for me
for finding jobs because I have no high school certificate….. ” (Devi, female, 18
years old,36 weeks gestation)
Many participants were hoping for having access to education in order to be
financially independent, as Aprilia reported:

“…..if there is a chance for me to have a free training skills such as tailoring or
knitting or catering would really help me (pause) these training skill may be
benefit for me to earn money and for not being dependant to my parents…..
(Aprilia, female, 18 years old, 29 weeks gestation)
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It was evident that education and employment were explained by many

adolescents in order to be financially independent from their parents. Being
married and dependant to their parents was a situation which not expected by
almost all participants.

Summary

The fourth theme is ‘Journey into new life’ which describes Indonesian female
and male adolescents transition from being single and then married. A revived
relationship with God seemed to reduce their feelings of guilt and distress by
seeking forgiveness from God. This was a kind of confession for adolescents,
which helped some adolescents feel optimistic about their life together their
future. There were also unique experiences for adolescents as they were not
being left alone to cope with their life difficulties, although their premarital
pregnancy was out with their cultural, religion and family expectations. All
participants’ parents provided emotional, financial, nutrition, and place to live.
Few of participants sought support from the teacher, peers and maternity
services. Both female and male participants needed more help related to
education and jobs in order to be financially independent. Overall, there were
enduring element of distress across all of subthemes.

5.5 Discussion
The main findings of study 2 reflect the experiences of both female and male
Indonesian adolescents during pregnancy. Initial explanation and discussion of
the four main findings are discussed within this section with a more detailed in
Chapter 7.

It emerged that relationships had grown into intimacy which led to adolescents’
desire and initiation of a sexual relationship. Romance, desire and love were
stated by adolescents and these drove them towards their ‘sexual debut’. Other
authors reported that with all unifying relationship there is a desire for intimacy
whether emotional or sexual (Raley et al., 2007; Sassler, 2010). Adolescent
sexual relationships often occurs within the context of loving each other (Manlove
et al., 2003; Royer et al., 2009; Jones and Furman, 2011). Whereas, in some
situations transactional sex is initiated by female adolescents (McHunu et al.,
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2012; Christofides et al., 2014), to earn gifts or money which also can be found
within study 1 (Gyesaw and Ankomah, 2013; Pogoy et al., 2014b).

During adolescence there is a development of sexual cognition as a sign of

puberty (Pestrak and Martin, 1985; Biro and Dorn, 2005; Fortenberry, 2013).
Puberty itself, for many scholars is defined as the period during which
adolescents reach sexual maturity and become capable of reproduction (Ruuska
et al., 2003; Biro and Dorn, 2005; Ahmadi et al., 2009; Fortenberry, 2013). The
desire to engage in premarital sexual relationship amongst adolescent in study 2
seems to be a normal process of adolescents’ sexual cognitive development. The
development of sexual cognition and earlier puberty appears to be having an
impact on adolescents’ sexual behaviour, that they seems to engage in sexual
relationships early than their previous generations (Friedman, 1992; Aurpibul et
al., 2016). Whilst, these factors are plausible reasons to increase adolescent
pregnancies (Aurpibul et al., 2016), there may be other factors influencing
behaviour.

Female adolescents in this study had limited bargaining power and negotiation
skill. For example, whilst female adolescent participants engaged in premarital
intercourse willingly, all female participants mentioned that this was initiated and
sustained by male adolescents. This finding resonates with an Indonesian
national health survey data about adolescent reproductive health, that amongst
992 female Indonesian adolescents who had sexual experiences, 13%
mentioned that they were felt pressured by their partner when they had sex (BPS,
2013). Males influenced female adolescents by proposing to have a sexual
relationship on their date and when female adolescents rejected, they
experienced verbal or emotional abuse. A further finding also shows that coercion
appeared, as one of the male adolescent participant purposefully wanted to make
their girlfriend pregnant in order to marry and control her girlfriend. These
behaviours might have happened because Indonesian culture is a patriarchal
society. Females are taught to not assert their needs but expected to fulfil the
needs of their partners. As asserted by Oakley (2005), it appeared that women
were culturally socialised to be subordinated in many societies and this resulted
in disregarding their aspirations and needs. Other literature echoed that gender
structures reinforces women subordination, for instance in their decision making
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regarding their sexuality (Maputle, 2006; Melvin et al., 2009; Goicolea, 2009).
Furthermore, according to BPS (2013) reported that amongst 10,980 Indonesian
adolescents, there were adolescents who approved premarital sexual
relationship i.e. 7 % was male, whilst only 1% female adolescents approved that
behaviour. Therefore, that acceptance of premarital sexual relationship amongst
male adolescents is possibly one of reasons why male participants in this study
were seemingly more active to engage in premarital sexual relationship
compared to female participants.

It appears that both female and male adolescents had limited knowledge, and
awareness related to contraception and preventing pregnancy. This was
plausible in Indonesia as discussing sex is generally taboo, contraception is only
for married couples and SRH education is only related to anatomical, biological
and physiological aspects instead of on how to prevent pregnancy. Contraception
knowledge was gained by hear-say, for example friends, assumptions were and
the female adolescents were trusting and assuming the boyfriend had superior
knowledge. These findings show consistency with previous research findings in
that limited knowledge and awareness of contraception was often reported by
pregnant adolescents (Gogna et al., 2008; Mushwana et al., 2015). It also meets
with the finding from study 1 that all included papers of study 1 mentioned that
limited knowledge related to SRH and contraception, and accessibility of the
contraception had contributed to adolescent pregnancy occurring. However, the
Indonesian Demographic and Health Survey in 2012 reported that amongst
10,980 Indonesian adolescents, 90 % of them know at least one modern
contraceptive method, and more than one-third of adolescents know at least one
traditional method, which means knowledge about contraception was widespread
amongst adolescents (BPS, 2013). The findings of this study are different with
the Indonesian health survey data which probably was because this study was
not directly designed to assess knowledge of contraception methods.

Access to SRH services were not easily accessed by adolescents as they were
located in the Public Health Centre during working hours when adolescents were
more likely to be at school or place of work. Additionally, during working hours
there would be adult people around the Public Health Centre which would risk
fear of being observed rather than a young friendly environment for adolescents.
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According to Heidari (2015), context and cultural values are significant aspects
that have to be considered in developing programmes and policies related to SRH
matters among adolescents. Findings from study 2 suggest that knowledge and
access to contraception as well as inappropriate strategies may be considered
as leading factors of why premarital pregnancy occurred.

Once adolescents were aware of their pregnancy, they were anxious, fearful,
shameful and worried as well as feeling shocked for both female and male
adolescent. One female participant attempted to commit suicide. It was plausible
because premarital pregnancy was socially unaccepted and these feeling appear
as manifestation of their psychological burden which led to their psychological
distress (Glazier et al., 2004; Barton et al., 2017b) and the temptation of
committing suicide seems to reflect that shameful and fearful was unbearable for
female participant. According to Eskin et al. (2016) psychological distress is
strongly associated with reports of suicide ideations and attempts, and unplanned
pregnancy has higher risk of psychological distress, particularly among women
who felt unhappy or ambivalent at start (Abbasi et al., 2013; Barton et al., 2017a).

All female participants were trying to terminate their pregnancy by using self-
induced abortion methods which are considered unsafe. The efforts to terminate
pregnancy was because female participants wanted to avoid parent’s anger and
social reprisal. Literature echoed that one reason that many adolescents
terminated their pregnancy is in order to hide their premarital sexual relationship
from their parents and community (Davis and Beasley, 2009; Okereke, 2010).
When the premarital pregnancy occurred in places where it is socially
unacceptable, with no legal access to medical abortion, adolescents attempted
to terminate their pregnancy with their own methods or access to illegal abortion
services (Sedgh and Ball, 2008b; Haddad and Nour, 2009; Bloomer et al., 2016).
In addition, previous research evidence shows that adolescent pregnancies were
mostly unplanned and it occurred because of a lack of education and awareness
about contraception and pregnancy prevention, child or adolescent marriage, or
partner violence and abuse (Crosby et al., 2003 ; Butt and Munro, 2007; Tatum
et al., 2012; Panova et al., 2016). As the pregnancy was unplanned, adolescents
put in attempts to terminate the pregnancy (Gao et al., 2008; Ip et al., 2009;
Vazquez-Nava et al., 2014). In low-lower and middle-upper middle income
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countries, two-thirds of unplanned pregnancies occurred among women who

were not using any methods of contraception and the pregnancy ended in unsafe
abortion, which contributes to maternal morbidity and mortality (Haddad and
Nour, 2009). In this study, female adolescents were vulnerable as they attempted
pregnancy termination, or self-harm and were at risk of morbidity and mortality as
they had no access to safe abortion.

Further findings suggest that both female and male adolescents experienced
negative judgement, shame, school exclusion and having to quit their jobs due to
the premarital pregnancy. In an Indonesian social context having a girlfriend or
boyfriend is commonly acceptable but it is expected with no premarital sexual
practices. However, the social context did not mitigate adolescents’ behaviour to
prevent initiation and desire of practicing premarital sexual relationship. Whilst,
the social context plays a powerful role when the pregnancy was realised as all
female adolescent participants tried to terminate their pregnancy. The findings
therefore indicate that shame and negative judgment on women was unbearable.
Meanwhile, there were also opposing facts that some male adolescents were
expecting to preserve the pregnancy but they have a lack of autonomy for their
girlfriends’ pregnancy. The findings also suggest that male adolescents were
experiencing stress as they have no autonomy of their girlfriend’s decision and
behaviour attempting to terminate the pregnancy. This is consistent with previous
research that ending pregnancy may present unique stressors to men as it
prevents them from acting in accordance with personal or cultural expectations,
which then means they tend to blame their own character for an unplanned
pregnancy (Coleman et al., 2009; Coyle and Rue, 2015). The findings also shows
different attitudes between female and male adolescents related to pregnancy
termination. The difference may be due to a culture in Indonesia as men are
thought to be responsible as a leader of their wife, children and women in their
family, whilst women are thought to be responsible for domestic matters, taking
care of children including pregnancy and serving their husband. Therefore, the
male adolescents’ intentions to prevent the pregnancy was their reflections of
being responsible. It is interesting to know that although there is a strong
patriarchal culture in Indonesian society, the finding in this study 2 showed that
 152

in some situations female adolescents have more autonomy than male

adolescents.

The family and social expectations can also be seen as a strong influence for
both female and male adolescents’ experiences in ‘ending their adolescents’ life’.
For example, the marriage was initiated by parents to avoid social judgement and
to obtain respect from the community. The findings show that although the
premarital pregnancy was a reason for adolescents to engage in marriage,
parents were powerful factor for them to engage in marriage. The power of parent
was more obvious as adolescents expressed that they were not ready to get
married. They were forced and left with no choice except to marry. The findings
indicate that parents had absolute control to play and set the family values,
whereby they were more likely reflecting general social cultural expectation in
Indonesia. Further discussion about how parents were powerful and having
absolute control for their children is presented in Chapter 7. It is also evident that
in Indonesian society, there is a norm that men who ‘make’ their girlfriend
pregnant, they need to marry their girlfriend in order to be considered as
responsible. It is also socially unacceptable for pregnant women to be unmarried
as it will be considered immoral and out of cultural expectation (Sedgh and Ball,
2008b). Therefore, such culture seems to situate both female and male
adolescents with having no choice except to get married. The finding in an
Indonesian context is different with evidence in some low-lower and middle-upper
middle income countries, particularly related to adolescent marriage due to
premarital pregnancy. In many cases in low-lower and middle-upper middle
income countries, premarital pregnancy resulted with single parenting such as in
Kenya (Mulongo, 2006), in Ghana (Gyesaw and Ankomah, 2013) and in South
Africa (Kaufman et al., 2001). Finding also show that marriage was expected to
solve problems related to social judgement and society exclusion, yet brought
subsequent problems for adolescents. For instance, exclusion by their peers,
isolation, financial difficulties, financial dependency and education termination.
These findings have consistency with the literature and finding of study 1,
reporting similar experiences amongst adolescents in low-lower and middle-
upper middle income countries (Maputle, 2006; Yardley, 2008; Sindiwe James et
al., 2012; Pogoy et al., 2014a).
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Religious values were also playing a role in both female and male adolescents’
spirituality. This can be seen from the experiences of both female and male
adolescents on how they viewed the premarital pregnancy as God punishment.
They felt that they were not following a religious path, which resulted in their guilty
feelings. Further steps they took to build a restoration of relationship with God by
confession. Literature mentions that religious confession for many people
reduces guilt and shame, bringing about social connection, meaning and
coherence to the person’s life (Murray and Ciarrocchi, 2007). The evidence also
shows that religious values were influencing both female and male perspectives
and attitudes. For example, they saw their past as a dirty life, premarital
pregnancy as punishment and praying was for seeking help. It is also more
obvious that spirituality appeared as they believe that God is their goal life, which
resulted in feeling of optimism and hope for their future. Further findings indicated
that as their journey into a new life brought them close to God and helped them
to structure their lives and minds as well as help them to develop aspirations. The
findings have consistency with other literature that spirituality is a resource that
can be used as an alternative way to help people cope with the stresses in life,
including those of their illness (Murray and Ciarrocchi, 2007; Peteet, 2007). As
well as God, parents provided support in terms of acceptance, financial support
and by providing accommodation and nutrition. Additionally, some adolescents
obtained support from healthcare providers. These findings are interesting to
know because though adolescents broke cultural and religious values, they still
accessed support and were not completely neglected.

5.6 Summary
This chapter has shown female and male adolescents experiences as a result of
premarital sexual relationship in Indonesia. It begins from their experiences
related to their engagement of sexual relationship and SRH education, their
experience with their own methods of preventing pregnancy and how they tried
ended the pregnancy. Furthermore, their experiences of engaging in marriage
was also discussed and narrated. The findings suggest that both female and male
adolescents experienced difficulties in managing their life as a consequence of
pregnancy and marriage. Marriage was expected to save their life from social
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judgement and taking responsibilities. However, it also created subsequent

problems because it occurred without any proper planning.

Although some adolescents are having support from their parent, healthcare
providers and or group communities after they married, both female and male
adolescents were more likely to have had life difficulties, for example
psychological distress, negative judgement, financial difficulties, hard to manage
their marriage relationship, and education as well as job termination. This
indicates that both female and male adolescents require support in order to plan
their future as expressed in their hope and needs. Additionally, it was also clear
that the family, culture, religious values and policy practices played a role in both
female and male perspectives which is reflected in their behaviour. The findings
in this chapter informed the interview questions of the further study i.e. study 3
which aimed to explore Indonesian young mothers’ and young fathers’ health and
social experiences in the period after their baby was born.
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Chapter 6 Study 3: An In-Depth Study of Young Parents’ Health

and Social Experiences

6.1 Introduction
Study 3 explored Indonesian young parents’ health and social experiences
following the birth of their first baby. This chapter includes a detailed account of
the process and methods of study 3 including the aim and objectives, methods
used including study population, sample technique and sample size, inclusion
and exclusion criteria, recruitment, data collection, data analysis and the findings
of study 3. The selected quotations from participants are also used in order to
describe the themes and subthemes of study 3. A discussion using wider theory
and literature is also provided to support and debate the findings. The summary
is presented in order to conclude Chapter 6.

6.2 Aim and objectives of study 3

The aim of this study 3 was to explore health and social experiences of
Indonesian young parents after the birth of their first baby in Indonesia. The
objectives of study 3 were to:

1. Explore young mothers’ health and social experiences after the birth of their
baby.
2. Explore young fathers’ health and social experiences after the birth of their
baby.
3. Compare and contrast health and social experiences and life changes of
young Indonesian mothers and fathers after the birth of their baby.

6.3 Methods
This section presents a detailed account of methods to improve transparency of
the process of conducting study 3.

6.3.1 Study population, sampling technique and sample size

The study population were adolescent Indonesian women whose pregnancy
resulted as a consequence of a premarital sexual relationship and their
adolescent Indonesian husbands. Sampling techniques were initially of
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convenience and snowball to recruit participants representing both young

mothers and young fathers. For the same reason as with study 2, two sampling
techniques were employed due to consideration of challenges that may be found
during recruitment of the participants. The sample size was planned and it was
expected 10 young parents including young mothers and young fathers would be
involved in study 3. Where possible adolescent couples were recruited. Whilst, in
practice two more participants were recruited due to addressed gender balance
and diversity. When there was 10 participants reached, only three young fathers
included. In total there were 12 participants (8 young mothers and 4 young father)
were included in study 3.

6.3.2 Inclusion and exclusion criteria

Table 6-1 provides the inclusion and exclusion criteria for study 3 which aimed to
explore Indonesian young parents’ health and social experiences after the birth
of their first baby, who had premarital pregnancy or were married during the
pregnancy. Participants who had an experience of being a young parent were
required therefore the criteria to have a first child aged between two months to
one year old, was set. Adolescents who were pregnant as consequences of rape
were excluded as adolescents with rape cases would have different social
reactions or judgement. People who become pregnant due to rape cases would
not be considered as people who out with cultural and religious values in
Indonesian context. Furthermore, pregnant adolescents as a result of rape cases
are allowed to access abortion as well as services in foster care for their baby.
For similar reason as with study 2, adolescents with learning disabilities were also
excluded as it was considered unjust as they were less likely to understand what
was required from them and why or they might be less likely to provide informed
consent to be involved in this study (McClimens and Allmark, 2011). The table 6-
1 present the inclusion and exclusion criteria of study 3.
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Table 6-1: Inclusion and exclusion criteria of study 3

Gender Inclusion Exclusion

Female 1. Indonesian resident. 1. Rape

2. Has her first child aged between 2 month to 1 cases.
year old. 2. Learning
3. Had a premarital pregnancy or married during disabilities.
pregnancy.
Male 1. Indonesian resident. 1. Learning
2. Has first child aged between 2 month to 1 year disabilities.
old.
3. Has a wife or a girlfriend with experience of
premarital pregnancy or married during
pregnancy.

6.3.3 Recruitment
Similar strategies to study 2 were used to recruited participants for this study 3
i.e. by using postnatal records to identify potential participants and by using
posters that were displayed in the waiting rooms of the public health centre and
midwifery private clinic. The poster was considered a possible way to recruit
potential participants by displaying brief information which may attracted
adolescents to participated. The poster also provided contact numbers of the
researcher so that potential participants could make contact and ask questions.
The postnatal records were used to identify potential participants because they
provided a detailed history of the pregnancy, delivery and postnatal care, details
of the partner or husband, age of participants, as well as a contact number and
address.

Details of how participants were recruited is explained in the following section:

1. Married participants
a. Young parents were identified from postnatal records by the researcher.
b. At the postnatal clinic appointment a midwife offered potential
participants an information sheet and a consent form and gained their
agreement for the researcher to contact them within three days to
ascertain whether they wished to take part in the study.
c. Within three days, potential participants were contacted by mobile
phone. A brief introduction was given including who the researcher was,
the purpose for contacting them and then checking whether potential
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participants had received the information sheets and a consent form

from midwife.
d. A brief explanation of the study related to the information sheet was also
given. Potential participants had the opportunity to seek clarification and
ask questions. When the researcher was assured that they understood
the information, they were asked if they were interested in taking part in
the study or not.
e. When potential participants expressed interest verbally to participate in
the study, an appointment was made for a face to face interview
session.
f. Before the interview session was conducted, an informed consent was
gained first by signing the informed consent sheet.
As with study 2 adolescents who were married (regardless of their age), were
legally permitted to give consent to participate in any research. According to
Indonesian Civil Law Code (Kitab Undang Undang Hukum Perdata) (KUHP)
article 330 Indonesia considers adulthood (age of consent) to be when people
are aged 20 or above or under 20 years of age and married. Furthermore, in
Indonesia, it is common that a woman’s partner or husband usually accompanies
them to postnatal care appointments, therefore a similar procedure to recruit
married male participants took place.

2. Unmarried participants
a. Stage a, b, c and d were followed as above.
b. When potential participants expressed an interest verbally, to take part,
it was explained that the researcher needed their permission to gain
consent from the adolescents’ parents.
c. In this situation, before the first interview session, informed consent was
gained from adolescents’ parents

In study 3 all potential participants were married, therefore the procedure of

recruiting unmarried participants was not used.

6.3.4 Data collection

An in-depth interview approach was used to explore young parents’ health and
social experiences. The topic guide was developed based on study 1 and 2 in
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terms of themes and context. The research questions were beneficial for the
researcher to guide the interview on the topics suggested by study 1 and 2. The
details of interview questions can be seen in the table 6-2.

Table 6-2: Interview questions of study 3

Interview Questions of Study 3

Young mother Young father

1. Theme 1 : Experience as a young 1. Theme 1 : Experience as young

mother father
 Can you tell me about your life  Can you tell me about your life
as young mother? as a young father?
2. Theme 2 : Life changing 2. Theme 2 : life changing
 And can you tell me about any  And can you tell me about any
changes to your life you have changes to your life you have
needed to make as young needed to make as young father
mother 3. Theme 3 : Support needed
3. Theme 3 : Support needed  Can you tell me about who has
 Can you tell me about who has helped you and what help you
helped you and what help you have needed so far?
have needed so far? 4. Theme 4 : life planning
4. Theme 4 : life planning  And how do you think the future
 And how do you think the future will unfold for you now? What are
will unfold for you now? What your plans?
are your plans?
Similarly to study 2, for study 3 process of recruitment, consent and interview
questions were piloted before use. A young mother participated in pilot research
process and interview questions. The pilot process confirmed that the process of
research was work appropriate as the pilot participant understood the PIS,
informed consent and also engaged in the interview without any significant
interruption. The interview questions appeared to work well that is to elicit
appropriate data, therefore no amendments were made (Green and Thorogood,
2009). A pilot interview is used to assess that participants not only understand
the questions but understand every single question in the same way that
researcher expected (Neville, 2007). Furthermore, there was information gained
that:

 A friendly conversation took place enabling the pilot participant to speak

about 30 to 40 minutes without any significant interruption
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 The pilot participants responded to the questions and seemed enthusiastic

about describing their story which suggested that they had a clear
understanding of the questions
 The pilot participant did not request an appointment session with midwife
after the interview, that suggest she had no complaints regarding the pilot
interview session.
 Probing questions were also used to gain further insightful perspectives
from the pilot participants and encouraged further explanation such as ‘tell
me more about your feelings on…..’ ; ’you said……..tell me a bit more
about that…….’ ; ‘you said…… expand on that if you can…..’ and ‘how do
you feel about that’.
The actual process of data collection started after pilot process ended and
participants were interviewed in one-to-one and audio recorded in a private room
of the public health centre or midwifery private clinic. Field notes were also taken
by the researcher after the interview ended written in Bahasa Indonesia. The
benefit of one-to-one in-depth interview was that the participants were free to
share their experience and explain their real situation privately (Morse et al.,
2001). If individuals were interviewed as a couple, they might not feel free to
speak out loud their truth or they might describe some experiences, thoughts,
and feelings, but not reveal to others (Taylor and de Vocht, 2011). Therefore,
one-to-one in-depth interviews were used to collect the data in this study.

Each interview for study 3 was recorded in in Bahasa Indonesia with a maximum
length of 60 minutes interview. Additionally, during the interview process, the
researcher also paid attention in particular to attitudes or gesture that could be
linked in data interpretation (Flick et al., 2007). For example their expressions,
intonation and emotional tensions were considered when making field notes after
interview ended. Participants were able to withdraw at any time before, during
and up to 24 hours after the interview without giving a reason. None of the
participants asked to withdraw from the study, therefore all the interview data
proceeded to data analysis. If participants expressed anxiety, discomfort or
distress during the interview, opportunity to have rest was available and consent
to continue would have been gained or another appointment, as suggested by
Brouneus (2011) and Macneil and Fernandez (2006). Midwives were accessible
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to support participants if they had any concerns related to the interview. None of
participants asked for rest during the interviews neither asked to seek support
afterwards from midwives.

6.3.5 Data analysis

The process of data analysis was using thematic analysis guided from the
framework described by Colaizzi (1978) as with study 2 in Chapter 5.3.5.
Although the process of data analysis of study 2 and 3 were separated, the
strategies of data analysis process were similar for study 2 and 3. The process
of transcriptions including using pseudonym and removing all details that
potentially pointed to participants; transcriptions were transcribed by the
researcher; audit checking was also used for checking transcriptions against
interview records by an Indonesian fellow; sample transcripts were translated into
English by the researcher and then checked by an Indonesian fellow who is fluent
in both Bahasa Indonesia and English, and translated back from English to
Bahasa Indonesia; field notes that were taken after each interview ended also
helped the researcher on data interpretation. The following box is a translated
example of the field note which was subsequently used to help data
interpretations.

Title: Field note of Interview of Participant 10 (Edi)

Date: 15th April 2015
Length of interview: 32 minutes 11 seconds
Descriptions:
Edi was coming to public health centre with his wife and his baby. During pre-
interview, Edi was really friendly and he talked and asked many questions related
to the research. However, I could see that he was not quite flexible on carrying
the baby but was maintaining to have contact with the baby. I could see that
when the baby cried, Edi was asking his wife to make the baby calm down and he
was expressing a panic attitude.
Edi was a young father of a baby aged 7 months old. I could see Edi was quite
easy to talk and he could described his experiences as a young father.
Interestingly, in the interview he stated that he is not a biologic father of his
baby. However, I could see that he felt no problem with that as he described
that he loves his family and he said he will do the best for them. Edi was really
enthusiastic on answering the questions and sometimes he slipped out of the
topic. During the data collection so far, he was the first male participants who
described any questions that researcher asked without rejecting any questions.
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Familiarisation was conducted by reading and re-reading through the data,

listening and re-listening to the audio recordings of interviews and identifying
emergent themes as well as considering the applicability of predefined themes.
Coding was by using an inductive approach and it was in English language in
order to start analysing further processes which were looking for patterns,
comparing and contrasting; abstraction and synthesis; production of thematic
account; development of typologies and looking for deviant cases (if any) to refine
the analysis. An iterative process of analysis was also undertaken in order to gain
insightful meaning from the data. QSR N Vivo 10 has been used for data
management of transcripts, scanned field notes, soft file related data and audio
recording. The following figure illustrates the sample of N-Vivo used on managing
sources of data:

Figure 6-1: N Vivo as data management for study 3

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6.4 Findings

This section presents the findings of study 3 includes characteristics of the

participants, process of participants’ recruitment and the emerging themes of
study 3.
6.4.1 Characteristics
The sample size in study 3 was 12 including eight young mothers and four young
fathers. All participants were married and four of the young mothers had married
mature men. Table 6-3 present the profile of the participants.

Table 6-3: Profile participants of the study 3

Name of Length of Descriptions
participants/ interview/
aged age of child
Couple Hesti (18) 49” / 7 Hesti left school early due to her
months pregnancy and then got married. At the
time of interview she was unemployed
and received financial support from her
parents.
Edi (19) 32” / 7 Edi is Hesti’s husband. He left school
months and at the time of interview he had been
in part time employment with a
minimum wage. He was in the process
of looking for better job.
Setyorini (19) 44”/ 4 Setyorini got pregnant aged 18 and left
months school due to premarital pregnancy.
Ririn (17) 47”/ 6 Ririn married when her pregnancy was
months in the 3rd trimester. She left her job due
to her premarital pregnancy.
Couple Paryati (16) 35”/ 2 Paryati was aged 15 when her
months premarital pregnancy occurred.
Andri (18) 37” / 2 Andri is Paryati’s husband. He was
months working to assist his parents and
looking for a job in a nearby city.
Couple Qoriatul (16) 37”/ 2 Qoriatul got married when her
months premarital pregnancy was in the 3rd
trimester. She left school due to
premarital pregnancy.
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Name of Length of Descriptions

participants/ interview/
aged age of child
Tri (19) 39”/ 2 Tri is Qoriatul’s husband. He finished
months his high school and started to work with
minimum monthly salary.
Eny (17) 45”/ 4 Eny got married when her pregnancy
month was in the 2nd trimester. She married a
mature man and quit her job to hide her
pregnancy from peers.
Sri (17) 47”/ 4 Sri left school as she become pregnant
months before marriage and then married a
mature man.
Couple Atika (19) 38”/ 3 Atika left school due to pregnancy. She
months got married just before 1 month before
he baby was born.
Febri (18) 35”/ 3 Febri is Atika’s husband. He is not in
months any school and at the time of interview,
he was working with a minimum wage.

6.4.2 Process of participants’ recruitment

The process of approaching participants was also employed and the process of
it can be seen in Figure 6-3.

20 young parents including seven couples and six young mothers were
identified from postnatal records and invited to participate in this study 3

Seven young parents declined due

13 young parents including eight
to several reasons:
young mothers and four young
 Two couples (four young
parents who moved away to fathers agreed)
other cities).
 One couple (two young parents 12 young parents
One young mother
couldn’t manage the time to
participated in the interview. participated in pilot including young

 One young mother did not any interview). Data not mothers and young
reason including in the fathers participated
analysis in the interview

Figure 6-2: Process of approaching adolescent participants for recruitment

to study 3
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All participants were identified from post-natal records in a public health centre
and a midwifery private clinic. All the participants in study 3 were married,
therefore consent was gained individually from participants and the procedure for
recruiting unmarried participants was not applied. There were no contacts made
from people seeing the poster, which may have been because potential
participants feel too shy to contact the researcher or reluctant to start initial
contact with the researcher. Displaying posters did not result in any participants
or queries. However, the posters may have contributed to participants’ decision
to take part in this study, because the posters provided brief information and they
were displayed in the waiting rooms of the public health centre and midwifery
private clinic which enabled people to read easily.

Initially, 20 young parents (seven couples and six young mothers) were identified
from postnatal care records and invited to participate in this study. Of these eight
did not participated in the study 3 due to several reasons. There were four young
parents (two couples) who moved to the different cities and declined to take part
in the study due to limited time to travel to the public health centre. Two young
parents (one couple) who declined because they couldn’t manage their time due
to full time working. One young mother decided not to take part for the study
without giving a reasons, it may because of the sensitive nature of the topic which
not all people would be able discuss. In total 13 potential participants were agreed
to be involved in this study, of these one young mother participated in pilot
research process and pilot interviews. In final stage, eight young mothers and
four young fathers were involved in the study 3. There was also evidence that six
young mothers have husband above aged 20 at the time of the pregnancy,
therefore their husbands were not approached.

6.4.3 Emerging themes

The experiences of adolescents as young mothers and young fathers are
described in this theme. The themes describes the experiences of both young
mothers and young fathers in their transition as being parents, when the baby is
aged between 2 months and 1 year old. There are three themes which emerged
from the data which is described in Figure 6-4.
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1. An overwhelming life
- My life is hard to manage: balancing on a tight rope
- Jobs and financial matters: not as easy as blowing
a balloon

Health and social

experiences after the birth
of the baby

3. My future plans and

my needs
2. Struggling to be
- Plans for work, parent: heavy rain that
vocational training and suddenly happened
continuing education without any clouds
- I want to stay close - Judgement
with Allah
-My married life
- I need support to be a
young parent -Parents' interference in
breastfeeding practice
- I don't want to have
another one

Figure 6-3: Themes and subthemes that emerged from study 3

The first theme is ‘An overwhelming life’ which reflects the experiences of young
mothers and young fathers about their tasks as young parents. ‘Struggling to be
parent’ depicts the experiences of young mothers and young fathers in how they
struggle with their life as a consequence of premarital pregnancy. ‘My future
planning and my needs’ show how young mothers and young fathers cope with
their recent life, manage their life plan and express their support needs to be
young parents.

6.4.3.1 Theme 1: An overwhelming life

The term an overwhelming is often used to describe a situation when people are
gaining something they had not expected, which is very intense and hard to deal
with (Strandberg et al., 2001; Wilkinson et al., 2012; Condon, 2014). The theme
of ‘An overwhelming life’ shows the experiences of young mothers and young
 167

fathers relating to their tasks as young parents includes how they managed their
life when their first baby was aged from 2 months up to 1 year old. It is evident
that young mothers and young fathers experienced difficulties in managing their
life as parents which is presented within the ‘My life is hard to manage: balancing
on a tight rope’ subtheme. Participants were also experiencing issues in terms of
employment and financial concerns, which are included in the ‘Jobs and financial
matters: not as easy as blowing a balloon’ subtheme.

6.4.3.1.1 My life is hard to manage: balancing on a tight rope

Parenting for some adolescents can be challenging as they find it hard to adapt
to the changes as well as their transition from single adolescents to adolescent
parents (Bailey, 2005; Tan and Quinlivan, 2006; Van der Borght and Hernandez,
2016). Such a condition was also experienced by young mothers and young
fathers in this study 3. The ‘My life is hard to manage: balancing on a tight rope’
subtheme presents the experiences of young mothers and young fathers related
to how they adjust and tried to manage their life as young parents . For instance
Hesti and Febri reported:

“Well (pause) it is challenging really (pause) at the same time I have to take
care of my baby (pause) provide food for my family (pause) clean the house et
cetera et cetera” (Hesti, female, 18 years old, mother of a 7 months old baby)
“…….because I was not prepared (pause) to get married and have the baby
(pause) these were not initially planned (pause) so now I can say it is kind of
disaster and sometimes I just get stuck because of having problems with money,
jobs, her (wife) (pause) her family (pause) my friends and even other people
(pause) they are just giving problems at the same time (pause) when one
problem is solved then another one just waits around the corner (pause) feel so
tired and stressed…..” (Febri, male, 18 years old, father of 3 months old baby)
Both young mother and young father found difficulties in managing their life
changing as parents as well as a wife or husband. It was evident that whilst all
young mothers experienced the burden of taking care of the baby and domestic
tasks, most young fathers felt overwhelmed due to their relationship with their
wife, parents, parents in-law or peers as well as financial matters. It was also
evident that many of the young mothers and young fathers experienced stress
due to trying to manage their life change and responsibilities as a young mother
and young father.
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Furthermore, findings also showed that in an Indonesian cultural context

domestic tasks and taking care of the baby are women’s responsibilities, Hesti
and Tri reported:

“Well I do not want to ask him too much (pause) like now for example (pause) I
prefer to ask my mother to help rather than ask helps from him (pause) I am
also trying my best to listen of what he said (pause) he asked me not to work
and stay at home (pause) as taking care of my baby is my job and he said he
will earn money for me and my baby” (Hesti, female, 18 years old, mother of a
7 months old baby)
“It feel so weird when helping my wife on baby matters (pause) I am not
confident enough and I also think that all of these tasks are kind of women’s
jobs (pause) but it doesn’t mean that I ignore her needs” (Tri, male, 19 years
old, father of a 2 months baby)
Data suggested that gender role division within participants’ married life
appeared. Gender role divisions amongst wife and husband refers to attitude on
how they shared responsibility as a wife and as a husband (Varga, 2003; Forste
and Fox, 2012). It appeared from the data that the attitudes of sharing parenting
responsibilities were influenced by social expectations within an Indonesian
context, in which further discuss under the section 6.5. For example Hesti and Tri
explained women took responsibilities for taking care of the baby and managing
the domestic tasks. Interestingly, although some young mothers and young
fathers were experiencing difficulties in managing their life changes, some of
them were accepting their new role as a parent:

“I don’t want to give more burden to him (husband) really (pause) what he does
for me and my baby is much more than enough (pause) so it is my responsibility
to take care of my child (pause) provide him foods (pause) and do what women
usually do (Hesti, female, 18 years old, mother of a 7 months old baby)
“Taking care doesn’t mean only cuddle or make him silent but for me it means
I have to be responsible for his (baby) entire life (pause) which is really big tasks
and hard for me as a young father and I have had no preparation before.” (Edi,
male, 19 years old, father of a 7 months old baby)
Many young mothers and young fathers reported that they were aware, accepting
and put effort to adjust their parent responsibilities. Findings suggest that some
participants had similar views related to parenting responsibilities and it is evident
that participants were adopting cultural values and social expectations on
handling their responsibilities as a mother and father. Findings also showed that
gender role divisions amongst young mothers and young fathers also can be
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found in their perception related to contraception, which can be seen from their
quotations, for example Qoriatul and Edi reported:

“I am okay for using contraception since I know it is a woman’s responsibility….

(Qoriatul, female, 16 years old, mother of a 2 months old baby)
“…..I am not interested in using that (any contraception) I am a man and will be
responsible to meet my wife’s needs and things like that is my wife’s matter….”
(Edi, male, 19 years old, father of a 7 months old baby)
All the participants described similar views related to contraception that
contraception is a woman’s responsibility as explained of Qoriatul and Edi. It was
evident that some young fathers also explained that they do not want to take
responsibility for contraception, so when pregnancy occurs it will be woman’s
responsibility.

Findings suggest that some of the young fathers were using their position as a
husband to purposively control their wife, whilst some of them were showing
supportive behaviour towards their wife as Andri and Febri reported:

“I am the one who asks her to stay at home and focus on taking care my child
(pause) because, based on my friends’ experience when women earn money by
their own (pause) they are quite hard to be controlled ……”(Andri, male, 18
years old, father of a 2 months old baby)
“I have to be responsible for my family (pause) when she is doing wrong then I
need to remind her (pause) well we are both still young but at least I put effort
on controlling her, (pause) is my responsibility and my right as well ….”(Febri,
male, 18 years old, father of a 3 months old baby)
Some of young fathers suggested that the husband’s role was to control their
wife’s life from employment and on the other hand some of them explained that
they controlled their wife and family as their effort to be responsible to their family.
Therefore, it was more likely that there were different attitudes on how a young
father were behaving in regards to controlling their wife. Some of them put efforts
on controlling their family in order to be in the right path, whilst some other used
their control to make barriers for their wife on accessing employment. Further
discussion about how power and control used within marriage relationship can
be seen in Chapter 7.

6.4.3.1.2 Jobs and financial matters: not as easy as blowing a balloon

Job and financial matters are often found to be issues when adolescents engaged
in parenthood (Hanna, 2001; Gillmore et al., 2008; WHO, 2014a), particularly
 170

when there is an absence adolescent parenthood support system and services

(WHO, 2014a). Within the subtheme of ‘Jobs and financial matters: not as easy
as blowing a balloon’, the experiences of young mothers and young fathers in
how they experienced jobs and financial issues are discussed. Like Sri and Edi
reported:

“……it is not easy for me knowing that he found it hard to get a job (pause) but
when I tell him that I want to look for job then he always get angry (pause) I
don’t understand what he actually wants as my son and I need money to buy
our basic needs (pause) but as a head of our family he has given me nothing
(pause) I am drowning really ….” (Sri, female, 17 years old, mother of 4 months
old baby)
“I feel so dizzy when it is still in the middle of month then all my money has gone
and it is happening in every month (pause) I have already sold my motor cycle
(pause) so if I don’t find a full time job soon it might become a disaster for me
and my family….”(Edi, male, 19 years old, father of a 7 months old baby)
Almost all young mothers and young fathers experienced problems related to
jobs and financial matters. They experienced financial difficulties to fulfil their
basic needs. Although some of young mothers and young fathers were financially
supported by their parents, this was not expected nor ideal, which led to some of
the participants feeling guilty and self-blaming. Hesti and Tri reported:

“I feel guilty as I have not given any happiness to her (Hesti’s mother) and now
I just make additional burden on her (pause) particularly in terms of economic
matters (pause) you know my family is poor (pause) that is why I did not
continue my education and then I tried to look for a job (pause) I tried to earn
money (pause) but then things happened (pause) I got my pregnancy and I had
to leave my job.” (Hesti, female, 18 years old, mother of a 7 months old baby)
“My parent is the one who supports my financial needs when I get stuck with
limited money now and even for my wife and my baby as well (pause) it is really
shameful actually but the fact is that I have limited money to be honest.” (Tri,
male, 19 years old, father of a 2 months old baby)
Findings indicate that some of the young mothers and young fathers realised that
gaining financial support from their parents were not expected, however, as they
have limited financial sources, such support helped them. Further findings also
suggested that being dependent on their parents or parents in-law was not ideal
for their lives as it affected their freedom of being young parents, which is
illustrated from the following quotes:

“….living with only my small family is in my wish list (pause) then I could manage
my new family life independently (pause) but the problem now is money (pause)
my husband is not ready yet to rent a house independently.” (Setyorini, female,
19 years old, mother of 4 months old baby)
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“I want to work in capital city so then it might be easier for me to find the job
(pause) so then I can be the real husband and can provide my family needs and
the most important thing is I could live independently (pause) as I said before
that I just really depend on my parent for many things now.” (Andri, male, 18
years old, father of a 2 months old baby)
Many young mothers and young fathers experienced a guilty feeling and were
embarrassed to be dependent on their parents whilst married. As within the
Indonesian culture there are some married couples living with their parents,
ideally it is expected that following marriage couples should live independently
from their parents or at least have an adequate income to fulfil their family basic
needs. Findings also suggest that many participants had aspirations that they
wanted to live independently, however their achievements were hindered by
financial constraint. It is evident that cultural values influenced the perspectives
of young mothers and young fathers in the concept of the ideal married couple
which will be further explained under section 6.5.

Additionally, findings show that the consequences of young couples being

dependent on their parents or their parents in-law or husbands, was that they
face difficulties in their decision making, as described in the following quotes.

“I want to live independently (pause) since my mother in-law interferes too

much in every detail of my new small family life (pause) that is bad behaviour
(pause) she is always commenting on how to eat or how to go to the toilet
(pause) it is really frustrating….” (Setyorini, female, 19 years old, mother of 4
months old baby)
“ Being dependant on somebody else is not good really (pause) because then I
need to remain silent of anything that happens to me and to my wife (pause) I
cannot say much when they (parents) say something negative about me and
my wife.” (Andri, male, 18 years old, father of a 2 months old baby)
Many young mothers and young fathers perceived that they had no autonomy as
they were dependent on their parents or their parents in-law, which seemed to
lead to internal conflict (ambivalence) amongst these young mothers and young
fathers. Therefore, some of them put their effort to finding a job, which was difficult
to find at best of times, in order to have an independent life, which is presented
in the following quotations.

“Well, it seems okay when my husband gives money to me (pause) but then he
said use it wisely (pause) so it is more likely he is not totally happy giving me
money (pause) if I have a choice it is better to have money by my own, I started
to look for a jobs but it is hard to find one (Eny, female, 17 years old, mother of
4 months old baby)
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“I have been looking for a job for a long time (pause) but it is not as easy as
blowing a balloon (pause) until today I have got nothing.” (Tri, male, 19 years
old, father of a two months old baby)
Almost all young mothers and young fathers in this study experienced difficulties
in finding suitable employment which resulted in being dependent upon others
(parent or partner) and subsequently seemed to contribute to their lack of
decision making and limited their freedom. Such situations seemed to contribute
towards young parents’ self-esteem and also their social relationships which will
be further discussed in Chapter 7.

Summary

Within this theme, experiences of young mothers and young fathers are
described including how young mothers and young fathers deal with their
responsibilities as young parents. The findings indicated that both young mothers
and young fathers experienced challenges in terms of managing their changing
life as young parents. For example, young mothers most often find difficulties in
coping and balancing with their responsibilities of taking care of their baby,
serving their husbands and also domestic tasks. Whilst, young fathers
experienced difficulties with financial matters, finding work and relationships with
their wife, parents, and parents in-law. In their transition into parenthood, findings
showed that young parents received financial support and accommodation from
their parents, yet they were still facing problems. For example, being dependant
seemed to lead to having less freedom and autonomy in decision making for both
young mothers and young fathers. This situation was more likely to lead to
feelings of guilty, self-blame, regret and shame as it was out-with the expectations
of Indonesian society.

6.4.3.2 Theme 2: Struggling to be parent: heavy rain that suddenly

happened without any clouds
According to the Oxford English Dictionary, struggle is a condition of putting in
hard efforts to do or get something. Struggling experiences are often experienced
by young parents as they deal with challenges that place extra demands not only
during their stage as adolescents but also on their ability to adapt to their new
role as a parent (DeVito, 2010; Strömmer et al., 2016). In many countries, in the
situation where young parents are not expected by society because it is out with
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cultural expectations, they often obtained social judgement and stigmatisation

(Wiemann et al., 2005; Yardley, 2008; SmithBattle, 2013). This ‘Struggling to be
parents: heavy rain that suddenly happened without any clouds’ theme therefore
discusses young mothers’ and young fathers’ experiences of struggling with their
life after the birth of their baby including their experiences of social judgement,
marriage relationship, and interference. Through the journey of becoming young
parents, adolescents were still experiencing society judgement due to their
premarital pregnancy, in which presented in the ‘Judgement’ subtheme. Both
young mothers and young fathers experienced difficulties in managing their
married life which is presented within ‘My marriage life’ subtheme. Additionally,
as they lived with parents or parents in-law they experienced interference in their
attempt to be parents, which is presented under ‘Parents’ interference’ subtheme.

6.4.3.2.1 Judgement
Judgement in society relationships is described as a process of considering
whatever is right and wrong related to the people’s attitudes (Johnson and Webb,
1995; Thompson et al., 2005). Society judgement is usually based on social
values which existed within a society and in some context such social values
become unwritten rule amongst society members (Eiser, 1990; Thompson et al.,
2005; Woo et al., 2017). Under the subtheme ‘Judgement’, experiences of young
mothers and young fathers in regards to society judgement as young parents are
described. It is evident that in this study 3 all young mothers and young fathers
experienced premarital pregnancy which is considered out with cultural and
religion expectations in Indonesia. For example, Eny and Tri reported:

“…….I live in a village (pause) and until today I still feel shy if I want to go out
from home (pause) I feel they look at me like stranger as I did make a mistake
as I got pregnant before marriage” (Eny, female, 17 years old, mother of 4
months old baby)
“People always comment on my life (pause) they told me that I have to mind
about my past (married due to premarital pregnancy) (pause) they said that it
may also happen in my child’s future life…..”(Tri, male, 19 years old, father of a
two months old baby)
All the participants in this study reported similar experiences of being judged by
the local communities, asserting that premarital pregnancy contravened
community expectations and was considered as a mistake, and the community
was judgemental. The consequences of such societal judgement was that young
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parents professed that this resulted in them becoming isolated. This situation
gave young parents additional burden and challenged them to engaged in their
communities. Some of participants also experienced disappointment that instead
of providing support to them, the community gave negative labels. As expressed
by Paryati and Edi:

“The most part that makes my burden more heavy is I have no information
about how to be a normal mother (pause) I have no preparation as my
pregnancy was not planned so it is not fair when people judge me if I am doing
wrong on how to be parent…” (Paryati, female, 16 years old, mother of 2
months old baby)
“……it is like a heavy rain that suddenly happened without any clouds and I did
not prepare any umbrella (pause) I have no preparation as a young father but I
know that a father has to be responsible for the family (pause) so then I think I
need some information to deal with that or at least instead of judging me
(pause) people should teach me how to be normal parent like them…” (Edi,
male, 19 years old, father of a 7 months old baby)
Findings suggested that both young mothers and young fathers found it was
challenging to become parents resulting from the community’s judgement without
giving them an opportunities to defence. Many of young mothers and young
fathers in this study expressed that they required support such as information or
training on parenting.

Seemingly, cultural values and beliefs shaped how young mothers and young
fathers located and explained their current circumstances. For example:

“….it is true when people say that what we planted in the past will be harvested
in the future (pause) it has happened to me I planted very stingy seeds and now
I am harvesting the worst one (pause) I got married due to my pregnancy then
it will end up with divorce….” (Ririn, female, 17 years old, mother of a 6 months
old baby)
“……. I also consider what people might say to me as I did a stupid thing and
made a girl pregnant (pause) and got married with no preparation and might
end up with a divorce……. (Tri, male, 19 years old, father of a two months old
baby)
Findings suggested that community judgement influenced the perspectives of
young mothers and young fathers for seeing themselves and cultural values may
have contributed to views regarding their premarital pregnancy linked with their
current life. The perspective of morality amongst both young mothers and young
fathers were more likely based on cultural values within their community and it
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seemed that they were making sense of their current world due to their past
attitudes. This situation will be discussed further in Chapter 7.

6.4.3.2.2 My married life

Literature reported that marriage for many people encounters challenges and
difficulties particularly when unplanned, it possibly would be more difficult (Story
and Bradbury, 2004; Asoodeh et al., 2010). Young mothers and young fathers in
this study also experienced a struggle with their married life as it was not planned
and they lacked preparation for engagement in married life. The ‘My married life’
subtheme therefore presents the struggling experiences of young mothers and
young fathers with their married life. Some participants were expressing to have
divorce ideation in order to be more feel better.

The following quotes are the examples of experiences of young mothers and
young fathers as Sri and Tri reported:

“I know that divorce is the bad thing and people should try to avoid it but in my
case I might feel better if I am living without him (husband) (raise eyes) (Sri,
female, 19 years old, mother of 4 months old baby)
“Sometimes I am thinking to leave her alone and bring the child with me when
I get really mad with her (pause) since I think she become worse day by day and
never shows respect for me (pause) I will give her 1 or 2 months for her to think
about this marriage then after that I will decide whether to divorce or not (Tri,
male, 19 years old, father of a two months old baby)
It appears that they struggle to manage their married relationships which lead to
their intention to divorce. It is also evident that some participants experienced
struggling in their married life. Such situation might be resulted from their
unpreparedness to engaged in married life. Literature reported that the problems
occur in married life are not only due to the attitudes amongst couples, but
problems may occur due to overambitious expectations and unpreparedness of
engaging in married life (Straughan, 2009; Ferguson, 2014). Furthermore, some
young mothers and young fathers were disappointed with the behaviour of their
partner following marriage. As reported:

“Definitely I will ask for divorce even though after divorce I am still not sure
what I will do (pause) he is not good for me and my son or even for my big family
(pause) I didn’t expect it before” (Ririn, female, 17 years old, mother of a 6
months old baby)
“I feel that sometimes she is beyond what she should do (pause) when she gets
angry she throws all our stuff (pause) pushing me and swearing something bad
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(pause) I have already told her when she calms down but then she does it again
and again (pause) ……” (Tri, male, 19 years old, father of a 2 months old baby)
Findings showed that some young mothers and young fathers experienced
difficulties in managing their marriage relationships. Some of them also
experienced verbal and emotional abuse from their partners. Some of them also
explained that their current partner’s behaviour were not met with their
expectations, which led to their disappointment. However, it does not mean that
all young mothers and young mothers were thinking about divorce as some of
them were trying to manage their issues as described by Setyorini and Edi.

“….. it is true that my husband is a mature man but we also fight so many times
(pause) sometimes I feel regret but then sometimes people talk about their
experiences on how they manage their life as a new mother and sometimes I
just get inspired from them…..”(Setyorini, female, 19 years old, mother of 4
months old baby)
“…we fight so many times and then we tried to talk each other to know her
feeling as well as my feeling (pause) it is hard but we have to learn ….”(Edi,
male, 19 years old, father of a 7 months old baby)
Some young mothers and young fathers were trying to keep their marriage
relationships. The findings indicate that although almost all young mothers and
young fathers experienced arguing, and also fighting, not all of them were thinking
about divorce, some of them intended to keep their marriage relationship.
Therefore, the differences in their experiences and decisions might be dependent
on several influential factors such as stress and coping mechanisms or possibly
a link with their own personal characters of young mothers and young fathers in
this study 3.

6.4.3.2.3 Parents’ interference in breastfeeding practice

Previous literature reported that parents and children’s relationships in some
cultures and communities become interlocked relationships throughout the life
course and in many aspects of life (Reczek et al., 2010; Santoso et al., 2016).
From this point of view, there were parents who were trying to influence their
children’s wellbeing into adulthood, which was possibly due to their entitlement
to the grown child (Birditt et al., 2009). Under the ‘Parents’ interference in
breastfeeding practice’ subtheme, experiences of young mothers and young
fathers in regards to their parents or parents in-law interference are discussed.
One example of parent’s interference was related to breastfeeding practices.
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Breastfeeding for some young women became an issue which was usually
caused by limited knowledge and information, people pressure and lack of a
support system (Brown and Davies, 2014; Syme et al., 2015). Such experiences
also were found in the study findings. The following quotes are examples of
experiences of young mothers and young fathers, Setyorini and Febri reported:

“….it is hard as a new mother who knows nothing about the baby (pause) then
your mother in-law takes hold of every decision for the baby (pause) including
feeding him rice porridge (pause) which I know it is not appropriate for a 4
months old baby (Setyorini, female, 19 years old, mother of 4 months old baby)
“…..I know that a baby should only have breastmilk until 6 months old as the
midwife said so but then her parents came and started to give my baby a bottle
milk last week…” (Febri, male, 18 years old, father of 3 months old baby)
Findings show that although young parents had relevant knowledge and
information related to the breastfeeding, they were having less control over their
children in breastfeeding practice due to their parents interference. Almost all
young mothers and young fathers explained similar views related to their baby
feeding practices which was influenced by their parents or parents in-law. Such
situations appeared to be one factor which created internal tension amongst
young parents in regards to breastfeeding practices. Many participants had to
practice breastfeeding contravening with what they wished due to their parent’s
interference. However, some of the young mothers commented on parents’
interference, as reported by Qoriatul:

“It is a bit slow but surely I feel they (parents in-laws) are changing quite
positively on accepting me and my baby and even my mother in-law is the one
whom always takes all the decision about baby matters (pause) such as when
it is time to feed my baby (pause) what foods need to be cooked for my baby
(pause) that makes me rest thinking about baby for a while” (Qoriatul, female,
16 years old, mother of 2 months old baby)
Qoriatul’s quote suggested that parents’ interference in some cases could be one
source of support for young parents as they adjusted to being parents. All
participants mentioned that breastfeeding and feeding of the baby were
influenced by parents or parents in-law, the examples of quotations can be seen
below.

“I heard from the midwife that I need to give him breastmilk only until he is 6
months old (pause) but then he always cried during night (pause) then my
mother in-law gave him mashed rice with palm sugar and it made him calm and
sleep during the night.” (Eny, female, 17 years old, mother of 4 months old
baby)
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“….my mother said that mashed banana with honey will make him grow faster
and it can build his immunity naturally (pause) she also said that when I was a
baby she did the same as my grandmother told her……”(Andri, male, 18 years
old, father of a 2 months old baby)
The above quotations are further findings that the role of family strongly
influenced breastfeeding and baby feeding practices. It is evident that family
patterns played a role in baby matters. The discussion about how family has
powerful influence within young parents married life will be discussed in Chapter
7.

Whilst, some young parents had information related to adequate breastfeeding

practices there were also some others who had misconceptions related to baby
feeding. Example of quotes related to that reported by Sri and Edi:

“During the 2 days after the birth of my baby (pause) my breasts didn’t produce
any milk for only a drop (pause) then I gave him formula milk since he started
to cry all over the night (pause) and at that moment my mother also agreed
….”(Sri, female, 17 years old, mother of 4 months old baby)
“….my baby finishes one box of formula milk every 4 days since he was 3 months
old (pause) that’s why he grows so quick and looks healthier than other babies
that only have breastmilk (pause) I am happy for that but it also causes a
problem since I need to provide more money to buy formula milk…” (Edi, male,
19 years old, father of a 7 months old baby)
Findings show that there were misunderstandings related to breastfeeding and
baby feeding amongst young parents. It also appeared that some young mothers
and young fathers gained permission from their parents to start giving foods for
their baby. It reflects that parents were also one of the important factors to
influence young parents’ decision in regards to their breastfeeding and baby
feeding practices.

Summary

The second theme is ‘Struggling to be parent: heavy rain that suddenly happened
without any clouds’ which describes young mothers and young fathers
experiences of struggling with their life after the birth of their baby. Findings from
study 3 suggest that both young mothers and young fathers still experienced
judgement and stigmatisation from their community due to their past experiences
i.e. premarital pregnancy. Further findings also indicate that both young mothers
and young fathers find challenges in managing their marriage relationship and
they experienced struggles in their marriage relationships. The situation
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happened due to both young mothers and young fathers feeling that their
husband or wife did not meet with their expectations. Some of the young mothers
and young fathers felt that their marriage does not work well and they are
considering to divorce. Whilst, some of them tried to manage and keep their
marriage relationships. Additionally, both young mothers and young fathers
experienced parents’ interference in their breastfeeding practices which resulted
in non-exclusively breastfeeding their babies. It also needs to be highlighted that
parents interferences were responded differently by young parents. Some of
them responded negatively, whilst some others responded positively.

6.4.3.3 Theme 3: My future plans and my needs

A ‘plan’ can be defined as an intention or decision about what one is going to do
and ‘ need’ refers to the support that people are required (Xie et al., 2009). In
relation to this study 3, the theme of ‘My future plan and my need’ describes the
experiences of young mothers and young fathers in the period of trying to manage
their life with their hope as well as their needs after the birth of their baby. Through
their process of engaging in the time of being parents, both young mothers and
young fathers were expressing future plans for their life which is described under
‘Plans for work, vocational training and continue education’ subtheme. Being
parents for some young parents also brought them to the God path, which was
more likely influenced by their religion values. Such experiences presents in ‘I
want to stay close with Allah’ subtheme. Furthermore, young parents expressed
their hope and needs regarding their current situation in order to be able to
manage their life which is described under ‘I need support to be young parent’
subtheme. Additionally, young parents were also expressed their aspirations on
planning for not having other children which results from their negative
experiences during pregnancy and delivery process. These experiences are
presented within the ‘I don’t want to have another one’ subtheme.

6.4.3.3.1 Plans for work, vocational training and continuing education

This sub theme describes experiences of young mothers and young fathers
related to their life plan, particularly in terms of work, vocational training and
continuing education. The following quotations describe their experiences.
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“I am about to find a high school to continue my education as my parents asked

me to do so and they will pay the tuition fees and they will rent a nanny to take
care of my child (pause) I can say they save my life right now……..” (Ririn,
female, 17 years old, mother of a 6 months old baby)
“If I have money (pause) I want to attend a training course about electronic
repairs or motorcycle repairs (pause) therefore I would have a skill to earn more
money (pause) I plan to borrow some money from my parents but it will not in
the few next months. (Andri, male, 18 years old, father of a 2 months old baby)
It is evident that some young mothers and young fathers have plans to continue
their education, however, financial issues were becoming challenges for many of
them as school required fees. Findings showed that almost all young mothers
and young fathers were financially dependent on their parents, therefore parents
become the most possible financial sources for them to continue education.
Furthermore, findings suggested that some young mothers and young fathers
were experiencing having no independent choices related to their life plan as they
are dependent on their parents, which is described in the following quotes.

“I asked my parents to have a small snacks shop (pause) so I can sell some
snacks for people around my village (pause) but then my parents said I might
better to have a course training for haircutting (pause) knitting (pause) sewing
or things like that (pause) then I think I will do it later when my child is aged 2
years.” (Setyorini, female, 19 years old, mother of 4 months old baby)
“I give a lot of burden to my parents and even now I also bring additional burden
which are my wife and my child (pause) I cannot pay them back but at least now
I will follow what they want (pause) initially I plan to continue my education in
the university but then my parents asked me to cancel it because now I need to
think about my wife and my child.” (Tri, male, 19 years old, father of a two
months old baby)
It appears that being dependent on their parents for many young mothers and
young fathers limited their autonomy to decide what they wanted, including their
intention to continue education. Almost all participants experienced similar things
that they were dependent on their parents, particularly in accommodation,
nutrition and finance which led them to having less autonomy in deciding what
they wanted to do. Furthermore, findings also suggested that some of young
mothers and your fathers gained support from their community to obtain a free
vocational skill as can be seen in the following quotations.

“…there is a free sewing course which is provided by women and a social

enterprise community (pause) but they only provide course not the money
(pause) so it is hard for me when I want to open my own sewing shop as it
requires to buy sewing machine and other tool kits ….”(Sri, female, 17 years old,
mother of 4 months old baby)
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“…..I don’t think it will be easy for me to open my own shop though they provide
a free consultation or training (pause) money is more important I think…” (Edi,
male, 19 years old, father of a 7 months old baby)
It seemed that although many young parents obtained support to improve their
skill, they still found challenges to start their own jobs. It is also interesting to know
that although some participants experienced exclusion and negative judgement
from their community, there were some others gaining support from their
community, which is plausibly beneficial for both young mothers and young
fathers in order to re-engage with their community.

6.4.3.3.2 I want to stay close to Allah

God for some people become an important aspect in their life and God is often
known and introduced to people through religion and belief. Literature shows that
religious values for some people and society become moral justices and practice
guidance, it also can influence people to behave and practise according to what
religion thought and expected (Bourg, 2007; Helve, 1994; Sporre and Mannberg,
2010). It is evident that religious values influence perspectives and behaviours of
young mothers and young fathers in this study 3. This ‘I want to stay close to
Allah’ subtheme describes experiences of young mothers and young fathers in
accepting their condition and trying to seek help from God. The following
quotations describe their experiences.

“……. I don’t want to felt in a big hole of sin again and again (pause) I know that
I just felt really dirty in the past (pause) but now I want to start to make life
become more close to Allah….. (Hesti, female, 18 years old, mother of a 7
months old baby)
“……that is what you have got when you avoid what Allah asked (pause) that is
why I am trying to manage my life and seek help from Allah the
greatest…..”(Edi, male, 19 years old, father of a 7 months old baby)
Many young mothers and young fathers described that they put their effort into
managing their life better than previously by following religious values. It is
evident that religion values appeared as one of rule which followed by all young
mothers and young fathers. It more likely influenced their perspectives related to
how they responded their current life situation. It included how they view
themselves and how they aim their goal life. For example, some of young mothers
and young fathers explained that their unlucky recent life happened as a
consequence of their past bad behaviour, Eny and Febri reported:
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“……my life is really difficult now (pause) but I realise that it is kind of a
consequence of what I did last time (pause) so now I am trying very hard to
manage it carefully and the most important thing is I am trying to seek Allah’s
helps.” (Eny, female, 17 years old, mother of 4 months old baby)
“…….I believe that Allah will not leave me alone (pause) Allah will help me
(pause) in some point in my life when I really get stuck….”(Febri, male, 18 years
old, father of 3 months old baby)
Findings showed that cultural and religious values influenced both young mother
and young father on viewing to their life. It also appeared that God became their
life goal for many participants. They also were trying to seek God’s help by being
close with God. Further findings also suggest that some young mothers and
young fathers confessed and tried to adjust as well as accept their current life
circumstances, Sri and Tri explained:

“…….I put my all of life to Allah really (pause) let Allah guide me to through my
future life (pause) I am now accepting my condition (pause) these difficulties
that I have now might be happened because of Allah want to warn me ….”(Sri,
female, 17 years old, mother of 4 months old baby)
“……now I am on the stage of trying to accept my life and want to seek help and
guidance from Allah….(Tri, male, 19 years old, father of a two months old baby)
It seems that young mothers and young fathers were sustained by their faith
system and their belief in God. The confession for some participants were
manifested by acceptances of their current life. Almost all of the young mothers
and young fathers suggested that religious value were more likely to lead their
process of accepting and adjusting their current life circumstances. It also was
more likely that religion values contributed to their coping management of their
current life problems.

6.4.3.3.3 I need support to be a young parent

Support in relation to study 3 refers to available sources for encouraging young
mothers and young fathers in their new role as parents. The ‘I need support to be
young parents’ subtheme describes the experiences of young mothers and young
fathers related to their views of support required as young mothers and young
fathers after the birth of their baby. The following examples of quotations of young
mothers and young fathers present their views.

“….it is really hard but I have to pass through and it may be very helpful when
someone teaches me how to be a mother and still could survive ….”(Sri, female,
17 years old, mother of 4 months old baby)
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“A session about rights and responsibilities as a husband and wife were

explained in pre course marriage but it was really general and I think it was set
for couples who are ready to marry (pause) so then I think a session about how
to engage in parenting would be more helpful for me and my wife (pause)
particularly for young parents with unplanned pregnancy like us.” (Andri, male,
18 years old, father of a 2 months old baby)
Almost all young mothers and young fathers explained that they needed practical
support in order to engage with their parenthood appropriately. Furthermore,
some young mothers and young fathers also expected to be treated differently
by their older counterparts in their community as described by Atika and Tri.

“…..it is also not fair when they treat me the same as older mother (pause) my
condition is completely different with them (pause) so when I don’t know how
to be a good mother (pause) they should tell me what I should do instead of
talking about me at behind of my back….(Atika, female, 19 years old, mother of
3 months old baby)
“……I just want people to respect my life (pause) people force me to do
something beyond my abilities (pause) they keep telling me that I should do
hard work and earn money (pause) as I have my wife and child (pause) they said
it is not good being dependant on parents (pause) well I know all of those things
(pause) I just only need time as it (married life) was unplanned….” (Tri, male, 19
years old, father of a 2 months old baby)
A need to be respected was needed for both young mothers and young fathers.
Many participants also explained the same views as there were experienced
disrespected by their society.

6.4.3.3.4 I don’t want to have another one

Within ‘I don’t want to have another one’ subtheme experiences of young mothers
and young fathers related to their aspirations on planning for not having another
baby are presented. Such experiences resulted from their negative experiences
during their pregnancy and delivery process which led to their feeling of being
traumatised. Traumatic events can be defined as experiences that put either a
person or someone close to them at serious risk of harm or death (Elhai et al.,
2005; Krysinska et al., 2009). Pregnancy and the delivery process for some
people is considered as a traumatic event because many people experienced
unexpected event such as seeing blood or having complication which put them
into risk of death (Ayers, 2004; Bljajic et al., 2004). Much of the literature echoed
that trauma can be caused by an overwhelmingly negative event that causes a
lasting impact on the person’s mental and emotional stability (Whetten et al.,
2008; Onyut et al., 2009; Haugebrook et al., 2010). Trauma can also occur in a
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situation when people have a lack of preparation and then they obtain something
unexpected (Haugebrook et al., 2010). The findings showed that pregnancy and
the delivery process became a traumatic event for some young mothers and
young fathers in this study 3. The ‘I don’t want to have another one’ subtheme
therefore discusses the experiences of young mothers and young fathers related
to their plan of not having another child because of their traumatic experiences in
the period of pregnancy and the process of the delivery. The following quotes of
young mothers and young fathers describe their experiences.

“…..I was bleeding in my pregnancy and then then again during my delivery
process (pause) I think I almost died due to bleeding as well (pause) I had
transfusion but you know it was a really scary experiences (pause) I think I will
not have another one (pause) and I think one is enough for me….” (Eny, female,
17 years old, mother of 4 months old baby)
“I still remember that day (pause) when my wife was crying and struggling to
deliver the baby (pause) I almost blacked out when the baby was crowning and
then hiding again (pause) it was kind of nightmare for me (pause) I feel very
traumatised with that….” (Edi, male, 19 years old, father of a 7 months old
baby)
Many young mothers and young fathers reported that they were traumatised by
pregnancy and the process of the birth, particularly when they were had
complication such as antepartum haemorrhage, complication birth or where men
witnessed their partner’s distress. With the lack of knowledge of delivery process,
some of the young mothers and young fathers appeared unprepared and they
were shocked following witnessing the birth, which was more likely contributed to
their injured traumatic experiences. These experiences seemed also had
contribution on their decision for not planning to have another baby as described
in the following quotations.

“My baby was stuck because I was too little to deliver the baby I think (pause)
it was really painful with the contractions and at the end I had to be sent to the
operation theatre (pause) so then you can imagine it was kind of hurt in this
(holding legs) and this (holding stomach) (pause) it was really painful (pause)
hurt (pause) tiring and again I have to struggle with the pain after the operation
(pause) oh God it my first and last one” (Atika, female, 19 years old, mother of
a 3 months old baby)
“…..when my wife started crying due to contractions I felt like my heart stopped
beating and I also started to feel dizzy (pause) even my hands were shaking and
all sweat came from all of my body (pause) I was really scared as the process
took a very long time and then ended up with an operation which, I could not
see her (wife) (pause) I was like a stupid man in the front of the operating
theatre (pause) I didn’t know what to do (pause) I think I will not plan to have
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another one for the next few years…..” (Febri, male, 18 years old, father of 3
months old baby)
Whilst some young mothers and young fathers experienced trauma by the
birthing process. They responded positively to the baby. Affection for the baby
was expressed, for example Paryati and Febri reported:

“I am blessed and really happy having my baby now (pause) all my sadness is
gone when I look at him (pause) I might be the one who would feel guilty all the
time if I did an abortion (Paryati, female, 16 years old, mother of 2 months old
baby)
“……. before I married my life was better in financial matters (pause) but don’t
get me wrong (pause) now I am also happy as I am having a beautiful wife and
the child (pause) people out there may in the battle for having a family or child
(pause) but I think one is enough for me (pause) when I see my baby I also
remember how difficult my wife carried the pregnancy….. (Andri, male, 18 years
old, father of a 2 months old baby)
Almost all young mothers and young fathers expressed positive attitudes towards
their baby. It appeared that many young mothers and young fathers were grateful
of having their baby although the pregnancy was unplanned. However, almost
participants explained the reason for not planning to have another child was due
to injured traumatised experiences. It is further evident that aspirations of not
planning another child happened due to injured traumatised experiences
amongst young parents.

Summary

The third theme of study 3 is ‘My future plans and my needs’ which describes the
experiences of young mothers and young fathers on how they manage their life
with their hopes as well as their needs after the birth of their baby. It is evident
that some young mothers and young fathers expressed their intentions of
continuing school. However, since they were financially dependent on their
parents, they seemed had no autonomy to take any decisions including
continuing educations. Further findings also show that the influence of religion
values were very powerful on the perspectives and behaviours of both young
mothers and young fathers, particularly on the adjustment of their current life.
Some young mothers and young fathers expressed that they believed their hard
life happened as consequence of their past mistakes. Both young mothers and
young fathers viewed the pregnancy as a punishment from God due to their
breaking the religious values. Additionally, findings revealed that some of the
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young mothers and young fathers expressed their aspirations and optimism as
they believe that the God will help them.

6.5 Discussion
The findings of study 3 highlight to the young parents’ health and social
experiences after the birth of their baby. There are three key findings and these
will be discussed within this section. From the findings, cultural values are more
likely to influence the experiences of both young mothers and young fathers. For
instance, it can be seen from participants’ perspectives about role divisions of
being a wife and husband. Role divisions within married life refers to divisions of
roles and responsibilities between men and women in their experiences as a
husband and a wife as well as parents (Morrill et al., 2010). The role and
responsibility divisions appeared as young parents’ experiences and the role
divisions were more likely influenced by Indonesian cultural values. It is evident
that in Indonesia the cultural value, domestic tasks and raising children are
women’s tasks, whilst men have a responsibility to work outside, earn money and
financially support their family. These role divisions were also found difficult for
almost all participants. Similar findings are echoed by previous research that role
divisions have a significant contribution to the transition of parenthood which in
some cases create challenges particularly amongst young parents (Trivette and
Dunst, 1992; Katz-Wise et al., 2010; Forste and Fox, 2012).

In social relation, cultural values were becoming unwritten laws and norms
resulted in community expectation as well as judgement (Oakley, 1992; Oakley,
2005; Maholo et al., 2009). This was particularly seen in this study that being
married and still dependent on others was not expected by young mothers and
young fathers. Although, there are many Indonesian groups of people that live
with their extended family, however, married people are still expected to be
independent when they engage in marriage. For example, they need at least to
be independent financially, have adequate income to support their family needs,
and to provide foods. Whilst, there is also an opposite group of people who are
expecting that when people engage in marriage they need to be independent in
terms of finance, foods and also houses. As marriage due to premarital
pregnancy became obligatory for the participants in this study, it was unplanned,
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and living independently was difficult due to lack of financial resources. Guilty
feelings and shame were therefore expressed by both young mothers and young
fathers in this study. The finding shows consistency with the findings of study 1
and 2 as well as other research evidence that has been documented as young
parents are often experiencing financial difficulties and are financially dependent
as a consequence of having limited financial sources (Kaufman et al., 2001;
Loaiza and Liang, 2013; Strömmer et al., 2016).

Judgement and stigmatisation from society related to past premarital pregnancy

were also still experienced by young mothers and young fathers. Seemingly,
cultural and religious values remain strong in Indonesian communities and in
many points of young parents’ experiences, the culture and religious values have
been used to judge wrong or right behaviour of people within communities. Since
premarital pregnancy was considered to contravene cultural and religious
expectations, therefore both young mothers and young fathers in this study were
considered as people who were out with cultural and religious expectations as
consequences of premarital pregnancy. This finding is consistent with the
findings in study 1 and 2. It also has consistency with other research evidence
conducted in some countries where adolescent pregnancy due to premarital
sexual relationship is considered out with cultural expectations, this situation
allows an additional burden for adolescents such as community judgement and
exclusion (Lall, 2007; Yardley, 2008; WHO, 2015; Weed and Nicholson, 2015).

Furthermore, the evidence also shows that relationship changes were

experienced by some young mothers and young fathers. Both young mothers
and young fathers were competing to control and influence, which created a
power struggle in their married life. There was a finding to indicate that some
expectations of their partners did not meet with their initial expectations. This
finding also meets with the finding from study 2 that there are challenging and
changing powers between female and male adolescents. Similar findings have
been reported elsewhere in that in some marriage relationships when power
struggles happened within married life, the couple often compares their
expectation about their relationship in the past and what actually happened as
facts (Story and Bradbury, 2004). There were also different experiences of both
young mothers and young fathers as some of them were also trying to manage
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and continue their marriage, whilst others were considering divorce. The finding
therefore is showing consistency with other research findings that regardless of
the age of marriage that in the stage of power struggle many couples end with
breaking down and divorce but many of them also can pass the situation by
compromising, accepting and learning to make win-win solutions (Yardley, 2008;
Asoodeh et al., 2010; Igbo et al., 2015). These findings show that marriage
produces knowledge and experiences for both young mothers and young fathers,
which can be responded to differently among individuals. The different responses
of young parents’ in regards to power struggling within their marriage relationship
also can be influenced by many factors, such as individual personal characters,
levels of stress, experiences as well as knowledge (Randles, 2016). Although
young parents in this study experienced the same i.e. married due to premarital
pregnancy, in the same context of Indonesian society, there were diversities
regarding their power struggles within their married life. It is also acknowledged
that some young mothers married mature men, however, in terms of attitudes
there were no specific information which guides the differences of power
struggling. Therefore power struggling is expected because they are different
individuals with different family backgrounds, social classes, knowledge,
perspectives and experiences as well as different characters.

Findings from study 3 also suggest that all participants were not exclusively
breastfeeding and the finding also indicates that parents’ interference influences
their breastfeeding practices. Even though some young mothers and young
fathers explained that they obtained adequate information from healthcare
providers, they were powerless to practice them, which is hindered by their
common family practices. The finding is in line with previous research findings as
factors that significantly contribute to breastfeeding practices are family, social
community and cultures (Agunbiade and Ogunleye, 2012; Wanjohi et al., 2017).
These are similar finding to study 2 that the power of family remains strong which
influences both young mothers’ and young fathers’ experiences and practices in
studies 2 and 3. Furthermore, less autonomy as parents was also shown from
the experiences of both young mothers and young fathers. For instance in
decision related to jobs and education as well as breastfeeding practices. It is
most probably because they were living with their parents. In the parents’ home
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they were still situated as children but they also desire to and are expected to find
a parenting identity. Therefore, it was more likely that conflicting identities
appeared. For example, young mothers and young fathers need to behave based
on their parents or parent’s in law’s family rules which resulted in personal
tensions, issues and conflict in their own decisions. The finding is consistent with
other literature that tensions usually appeared in between conflicting identities of
being parents and children when people are living with their extended families
(Brodie, 1997; Farber, 1999; Sonuga-Barke and Mistry, 2000). In terms of
education, they also experienced education termination because they are
financially dependent on their parents, whilst education is not free in an
Indonesian context. The evidence also meets with study 1 and 2 as well as other
wider literature that pregnant adolescents are often experienced education
termination and have limited opportunities to develop their vocational skills due
to burden as parents and responsibilities as mothers as well as a lack of financial
support (Maputle, 2006; Yako and Yako, 2007; Klingberg-Allvin et al., 2008;
Sindiwe James et al., 2012).

There was a similar finding as in study 2 that belief in God plays a role in the
experiences of both young mothers and young fathers in this study, in their early
parenthood. The finding also indicates that their belief in God seemed to created
participants’ spirituality, in which was influenced from their religious values. The
findings suggested that both young mothers and young fathers in this study 3
were trying to reconstruct their relationship with God, which led to their
confession. Both young mothers and young fathers were experiencing guilty
feelings and viewed their life as a punishment from God, which shows how
religious values influence their perspectives on seeing themselves. The finding is
line with literature that has been documented as confession can be used as
alternatives to treatment that leads to resilience from moral emotions like feeling
guilty and shame (Ali et al., 2004; Tangney et al., 2007). Additionally, in terms of
needs, all participants mentioned that education, jobs, and support to be young
parents were required. There is a finding that adolescents were requiring support
which should be considered by governments or institutions who focus on
adolescents’ reproductive health. This is because previous research findings
indicate that support during pregnancy and after the birth can have a number of
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interrelated positive impacts on the emotional wellbeing of young mothers,

particularly when the pregnancy was unintended (Maputle, 2006; MCur et al.,
2010; Greenfield, 2011).

Additionally, it is also evident that both young mothers and young fathers in this
study experienced trauma of the process of delivery. It shows that they were
shocked with the experiences which is most probably due to limited knowledge
and information related to the process of delivery. It may also because both
young mothers and young fathers in this study 3 were not obtaining adequate
antenatal care, therefore it has an impact on their lack of preparation for coping
with stress during the process of pregnancy and delivery. The finding is consistent
with evidence from previous research that providing information, education and
behavioural approaches during the antenatal period significantly influences how
pregnant adolescents and their partner cope with stress and anxiety related to
pregnancy and the delivery process (Hodgkinson et al., 2014;
Madhavanprabhakaran et al., 2015). It was evident that most of participants were
experiencing late antenatal booking. It is likely that participants sought medical
consultations late due to premarital pregnancy being socially unacceptable which
resulted in their effort in trying to hide their pregnancy. Previous research
documented that it is quite often that pregnant adolescents have late antenatal
care visits due to several reasons such as avoiding judgement, trying to hiding
pregnancy or lack of awareness about the health benefits of antenatal care
(Phafoli et al., 2007; Gross et al., 2011).

6.6 Summary
This chapter presents study 3 which aimed to explore health and social
experiences of young parents’ after the birth of their baby. It sets out to explain
young parents’ lives after their baby is born including life experiences, life
changes, support needed and life planning. There are three themes emerged
from the data which are ‘An overwhelming life’, ‘Struggling to be parent: heavy
rain that suddenly happened without any clouds’ ‘My future plan and my needs’.
The findings indicate that after the birth of the baby, young mothers and young
fathers also find that their life is still challenging. The current life of becoming
young mothers and young fathers brings difficulties for both young mothers and
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young fathers because they do not have enough preparation. Furthermore, role
division powered by social culture was also shown in their married life. It is evident
that young mothers were having issues of having burdens in domestic tasks,
whilst young fathers were more focused on having burdens in their relationships
and financial matters. Both young mothers and young fathers were also still
experiencing social judgement and stigmatisation as a consequence of their
premarital pregnancy, and the jobs, education and financial matters become
issues for both young mothers and young parents. It also appeared that parents’
interference was experienced by participants particularly in terms of
breastfeeding practices. It reflects that parents’ pattern was an important aspect
on the breastfeeding behaviour amongst young mothers and young fathers in this
study. Additionally, feeling traumatic about pregnancy and the process of the
baby’s birth were also experienced by both young mothers and young fathers
which led to their plan of not having another child. There was evidence to suggest
that both young mothers and young fathers were trying to manage their life and
they also require support and help to be young parents.
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Chapter 7 Discussion and Conclusion

7.1 Introduction
The main focus of this thesis was to understand the Indonesian adolescents’
experience of their pregnancies as a result of premarital pregnancies and early
parenthood which considered out with cultural and religion expectations in
Indonesian society. The purpose was to explore and illuminate Indonesian
adolescents’ reproductive practices, and their experiences during pregnancy and
early parenthood, so that we can understand their experiences on in a social
context and understand how some adolescent behaviours were out-with cultural
and religious expectations. The research study consisted of three individual
studies: Study 1 was a qualitative systematic review (see Chapter 4), study 2 was
and in-depth study of Indonesian adolescents’ reproductive health and their
experiences during pregnancy (see Chapter 5) and study 3 was an in-depth study
of Indonesian young parents after the birth of their baby (see Chapter 6). It is
through data analysis from the interviews that these findings have emerged.

In this Chapter 7, which is the final chapter of this PhD thesis, an overview of the
research aim research questions and findings of study 1, 2 and 3 are provided.
Following this, an overarching discussion of the key findings of the research is
presented along with discussion of wider theories and wider literature to support
and debate key findings. Foucault’s perspective related to power relationship
within society is used as a lens to explain the relationship experiences of
Indonesian adolescents during pregnancy and their early parenthood. A model to
explain how power is dispersed in Indonesian society, as found within the data,
was also developed. Adolescents’ relationships and behaviour were complex and
influenced by numbers of factors which are discussed within this chapter.

The strengths and limitations of this PhD research will be considered together
with the originality, implication of this research, recommendations, dissemination,
concluding remarks. In doing so reflection of the process after data collection are
also provided.
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7.2 An overview of the research aim, research questions and

key findings
The aim of this research was to explore, illuminate and understand Indonesian
adolescents’ reproductive practices and their experiences during pregnancy and
early parenthood. There were three research questions to meet the aim, these
were:

1. What are the health and social experiences of pregnant adolescents and
their partners in Indonesia and other low-lower and middle-upper middle
income countries?
2. What are Indonesian adolescents’ experiences during pregnancy?
3. What are the experiences of Indonesian young parents after the birth of
their baby in Indonesia?
In order to address the research questions, three phases of qualitative studies
were applied namely study 1, 2 and 3. Study 1 was a qualitative systematic review
(see Chapter 4), study 2 was an in-depth study of Indonesian adolescents during
pregnancy (see Chapter 5), and study 3 was an in-depth study of Indonesian
young parents after the birth of their baby (see Chapter 6). Figure 7-1 represents
the overview of the main findings of study 1, 2 and 3.
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Figure 7-1: Overview of main findings from study 1, 2 and 3

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7.3 The dominance of culture and religion upon adolescents’

experiences
This section will discuss the overarching main findings of this PhD research
drawing upon Foucault’s views of the concept of power within society (Foucault,
1982; Foucault et al., 2000) as a lens to help explain the context within which
adolescents were living and the influence of social relationship. It needs to be
highlighted that the dominance of cultural expectations appeared within
participants’ narratives of the study 2 and 3. The qualitative systematic review
(study 1), wider theories and literature are employed to support and debate the
findings. A concept of power relations in society (see Chapter 1 section 1.4) within
this research helps to explain how different individuals or groups within society
see themselves and interact with others (Sertel, 1971; Foucault, 1982; Foucault
et al., 2000; Hsu, 2014).

One of many issues running through this thesis is the ‘power’ and the subsequent
effect on the quality of the relationship between adolescents and societies;
adolescents and family; adolescents and partners; and within adolescents itself.
Indeed, the literature explain that culture plays a dominant role in the society; it
influences and shapes the system society, structures and social classes of
individuals and their behaviour (Foucault, 1982; Harish, 2014). According to
Ewing (2008) culture is the full range of learned human behaviour patterns, it can
be more effective as a survival tool, rather than reliance on the instinct of people
or individuals within society. This is likely because most human behaviours are a
result of social learning rather than instincts, therefore without culture society
might not conform to a particular law or norm (Ewing, 2008). Culture also helps
people adapt to current life as a culture is formed and influenced by past
experiences, for example what is acceptable and unacceptable and then
challenge the current social norms to continue, to find out what is and is not
accepted within society life (Hannover and Kuhnen, 2009; Thompson, 2012).

In addition, Foucault (1982) in Sloan (2007) argues that culture is a hierarchical

organisation of values, it is accessible to everybody, but at the same time, culture
creates a mechanism of selection and exclusion and hierarchical organisation of
society. The power of culture can also be diffused and manifest in both written
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documents such as government policy, social practices and unwritten norms

such as society values and normal practices (Foucault et al., 2000; Gallagher,
2008). The power of culture can also be seen in the way that society classifies
‘wrong’ and ‘right’ attitudes within a society, for structuring social class, or for
differencing gender roles such as women have major roles on domestic tasks
whilst men have a major role in earning money (Oakley, 1976; Oakley, 2005;
Forste and Fox, 2012). The theory of the power of culture can be seen in
adolescents’ narration relating to policy, practices, expectations, family,
behaviour and also their relationship. Figure 7-2 is a model to show the
dominance of the power of culture and religion that has emerged from the
findings.
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Power of culture and religion

Policy and practices

Family and individual

Journey into an unplanned

pregnancy, marriage and parenthood

1. Sexual
2. Its shouldn’t 7. My future
debut 3. Ending
4. Journey into 5. An and my plan
have happened 6. Struggling to
adolescent life
new life Overwhelming life be parent

Figure 7-2: Model to show dominance of the power of culture and religion on Indonesian adolescents’ unplanned journey
 198

It is evident that in an Indonesian context, culture and religious value systems

seem mutually exclusive, as they are difficult to separate from each other. This
perspective is in line with a theory from Koentjaraningrat (1976) an Indonesian
anthropologist who reported that ‘budaya dan agama sangat berkaitan erat dalam
keseharian masyarakat Indonesia’ (page 57), which means culture and religion
are mutually chained in Indonesian people’s life. Therefore, cultural and religion
values are adopted in their life discourse and relationship. It also manifests in
their inner personal attitude, thoughts, beliefs, and knowledge as well as their
experiences. For example, in this PhD research context, premarital intercourse
is prohibited in Indonesian society, the prohibition seems to come from Islamic
values but then it seems to be accepted and then cultured by followers of other
religions in Indonesia, therefore the prohibition of premarital intercourse has
become an unwritten law in Indonesian society, regardless of religion.

Thompson et al. (1990) and Storey and Storey (2009) argue that culture refers to
the accumulation of knowledge, experiences, beliefs, values, attitudes,
meanings, hierarchies, religion, notions of time, roles, spatial relations, concepts
of the universe, and material objects and possessions acquired by a group of
people in the course of generations through individual and group. It therefore
appears that religion can also be a cultural system within particular groups in the
society (Swingewood, 1998; Edgar and Sedgwick, 2002; Storey and Storey,
2009). For example, when a particular religion is practised, followed and cultured
by people in society, then it can be powerful to influence the society practices
such as community behaviour and expectation (Foucault and Carrette, 1999).
This explanation of culture can be seen from adolescents’ experiences that their
premarital pregnancy, was beyond the cultural and religious expectation, resulted
in judgement, exclusion and stigmatisation among Indonesian adolescents.
Considering the explanation above, therefore the power of culture and religion
will be considered as mutually exclusive.

Findings also revealed that the dominance of cultural expectations within

Indonesian society played an important role in Indonesian adolescents’
experiences, from the beginning of their sexual debut into their unplanned
pregnancy, marriage and parenthood. The figure 7-3 is a word cloud presenting
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the complex of experiences and aspects contributing to the experiences of

unplanned pregnancy, marriage and parenthood.

Figure 7-3: Word cloud of experiences and aspects that contributed to

adolescents’ experiences of unplanned pregnancy, marriage and
parenthood.
At the beginning of their sexual debut for instance, findings showed that
adolescents were reluctant to access SRH information and services because in
Indonesian social culture, discussing sexual matters is taboo. Furthermore,
‘discussing sex is taboo’ also appears in public policy and practice, such as in
Indonesian schools. It is evident that SRH education was provided in the school
curriculum (BKKBN, 2015), but, instead of focusing on reproductive health,
preventing adolescent pregnancy, and on behaviour and relationships, the SRH
curriculum focuses on biological and physiological reproductive organs. This
apparent lack of SRH knowledge including pregnancy prevention among
Indonesian adolescents, which is likely to be one factor contributing to their
sexual debut and pregnancy. Others have echoed that SRH education and
information as well as contraception advices and contraception need to be readily
available and easily accessible to adolescents in order to reduce the number of
adolescent pregnancies (UNFPA, 2013; UNPF, 2013; Lemon, 2016). The
importance of SRH education and information for adolescents also needs to be
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considered and campaigned among parents and societies, because in many

societies talking about sexual matters is not common or even shameful within
family and society (Shrestha, 2002; WHO, 2009; UNFPA, 2013). Uncommon
conversation related to sexual matters within society may also result in a lack of
understanding about SRH, pregnancy prevention and contraception amongst
adolescents. Therefore, it can be seen from the findings that there is a culture in
Indonesian society that can limits the access and availability of SRH education
and information among Indonesian adolescents, which could be one factor
contributing to adolescents engaging in premarital sexual relationship which
leads to the unplanned adolescent pregnancy.

Findings from this study also suggest that when an unplanned pregnancy occurs,
the journey into unplanned marriage and parenthood begins with a dominance of
cultural expectations. Societal stigmatisation, judgement, isolation, and exclusion
were experienced by pregnant adolescents and their partners as they were
considered as people behaving out-with Indonesian cultural expectations.
Marriage was initiated by adolescents’ families in order to meet society
expectations and this placed adolescents with no choice except marrying. The
finding is similar to previous research documented that social power including
society norms enable people to govern the way of society perceive, judge, and
interact with others (McGee, 2013). The psychosocial consequences of
unplanned pregnancy therefore can be seen as a result of how cultural
expectations are powerful in influencing people’s perceptions within society to
judge and exclude those who broke the society values.

Additionally, the power of culture also influenced adolescent marital relationships,

and role divisions as husband and wife as well as when adolescents engaged in
parenthood. In Indonesia, a patriarchal society in general is strong within society,
such as in Java where the research was conducted, there is a societal
expectation that women were expected to have a major role in domestic tasks
and caring for children, whilst men were expected to earn money and fulfil their
family needs (Ray-ross, 1997; Morrell, 2002; Vaezghasemi et al., 2014). Findings
show that adolescents attempted to adopt cultural expectations, however, since
they lacked preparation for their marriage and subsequent parenthood, they
found difficulties in managing their life. The findings revealed that different
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difficulties happened between female and male adolescents (Chapter 6 Section

6-4). For example, the findings showed that some young mothers experienced
overwhelming tasks of caring for their baby, providing food for family, laundering
and managing other house work, whilst, young fathers experienced stress in
finding a job or earning sufficient income for their family. Similar findings have
been asserted by others claiming that culture is a social power and it is one of
the most important factors that shapes human personality, behaviour and
perceptions (Foucault, 1991; Matsumoto, 2007; Hill and Tyson, 2008).

The practice of role division among Indonesian young parents can be seen clearly
in that adolescents attempted to fulfil what the society expects. It is evident that
there is a traditional Indonesian proverb for women which is ‘wanita itu harus bisa
mengurus dapur, sumur dan kasur’ which means that women have a
responsibility to provide food for family, laundry and clean the house as well as
having to please their husband in sexuality (Heraty, 2002; Sugihastuti et al.,
2007). This proverb is well known across Indonesian society and generally
accepted that the main role of women is doing domestic tasks and raising a
family. There is also evidence that in Indonesia the majority of people are Muslim
and there is a Prophet Muhammad sentence which recognised about a women’s
role, which is narrated by Abu Huraira, "The righteous among the women of
Quraish are those who are kind to their young ones and who look after their
husband's property" (Elias, 2010). However, this Prophet Muhammad’s sentence
has been interpreted in many different ways. For example, one interpretation has
been understood that as women’s roles are raising the children and caring for the
husband, which considers that domestic tasks and home are women’s
responsibilities. It is possible that such practices keep women at home, limit
access to higher education, render women inferior and unequal to men. It is
plausible that such practices also set women’s expectation to a lower level
education than men and consequently reduce young mothers in a place of less
opportunity to work outside the home. Although these views are held by some
Indonesian people, there are also many others Indonesian people who argue that
such interpretation and implementation related to Prophet Muhammad’s
sentences are misplaced and another different interpretation is that as women
have to manage their young ones (children) as well as managing husbands’
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property therefore women need to be educated, trained and supported in order

to be able to manage their roles appropriately. Whilst, men in an Indonesian
context are thought and expected to have responsibilities for earning money,
fulfilling the family needs and becoming leader for their family (Ray-ross, 1997;
Morrell, 2002). Therefore, the role divisions which have been practiced by young
parents in this study were more likely adopted from the society practices in an
Indonesian context.

Interestingly, whilst there are different perspectives on the women’s role in the
family within Indonesian society, there are limited debates, discourses or
contradictory views with regards to men’s roles, particularly in an Indonesian
context. It seems to be that men’s views related to their responsibilities and
divisions were less explored. This is probably because there are limited issues or
conflicts that have appeared regarding men’s role divisions or it may also be
because of less concern about men’s needs; or it may also due to limited studies
questioning what men’s views are related to their responsibilities and role
divisions. It is possible that little interest has been paid towards male adolescents’
role in other countries helping to explain why no such studies were included in
study 1. Therefore, further exploration related to how men view their
responsibilities and role divisions within their family, which is constructed by
cultures probably needs to be explored in order to provide research evidence, in
which may also be beneficial in promoting men’s health and wellbeing as well as
that of the family.

7.3.1 The dominance of the power of culture and religion upon policy
and practice
The power of policy and practice can also be seen throughout the findings of this
research as an important aspect which needs to be highlighted in Indonesian
adolescents’ unplanned journey of pregnancy, marriage and parenthood. Policy
and practice may be guidelines, rules or principles that are formulated or adapted
by an organisation or government towards specific service delivery including
laws, regulations and organisational policies, which affect social welfare policy
and social work practice (Wafula et al., 2014; Batra and Bird, 2015). For example,
the findings indicate that Indonesian adolescents have no access to any form of
formal contraception service since these services are only accessible to married
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couples. This government policy seems to be informed by the Indonesian culture

value that premarital sexual relationship is prohibited, therefore, only married
Indonesian people are able to access contraception. This aspect of Indonesian
cultural seems to be closely aligned with Muslim values that is premarital sexual
relationship is considered as immoral behaviour. The Qur’an which is a holy book
of Islam stated “And do not approach unlawful sexual relationship. Indeed, it is
ever an immorality and is evil as a way [Surah Al-Isra (17:32)]” (Itani, 2014).
Therefore, there is an expectation that premarital sexual relationship needs to be
avoided by people who believe and live by Islamic values. As contraception is
defined as methods or techniques to prevent pregnancy as a consequence of
sexual relationship, therefore in order to access the contraception, Indonesian
people generally are expected to be in a married relationship.

Evidence from other literature confirms that in other cultures contraception is

prohibited as it is considered as a barrier to the life of children and it also changes
the natural system given by God (Hunt, 2002; Iyer, 2002; Regnerus, 2005). For
example, there are some groups of Muslim people who believe that contraception
is against the right of children to life as there is a verse in the Qur’an which states:
"You should not kill your children for fear of poverty [Surah Al-Isra (17:31)]" (Itani,
2014), which is interpreted by some groups of Muslim people as including a ban
on contraception as well as infanticide (Srikanthan and Reid, 2008; Shaikh et al.,
2013). On the other hand, there are also groups of Muslims who argue that
contraception that does not have a permanent effect is permissible as they are
not permanently preventing conception but are only controlling the birth and this
is also beneficial to preserve the health of the mother or the wellbeing of the family
(Krehbiel Keefe, 2006; Sueyoshi et al., 2006). Whilst, there are contradictory
issues in relation to whether contraception is permissible, in this Indonesian
context, contraception was not accessible to adolescents due to their status as
unmarried individuals and the cultural values which consider premarital sexual
relationship as immoral.

Furthermore, the findings also revealed that all adolescent women had attempted
to terminate their pregnancy by using their traditional methods as policy and
health practice considers that abortion is acceptable only when undertaken for
medical purposes in Indonesian health practices (Sedgh and Ball, 2008b). It is
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therefore evident that cultural and religious values and beliefs influence health
policy and healthcare practice. In an Indonesian context, there is a belief that
abortion is permitted, when the mother’s life is considered to be more important
than that of the embryo (Bennett, 2001; Sedgh and Ball, 2008b; Nasir, 2011). For
example, when mother has poorly controlled diabetes with severe maternal
cardiovascular, renal, and vision complications which cause a significant
problems during pregnancy and put a fetus and a woman's life at risk if difficult to
control. There is also a belief that the soul does not enter the foetus until the
120th day of gestation, which indicates that an abortion, if deemed appropriate,
should be carried out before that time (Sedgh and Ball, 2008b; Nasir, 2011;
Surjadjaja and Mayhew, 2011). Within the Qur’an there is a verse recognising the
process of pregnancy, which is interpreted as the process of human creation that
“Certainly We created the human being from an quotes of clay. Then We made
him a drop of (seminal) fluid (lodged) in a secure abode. Then We created the
drop of fluid as a clinging mass. Then We created the clinging mass as a fleshy
tissue. Then We created the fleshy tissue as bones. Then We clothed the bones
with flesh. Then We produced him as (yet) another creature. So blessed is Allāh
(SwT), the best of creators! [Surat al-Mu`minūn (12-14)]” in (Itani, 2014).
Additionally, the creation of the foetus, it is narrated from the Prophet (S): “The
seed in the womb of the mother (takes) 40 days to become a clot, then after 40
days it becomes a lump of flesh (foetus); when the child is 4 months old, by the
command of Allāh, 2 Angels give the foetus a soul (rūĥ) and specify the
sustenance (Rizq), period of living, deeds (A°māl), prosperity and adversity of the
child.” Therefore, it is perhaps for this reason that it has been interpreted that an
abortion, if deemed appropriate should be before the 120th day of gestation in
Indonesian healthcare practices. Previous research findings have reported by
Bloomer et al. (2016), confirms that the perception and treatment of practices
related to abortion are constructed by the meaning of abortion within societies’
social history, gender and culture including religion. The literature also reports
that abortion as contradictory issue not only in Indonesia but also in other
countries (Dixon-Mueller, 1990; Ahman and Shah, 2010; Vlassoff et al., 2016).
Some arguments are concerned about the baby’s right to life and some are
concerned about their religious expectations. The findings in this PhD research
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revealed that adolescents attempted to terminate their pregnancy by their own

methods as legal abortion from healthcare services was not accessible for them.
This appeared to be because their pregnancy was socially unacceptable with
enduring consequences.

Further findings also suggest that the dominance of the power of culture and
religion can also be seen has influenced and shape the provision of services of
the SRH information for adolescents. In an Indonesian context, SRH services
which are available in public health centres seem to be hard to access for
Indonesian adolescents as they are in public areas where there are mostly adults
around. Such conditions may lead to a feeling of reluctance to access the SRH
services as discussing sexual matters is considered as taboo. Therefore,
Indonesian adolescents were probably fearful of society judgement if they wanted
to access SRH services. In addition, the power of the idea that discussing sex is
taboo seems also manifest in the school curriculum where the SRH curriculum
focusses on the biology and physiology of the reproductive organs rather than
explaining adolescents’ behaviour and relationship which lead to adolescent
pregnancy and contraception. In every society, there are topics which are
believed to be not appropriate if spoken about at public occasions, which are
often called taboo (Gao, 2013). Other scholars also define taboo as the
prohibition or avoidance in any society of behaviour believed to be harmful to its
members in that it would cause them anxiety, embarrassment, or shame (Biro
and Dorn, 2005; Regmi et al., 2010b; Crespo-Fernandez, 2015).

Additionally, the institutions of SRH limit access of SRH services as they are
provided during working hours which are the same as school hours. The
limitations around access to SRH services seem challenging for adolescents
which for these participants, led to a lack of knowledge and information and
consequently may have contributed to adolescent pregnancy. In this case, the
findings participants’ narratives concurred with findings of the study 1 as almost
all of the included papers mentioned that one of the most influential factors
leading to adolescent pregnancy was a limited knowledge and limited access to
contraception (Yako, 2007; Klingberg-Allvin et al., 2008; Maholo et al., 2009;
Goicolea, 2009). The literature confirmed that in order to enable wider
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accessibility of SRH programme interventions and services for adolescents,

services needed to make the programme friendly for adolescents (WHO, 2012).

Further findings also indicate that policy and practice played an important role in
adolescents’ school exclusion. As it was evident that some Indonesian
adolescents were excluded from school due to their premarital pregnancy. The
findings suggest that the school policy practice also seems to have adopted the
cultural value. As premarital pregnancy is prohibited and it is considered an
immoral practice, therefore school exclusion seems to be a kind of punishment
for those who behave out with the school’s values and expectations. In this case,
the concept of Foucault (1991) seems to be applicable since he argues that
punishment has moved from the body to the soul. Therefore instead of torturing
the body, social exclusion is one type of punishment used to control people’s
behaviour at a social level.

A further point that could be highlighted in terms of how the power of culture is
manifested in policy and practices is that policy and practices have been created
from knowledge which resulted from society relationships. The knowledge was
adopted, formed and circulated by experts in society such as by the government
to manage and control the system, in Foucault’s concept this can be considered
as power-knowledge (Foucault and Gordon, 1980). For example in Indonesia, it
is evident that policy practice have been developed and implemented by the
Indonesian government, whereby the Indonesian government itself involves
Indonesian people who have personal knowledge and experiences gained from
their society relationships in Indonesia (Warka, 2011). The Indonesian
government involves people whom are responsible for the day-to-day
governance of the nation i.e. the president and vice president and also a group
of people who are responsible for law-making including establishing broad
guidelines of state policy, and amending the constitution which is called People's
Consultative Assembly (PCA) (Warka, 2011). It is also evident that only
Indonesian national are able to be part of the Indonesian government and those
people who are members of Indonesian government build interaction with
Indonesian people in Indonesian society (Liddle, 2004; Fossati, 2017). Therefore,
it seems to be no surprising fact that the product of policy and practices that are
implemented in Indonesia has been strongly influenced by cultural and religious
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values that were practiced in an Indonesian context. The policy practice includes
policy and practices related to SRH for adolescents, as the people who establish
policy are the Indonesian government which involves Indonesian people in an
Indonesian context. Consequently, as membership of PCA are grounded in
Indonesian society, consensus of opinion, which informs policy and practice, is
likely to be influences by strong culture and religion values. When the findings is
applied to Foucault’s concept of ‘power-knowledge’ (Foucault and Gordon, 1980),
the policy seems to be a knowledge in order to control people in society to behave
as policy makers wish. The findings suggest that the power of Indonesian culture
influences how policy and practices operate in Indonesian society, particularly for
adolescents SRH.

Wider literature also mentioned that in terms of SRH policy and practice, most
literature reported that important factors need to be considered such as the
accessibility of contraception and abortion, SRH education and campaigning,
maternal services for adolescents and adolescent parenting services. The
literature also indicates that adolescent pregnancy was also considered as a
public health issue and WHO also recommended that every national government
needs to put efforts into reducing the number of adolescent pregnancies as they
are aware that adolescent pregnancy brings negative consequences for maternal
and children’s psychosocial and health outcomes (Sindiwe James et al., 2012;
WHO, 2014a; WHO, 2015). The findings therefore support Foucault’s theory that
the policy practices were produced from the government’s intention to manage
the population in the larger societal body (Foucault and Hurley, 1990).

7.3.2 The dominance of the power of culture and religion within

family
The power of culture was also evident within the family which also has inherent
power. Kranichfeld (1987) refers to family functions which have individuals as
units and among these individuals there is an interaction process to influence
each other. For example, parents teach their children to behave as they and
society would expect. According to Okulicz-Kozaryn (2010), parents are one
crucial factor in determining children’s behaviour and within the family, parents
have autonomy for their children. Foucault (1991) argues that the family is a
traditional sovereign institution whose power has been slowly diluted overtime,
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as normally there is authority of parents over children. For example, within this
PhD research adolescents whom were not married needed their parents’ consent
to be involved as participants. However, others report that developing parents’
and children’s relationship is challenging, particularly when children are entering
adolescence (Goldstein et al., 2005; Yaacob, 2006; Mangeli and Toraldo, 2015).
Arnett (1999) suggests that adolescence is a time of storm and stress, describing
extreme parent-child conflict and adolescent rebellion as an inevitable part of the
adolescence years. The theory of Foucault related to power within family can also
be seen from the experiences of adolescents related to their relationship with
parents and how the power of culture had an influence on the relationship of the
adolescents and their parents during their pregnancy and their early parenthood.

It was interesting to note that when unplanned pregnancy occurred, all

adolescents returned to their family homes. This situation seems to suggest a
unique experiences, whereby the adolescents both is a child as well as becoming
parents. It is also apparent, within Indonesian cultural that children are always
considered as children by their parents, therefore although adolescents were
becoming adults, they were likely to have less authority than their parents as they
are still expected to behave as children when with their parents (French et al.,
2013; Santoso et al., 2016). Chang (2007) also suggests that Asian parents
tended to be more authoritarian than American parents which influenced on
adolescents’ self-esteem (Chang, 2007). Since this PhD research conducted in
Indonesia which is part of Asian countries, therefore such culture also can be
seen from the PhD research’s findings, which seems to lead to some internal
issues in their parent-children relations. For example, a feeling of powerlessness
was evident which explained that the power of family strongly pushed
adolescents into engage in marriage, whilst adolescents were left with no choice
except to engage in unplanned marriage which was initiated by their family. The
findings indicated that parents were trying to force their children to marry to fulfil
the Indonesian society expectation. Marriage seems to be the only way for
adolescents with premarital pregnancy to be accepted by society and legalised
as a couple. In an Indonesian society context, it is not socially accepted to be a
couple without being married or to be an unmarried pregnant women. It is also
not common for a couple to live together without being married. Taylor (2017)
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suggests that children internalise an awareness that they are under the
surveillance of their parents, whilst parents are conscious of their surveillance by
neighbours. For example, within this PhD research findings show that all
adolescents agreed to marry because their parents asked for this, whilst their
parents seemed to initiate this marriage due to wanting to fulfil society’s
expectation. In regards to the theory of Foucault (1991), the case of adolescents’
marriage, parents indeed seem to discipline their children to meet with cultural
expectations in order to normalise their lives as well as to minimise shamefulness.
Foucault (1991) also explains that surveillance is a part of disciplinary practice
which can also be seen as a power of discipline, which Foucault calls ‘discipline
societies’ (Foucault, 1991; de Bustillo et al., 2006). Foucault analyses the system
of prison, incorporating his idea of the ‘Gaze’ which is symbolised through the
‘panopticon’. Panopticon means a circular prison with cells arranged around a
central well, from which prisoners could at all times be observed. The ‘Gaze’ is
important because it reminds people of the fact that it is not always important to
watch over people because they will begin to set standards of living on their own,
thinking they are being watched and surveillance. In turn, the ‘gaze’ creates an
idea of constant self-surveillance among subjects, who become complicit in the
production of themselves as normal individuals (Peres et al., 2011; Rye, 2014;
Bourke et al., 2015).

Furthermore, in an Indonesian cultural context, children are expected to please

their parents and respect what parents ask. As such, in many practices children
have less autonomy even to decide what they actually want and begin to
passively accept any treatment from their parents. There is a traditional proverb
called ‘kualat’ which is generally interpreted by Indonesian that people who
disrespect their parents, will obtain something bad. This interpretation is similar
to ‘karma’ in Indian society where the sum of a person's actions in this and
previous states of existence are viewed as deciding their fate in future existences
(Goldman, 1985). It seems therefore that the power of culture can be considered
as one reason why adolescents were behaving passively towards their parents
and accepted what their parents asked.

Findings also suggest that adolescents had no choice other than to accept
marriage which was initiated by their parents. Hence, it seems that adolescents
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behave passively as children of what society expected, that is accepting what

their parents asked of them. In Islamic values which is the religion of almost all
the participants, there is a recognition of and a request for every Muslim to
respect their parents in the Qur’an verse that ‘Your Lord had decreed, that you
worship none save Him, and (that you show) kindness to parents. If one of them
or both of them attain old age with you, say not "Fie" unto them nor repulse them,
but speak unto them a gracious word. And lower unto them the wing of
submission through mercy, and say: My Lord! Have mercy on them both, as they
did care for me when I was young [Surah Al-Isra’ (17:23-24)] in (Itani, 2014). This
seems therefore to be one of the reason why adolescents were complying with
engaging in marriage. Whilst, participants’ parents were trying to fulfil society
expectations, parents also seemed to feel pressure from society to behave as the
society expects. Consequently, they also diffused their power to show their role
as parents which aims to be responsible. Although such parents’ practice more
likely resulted in less autonomy for their children to decide what they actually
want.

However, in Java there is a proverb which is ‘anak polah bopo kepradah’ which
means that parents have to be responsible when children commit something bad
or immoral. The initiation of adolescent marriage, therefore, seems to have to be
accepted by adolescents in order to fulfil their parents’ expectations and parents
were also trying to show their responsibility for what their children have done.
Parents who are also considered units to diffuse religious values upon their
children, also seem to have the temptation to initiate marriage as their
responsibility to the cultural society as they are considered a unit of society, at
the same time they were also showing their responsibility to the religion as
parents, in which they have responsibility for what their children of what children
have done. There is also a proverb that mentioned about a parent’s role in
diffusing cultural and religious values that is ‘rumah adalah madrasah pertama
bagi anak-anak’ which means in the home (which points to parents) is the first
place for children to learn cultural and religious values. It is probably the reason
why the parents of adolescents in this study initiated the marriage among
adolescents, as parents are also being watched by society to behave as society
expects.
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Findings also revealed that parents were playing an important role in adolescents’
transition into parenthood. Less autonomy again was experienced by almost all
adolescent participants after their baby was born. For example, decisions about
breastfeeding and infant feeding practices were strongly influenced by their
families. These findings meet with previous research that shows that less
autonomy as parents among adolescents often occurs because quite often
adolescent parents still live with their family (Strömmer et al., 2016). It is evident
that parents within the family naturally have authority over their children
(Foucault, 1991). However, in such living arrangements, it can lead to internal
tension and conflict among those adolescents (Halford et al., 2010; Lazarus and
Rossouw, 2015). Adolescents in this study were situated as children who are
expected to behave under their parents’ control but at the same time they were
also expected to behave as ‘normal’ parents like their older counterparts as their
society expected. It is evident that from the perspective of the parent-children
relationship, children had to be under greater surveillance of responsible adults
(Gadda et al., 2008). According to the concept of Foucault (1991) in Gallagher
(2008) with regards to the parents-children relationship, parents have an
essential role to discipline their children through processes of training, correction,
normalisation and surveillance.

It also needs to note that there was a lack of assertiveness among participants,
for example, to speak about what they needed and wanted to their parents, which
was possibly shaped by how society constructs their view regarding how to
behave with parents as well as their older counterparts. This may be explained
by a local cultural expectations, for example the research was conducted in Java
and all participants’ ethnicities were Javanese, particularly in Yogyakarta where
the Javanese Royal Family still reside. The royal family is considered to be one
the reasons that in Yogyakarta, Javanese traditional cultures and beliefs remain
strong and become unwritten rules within Javanese society. There is a proverb
spread within Javanese society ‘bekti marang leluhur’ which is interpreted as
meaning that Javanese people are expected to respect their ancestors by
preserving their culture and beliefs to be passed onto younger generations
(Koentjaraningrat, 1976). There are well known Javanese cultures across
Indonesian society. For example, people are always expected to be considerate
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of people and others’ needs rather than their own needs, as well as accepting
everything that has been obtained as a proof of thanks for what God has given.
There is also a cultural norm–named ‘unggah-ungguh’, which is a rule of
Javanese on how to behave and show manners in society. The Javanese are
also known as people who are softly spoken, patient, polite, ‘nrimo’ (accepting),
and sincere (Dewi et al., 2017). They do not like to speak loudly, behave harshly,
or express ‘strong emotion’ such as anger (Endraswara, 2003). These social
expectations seem to lead to a lack of assertiveness and deference among
Javanese people, therefore in this PhD research, adolescents as well as their
families seemed to adopt the Javanese cultural values. Evidence of this can be
seen as there was no insisting behaviour expressed by adolescents or their
parents in opposition to adolescent marriage. Although, all adolescents
expressed that they were not ready to marry they complied. It would have been
illuminating to explore unplanned pregnancies and marriage among adolescents
involving their parents in order to provide a wider perspective related to
adolescent pregnancy from a different a subject of study.

However, an apparent lack of assertiveness among adolescents may also be due

to their age. All participants were aged 19 or less at the time of this study. In
adolescence, the cognitive and emotional aspects are still under development
(Kaye, 2008). Furthermore, literature also documented that gender, age and
education significantly contributes to the level of assertiveness (Kilkus, 1993;
Onyeizugbo, 2003). In relation to that, findings revealed that none of the
adolescent participants in this study were engaged in higher education, therefore
this may also become a further reason which led to a lack of assertiveness among
adolescents in this study with regards to speaking out against their society’s
cultures. Previous research show that education may build self-esteem as during
the process of education people are more likely to be think about communication,
decision making, meeting challenges, receiving feedback and self-confidence
(Shiwach, 1997; Cavazos-Rehg and DeLucia-Waack, 2009; Van Eckert et al.,
2012).
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7.3.3 The dominance of the power of culture and religion upon the
individual and spirituality
The power of an individual refers to individual autonomy or authority that enables
an individual to make decisions, have a relationship with others, or do whatever
is necessary (Klepec, 2003; Romano, 2009). The power of an individual is also
defined as personal power which refers to self-assertion, a natural striving for
love, satisfaction and meaning in one’s interpersonal world (Alex and Jean, 1994;
Langlois, 2013).

Findings indicate that in the beginning of adolescents’ relationships, both female

and male adolescents were showing their love for each other which brought them
into intimacy and their initiation of premarital sexual relationship. Similar findings
(but in the context of adults) can also be seen from previous research focusing
on relationships, that sexual relationship is an intimate process and an important
aspect of the process of growing a loving relationship (Hendrick and Hendrick,
1991; Ahmetoglu et al., 2010; Alea and Vick, 2010). Therefore, the engagement
of premarital sexual relationship among adolescents in this study was more likely
a milestone of their growing loving relationship, which on the other hand also led
to their unplanned premarital pregnancy.

Conversely, virginity is still considered as highly valuable in Indonesian society,

it is called ‘kesucian’ or ‘kehormatan’ which means as ‘purity’, ‘honour’, or
‘sanctity’ (Situmorang, 2003). Previous research reveals that virginity is a concept
shaped by society or religion and has an influence on how people show their
sexual ideologies as well as sexual practices (García, 2009; Le Espiritu, 2003;
Mitchell, 2015; Amer et al., 2015). Other literature has documented that in other
cultures women are thought to retain their virginity in order to be viewed as
respectable and religion has been become a major proponent of the power of
virginity (Gleixner, 2005; Ogland et al., 2011). Whilst, some societies still consider
virginity to be important and an honour, others believe that virginity is a
construction of societal power to control women’s sexuality and fear them having
natural sexual desires, as well as pleasure (Awwad, 2011; Christianson and
Eriksson, 2015). Indonesian society expects women to keep their virginity until
the day of marriage, and female are supposed to give their virginity to their
husband. However, the facts show that female adolescents were engaging in
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premarital sexual relationship, in order to show and proof their love for their
boyfriend. Therefore, there may be multiple pressure which influenced
adolescents’ behaviour and their view of the concept of virginity. On the other
hand, adolescents’ premarital sexual relationship behaviour among adolescents
probably may an attempt to resist what their previous generation thought and
behaved. Adolescents seems to go in the opposite direction to what society
expects. As instead of keeping the value of their virginity, adolescents give the
engaging premarital sexual relationship as proof of their love. These findings
reveal that power can be seen as not static but as dynamic across and within the
society as well as upon an individual. However, there were also evident from the
previous research that other group of Indonesian adolescents behaved differently
as they viewed that virginity is an ‘honour’ for their future husband (Situmorang,
2003). The both findings form this PhD research and previous research suggest
that power is dynamic, it works in a setting, exercised within different dimensions,
it can change, it is not concentrated on a single individual or class and it is
intentional (Foucault and Gordon, 1980; Foucault, 1982; Sloan, 2007). Therefore,
among Indonesian groups of adolescents, there are different views and
behaviour in regards to the virginity.

It is evident that adolescents participants in this PhD research were rebellious.

Rebellion is defined as the action or process of resisting authority, control, or
convention (Reed, 2015). Rebellion in some cases is shown in the age of
adolescence, as in this period some of the young people proudly assert
individuality from what parents or societies like or independence from what
parents or societies want and in each case succeed in provoking their disapproval
(Jensen et al., 2004; Luthar and Ansary, 2005). The findings in this study indicate
that Indonesian society seems to control and surveillance people’s behaviour by
using cultural norms, whilst adolescents were trying to resist the cultural power
and society control. Foucault (1991) suggests that the society is more likely to be
a panoptical tool towards adolescents to ensure they behave in certain way.
Whilst, adolescents’ rebellious behaviour seems to be a resistant to the power of
culture and religion which are strongly diffused within Indonesian society.
Foucault and Hurley (1990) agree that ‘when there is a power, there is a
resistance’. Resistance itself can also be considered a source of power which in
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social relationships usually comes a from different direction to that of the

mainstream (Heller, 1996), in which also can be seen form the rebellion of
adolescent participants within this PhD research.

Furthermore, findings also indicate that puberty, which leads to sexual interest as
well as sexual desire also seemed to have influenced adolescents in their
decision-making related to engaging in premarital sexual relationship. Desire is
described as an individual’s power, which leads to humans ‘wanting’ or ‘wishing’
for something to happen that will bring their satisfaction or enjoyment (Ceccoli et
al., 2000). The power of an individual with regards to sexual desire was probably
one reason which enabled both female and male adolescents to engage in
premarital sexual relationship. Foucault and Hurley (1979) explain that power not
only appears in the economy or state but also in a micro level of power relations,
for example in the institutions of marriage, motherhood and also in everyday
rituals women’s and men’s relationship.

Additionally, media such as the internet and television, provide open access and
exposure of adolescents with global lifestyles. It is evident that there are
international movies and programmes which promote female and male
relationships, in which contain sexual relationship outside of marriage as part of
their relationship intimacy. Local assumption that access to movies and shows
seems to have an impact on adolescents’ behaviour and life style. During process
of data collection, there was evidence that all adolescents participants have at
least one smart phone with them which enabled them to access the internet.
Adolescents therefore probably tended to imitate lifestyles that they have seen
from the media including practising premarital sexual relationship. The finding is
in line with previous research that shows exposure to sexual content from the
media is linked to the initiation of adolescents in engaging in sexual relationship
(Buerkel-Rothfuss, 2004; Semati, 2008).

Furthermore, as the desire of sexuality is a normal part of puberty amongst

adolescents, the media also seems to increase the desire of sexuality via the
visual and audio exposure related to sexual matters (Semati, 2008). Other
research has reported that that Indonesian adolescents were accessing internet
websites to explore information related to sexuality matters (detailed explanation
in this study background) (Panji, 2014). Media therefore also seems to be a part
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of culture which is possibly contributing to adolescents’ engagement in premarital

sexual relationship among participants. According to Martinez (2013) the media
is a major contributor to the cultural forms within society. Within the findings, it
can also be seen that premarital sexual relationship which is out with Indonesian
cultural expectations were practised by adolescent participants. Further research
that aims to explore adolescents experiences related to how media influences
their sexual practices and behaviour may be important to be conducted in order
to provide research evidence which can be linked to adolescent pregnancy.

The findings suggest that male adolescents tried to influence their girlfriend to
engage in sexual relationship and some female adolescents experienced
emotional abuse when they refused. Therefore, to avoid abusive behaviour some
female adolescents submissively accepted the requests of their boyfriends to
initiate premarital sexual relationship and continued on demand. As Foucault
(1991) argues that discipline is a mechanism of power that regulates the thoughts
and behaviour of people. Findings show that some male adolescent participants
disciplined their girlfriends with emotional abuse was more likely seen as a
punishment for female adolescents (if they rejected a sexual relationship).
Foucault (1982) in Hartmann (2003) also argues that individual power functions
in every human relationship as a mechanism to influence individuals to behave
in certain way. This mechanism together with adoption of Indonesian patriarchal
culture that men are strong and they are expected to be decision makers, whilst
women are followers and they are expected to please what men request
(Vaezghasemi et al., 2014).

The power of an individual can also be seen throughout the findings. For example
power struggling within adolescents’ marriage as well as their decisions and plans
to divorce. Power struggling within a marriage refers to efforts to compete, control
and influence between a wife and husband (Amato and Previti, 2003; Randles,
2016). It is evident from the findings of this study that some adolescents were
experiencing power struggle as a wife and husband. Some of them planned and
decided to divorce and some of them tried to manage their marriage problems.
Marriage can be considered as an institution where individuals’ power is
exercised between a wife and husband (Foucault, 1990; Kelly, 2013). When there
is power imbalance between a wife and husband, it often leads to conflict within
 217

marriage relationships. When this finding is applied to Foucault’s theory of power

and resistance (Foucault, 1991), the cases of power struggling which were
experienced by adolescents seem to be a resistance to the power of each
individual, either wife or husband when the power imbalance occurred.

Scholars also suggest that a micro level of a social body can be an individual
within family, a family within society or it can also be a group in wider society
groups (Karademir, 2013; Agis, 2016; Revel, 2017). The theory links with these
study findings that both female and male adolescents had individual power which
manifest in several findings, such as both females and males were initiating
premarital sexual relationship as a point of growing their loving intimacy; they are
also have initiation to address cultural expectations on role divisions within their
marriage; and adolescents also experienced power struggling as they attempted
to influence each other in their marriage relationship. The power of an individual
therefore in line with the theory of Foucault that power operates at the most micro
levels of social relations and it comes from everywhere (Foucault et al., 2000).

A unique finding in this thesis relates to the ‘power of spirituality’ as it appeared

strongly throughout the experiences of adolescents. The findings show that
power of culture and religion influenced Indonesian adolescents’ spirituality
during their pregnancy and their early parenthood. Spirituality is a source of
power and it refers to an outlook on life, commitment and a personal relationship
with God; spirituality also includes personal belief into God which provides
reinforcement and fulfilment (Boyd-Franklin, 2003; Walsh, 2009). Other scholars
argue that spirituality involves making sense of life situations, beliefs and
standards that are cherished, experienced and an appreciation of a dimensions
beyond the self. Such as relationship with God, a higher power or the
environment, and an unfolding of life that demands reflection and experience
(Martsolf and Mickley, 1998; Tanyi, 2002; Clarke, 2006; Miner-Williams, 2006).
Many adolescents expressed that their past behaviour (committing premarital
sexual relationship) was ‘dirty’ behaviour. ‘Dirt’, contextually, means something
that needs to be cleaned, whilst other scholars also mentioned that dirt is a
pollution (Simpson et al., 2012). In the area of social psychology, ‘dirt’ or ‘dirty’
behaviour has been used as metaphorical language to represent actions or
practices that are morally bad or wrong behaviour (Hughes, 1999; Crespo-
 218

Fernandez, 2015). Ashforth and Kreiner (1999) and Hughes (1962) argue that
the meaning of ‘dirt’ can be used both in the material and moral sense. The
metaphoric word ‘dirty’ has been used widely in the theory and research related
to sexuality, for example to describe ‘prostitution’, as ‘dirty’ work (Simpson et al.,
2012). In some societies ‘dirty’ behaviour is a description of behaviour which is
against cultural and religious norms within society (Ashforth and Kreiner, 1999;
Simpson et al., 2012). In an Indonesian context, premarital sexual relationship is
out-with cultural and religious values, adolescents in this study therefore seemed
to view their past behaviour as dirty behaviour in contrast to the purity of God,
which also reflects that their view is influenced by the power of culture and
religion.

Adolescents also provided perspectives towards their relationship with God as

well as their perspectives for considering right and wrong behaviours. Foucault
(1991) helps to understand a metaphor of ‘dirty behaviour’ as a tool to describe
a certain behaviour and practice, in which can be considered as a technology
from people’s knowledge. Technology has been used generally by Foucault to
encompass broader meanings of a general collection of specific techniques in
people’s life (Foucault and Hurley, 1990), including materials or verbal (Foucault
et al., 2000). This knowledge, which can also be considered as how power is
operated and has been used to represent particular perspectives, conventions,
and motivations. As such, in this study, the dirty behaviour represents the
immorality of being engaged in premarital sexual relationship. This power then
seemed to lead to the creation of a desire to conform to the norms of prohibition
regarding to premarital sexual relationship among Indonesian society. In addition,
this desire to confirm to norms, therefore, leads adolescents to sustain their own
oppression voluntarily, through self-disciplining and self-surveillance. Self-
monitoring among adolescents then seems to have been achieved in
adolescents’ current life practice and discourse. It can be seen that adolescents
felt compelled to regulate their bodies to conform to norms by accepting the
marriage which was initiated by their parents. Adolescents expressed their
acceptance of what they "should" and "should not" do and to "confess" to God to
any deviation from these norms. Additionally, accepted marriage, leaving
 219

schools, adapting female and male roles were also evident of how power of
culture and religion were diffused and adolescents also attempted to conform.

Confession can be defined as a written or spoken statement that people say when
they feel guilty for committing something outside of expectations (Morrison, 2012;
Rana et al., 2015). For example, findings suggest that the unplanned journey into
pregnancy, marriage and parenthood drove participants to attempt the restoration
of their relationship with God. It is also evident that their restoration of building
their relationship with God led them to seek help from God. Adolescents also tried
to cope as well as manage their life difficulties with their power of spirituality
towards God. They believed God is their life goal which seems to suggest that
they interpret and adopt their religious values. There is a Qur’an verse "Seek
forgiveness of your Lord and repent to Him, [and] He will let you enjoy a good
provision for a specified term and give every doer of favour his favour. But if you
turn away, then indeed, I fear for you the punishment of a great Day [Surat Hūd
(11:3)]” (Itani, 2014). Foucault’s theory in Rabinow (2009) which suggest that
spirituality is the method of the subject uses to transform him or herself in order
to gain access to the forgiveness. When it is applied in this study, spirituality with
God is the method among adolescents which is used to transform themselves to
gain to forgiveness based on their religious expectations. Findings also show that
adolescents considered God as their life goal and seeking help from God by
praying. Some of them also expressed their optimism as they believe that God
will help them to solve their problems.

The findings also indicated that participants considered their recent life difficulties
as a punishment and a warning to get close to God, which led them to confess
their past to God. Stigma, judgement, exclusion and other life difficulties which
were experienced by adolescents were their life punishment. Foucault and Hurley
(1979) argue that the history of our present is primarily conceived as a critical
attitude towards the configuration of power relations given at a certain time. This
theory can be seen from the findings that the participants viewed that rebellious
behaviour was their history, which led them into their recent practice of
confession. In addition, adolescents’ spirituality with the God was powerful in that
they developed feelings of optimistic and self-transformational. Literature related
to spirituality suggest that orientation may manifest as a deeply ingrained
 220

personal belief system, which may also be seen in individuals’ personal practices
(Murray and Ciarrocchi, 2007; Rabinow, 2009). It is evident that spirituality seems
to influence adolescents’ ability to cope with their recent life difficulties.

7.4 Strengths and limitation of the study

The strengths and limitations of the individual studies conducted in this research
have been discussed in their individual chapters. This section discusses the
strengths and limitations of the overall exploratory study that had been employed
to obtain the aim of this research.

As the aim of this research was to explore Indonesian adolescents’ reproductive

practices and their experiences during pregnancy and early parenthood, thus,
selecting exploratory qualitative study as the research design to achieve the aim
was appropriate because it helped researcher to gained in-depth information from
adolescents. Furthermore, having involved both female and male adolescents in
this research is one of the strengths of the research. This is because data were
generated directly from both female and male adolescents’ own voices, not from
other third parties such as parents or health providers. The benefit of having direct
involvement of both female and male adolescents enabled the researcher to
directly hear their own views, expressions and also insight experiences.
Additionally, involving males as participants was also a strength of this study as
the researcher therefore could compare and contrast between female and male
experiences. Moreover, the use of one-to-one in depth interviews was also
beneficial in exploring both female and male adolescents’ experiences as they
could express their experiences privately. The credibility, transferability,
dependability, and confirmability were maintained during the research as can be
seen detail in Chapter 3 and in the individual methods of study 2 (Chapter 5) and
3 (Chapter 6).

However, it should be acknowledged that, despite the strengths of the approach

adopted, there are some limitations to be considered. Since this study is a
reflection of adolescents’ perspectives in only a single case study and at a
particular place and time, the evidence of this research may not reflect the larger
perspectives. Furthermore, since there were only a single public health centre
and a single midwifery private clinic as research fields for collecting and
 221

generating the data, therefore the findings would only reflect the experiences in
those particular places. If there were more research fields, a wider spectrum of
experiences may emerge. Additionally, it can be noted that interviews were in
Bahasa Indonesia and some of the English translations were rephrased or made
more understandable to the English speakers.

7.5 Originality
The originality of the research is commonly associated with something truly novel
or unique about the research (Gil and Dolan, 2015). Scholars have mentioned
that originality is one important aspect that needs to be considered when
conducting PhD research. This is primarily because originality results in the
production of ‘new knowledge’, which can inform the topic area and discipline
(Edwards, 2014; Gelling and Rodriguez-Borrego, 2014; Snowden, 2014; Gil and
Dolan, 2015). In terms of this PhD research, originality has been considered and
maintained, which is evident through the process of cross-cutting theories,
methodologies and approaches. In the process of writing when quotations are
used, the researcher has tried to put efforts into providing paraphrasing
sentences, giving citations and also references in order to avoid plagiarism.

Furthermore, the qualitative systematic review facilitated a critical appraisal

process and synthesis of included papers’ findings and it also identified gaps
which were subsequently addressed in study 2 and 3. For example, findings of
the qualitative systematic review suggest that there were no included papers
conducted in Indonesia exploring adolescent pregnancy experiences and no
male participants were included. Therefore, the empirical component of this study
2 and 3 have been conducted in Indonesia and included male adolescent
participants.

It is evident that this PhD research explored the experiences of Indonesian

adolescents during their pregnancy and early parenthood with only had a small
sample which qualitative research usually have, in a particular Indonesian context
and group of people. However, this research contributes in providing knowledge,
information, evidence and recommendations based on the current research
findings which will be beneficial for further fellow researchers, education,
 222

governments and institutions which are concerned about adolescents SRH

matters, particularly adolescent pregnancy and parenthood.

Although some of the findings concerning adolescents’ experiences of this

empirical research have been echoed by the findings of the qualitative systematic
review, there were unique findings such as specific male experiences regarding
to the pregnancy and parenthood, role differences between female and male
adolescents, adolescent marriage which were being initiated by families,
spirituality which has a significant impact in this study and as well as different
specific contexts and times where and when this study was conducted.

7.6 Implications of the research

Do nothing and the problem will remain and probably increase given the
trajectory. This means adolescents will often live in distress or divorce, with poor
education and employment opportunities and have limited opportunity to
contribute to the economy, have no opportunity to practicing breastfeeding
appropriately and have unhappy lives which may impact on the children. The
implication of these findings are to inform and shape policies that change practice
as a means to reduce unplanned pregnancy. This could be done by improving
SRH education amongst adolescents, improve access to contraceptive advice
and contraceptives for adolescents whom engaged in sexual relationships,
empower young people via education so they can make better choices regarding
whether they want to engage in premarital sex or not, improve access to maternity
services if pregnancy occurs including preparation for marriage and parenthood
as well as support for breastfeeding, improve adolescents’ skills in developing a
relationship and better access to continued education to enhance employment
opportunities so that ongoing dependency on their parents in not needed. The
recommendation which follow suggest ways in which changes to policy that could
inform a change in practice and empower adolescents to make better decisions.

7.7 Recommendations
The following recommendations are made based on the findings of the thesis and
the recommendations focus on strategies in order to strengthen the prevention of
adolescent pregnancy, making SRH education and information easy to access
 223

by adolescents, developing adequate care pathways when pregnancy occurred,

and giving opportunity for adolescents to access to school or education.
Additionally, recommendation for future research is also presented within this
section.

7.7.1 Recommendations for practices

 SRH education and information is one of adolescents’ needs in order to
prevent adolescent pregnancy. SRH clinics therefore should be youth friendly
and easily accessible. These strategies can be considered:
o SRH clinics in public health centres and schools need to be more
innovative to gain adolescents’ awareness about the services. For
example by using mobile technology such as social media or App
may also be effective as an alternative tool to gained SRH
awareness amongst adolescents, SRH education and campaign.
Smart phone was very popular and internet can be easily being
accessed by adolescents.
o Social media could also become one of strategy to improve
adolescents’ literacy about SRH health. A team to develop this SRH
services programme could be initiated, such as including midwives
for manual and online SRH materials and teachers as well as peers
for raising adolescents’ participation and awareness about the
programme. Therefore adolescents could access both manual
materials in clinics as well as online materials in the social media.
o SRH education and curriculum in school may also need changes
not to only focus on biological and anatomical reproductive organ,
however, it may be more appropriate if it includes education related
to preventing pregnancy, relationship which have high risk of
adolescent pregnancy, and developing awareness about the
disadvantages of adolescent pregnancy.
o Contraception for unmarried people is still contradictive issues in
Indonesian context. However, make contraception advices and
accessible for adolescents who already engaged in sexual
relationship may also need to be initiated. Therefore, research to
explore public acceptances related to contraception for adolescents
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who are already engaged in premarital sexual relationship is

needed in order to understand the response of how public
responses about ideation of contraception advices and
contraception services for unmarried people.
 A care pathway is required when pregnancy occurs including maternal care,
support for developing marriage relationship skill as well as parenting.
o In terms of maternal care, a specific training about adolescents’
maternal care for midwives need to be provided, this training would
enable midwives to deliver the services specifically for adolescents.
o Maternal care for adolescents also required a welcoming
environment such as displaying poster about young parenthood in
clinics’ waiting room in order to make them to feel that they have a
place for maternal care.
o Maternal care for adolescents also need to be easily accessible, a
home visit may also need to be considered. Holding maternal
services in both clinics and home visit may be make wider
accessibility for adolescents in obtaining maternal care.
o Adolescents’ maternal care need to consider adolescents’
circumstances particularly when adolescent pregnancy is
unplanned such as life difficulties which led to psychological
distress. Therefore, maternal and perinatal mental healthcare also
need to be provided for adolescents.
o Support for developing marriage relationship skill as well as
parenting skill is also needed amongst pregnant adolescents and
their partner/ husband. For example by providing marriage and
parenting courses in order to improve their knowledge and skill
about managing marriage relationship and parenting.
o Manual guideline for engaging marriage and parenthood
specifically for adolescents can also be considered to help
adolescents manage their life difficulties and adjustment for being
wife and husband as well as parents.
o Support for breastfeeding is needed to help adolescents being
confident to practice it appropriately. Promoting and educating the
 225

benefit of breastfeeding and the way to practice is needed to be

provided. This may be also more beneficial to include their husband
as well as their parents/ or parents in-law as findings show about
interference of parents/ or parents in-law in breastfeeding practice.
o Pre-qualification of midwifery education is required to develop an
awareness and understanding about pregnant adolescents and
their partner’s needs amongst midwifery students. Therefore, it
would plausibly have impact on their attitudes towards adolescent
pregnancy in their practice.
o Although this study was not designed to detect the poor outcome of
adolescents pregnancy, wider literature explained that adolescents
pregnancy has high risk of adverse outcome of maternal and child
health. Therefore developing maternal care guideline specifically
for adolescents which include detection of risks complication which
may be experienced by adolescents needs to be considered.
 Inclusion in school for both female and male adolescents also could be an
alternative for adolescents for them to sustained their life because education
would probably make wider opportunity for them to access employment and
subsequently they could become financially independent. The school
inclusion could be applied by using strategies:
o Giving opportunity for male adolescents to stay at the school.
o Providing a class only for pregnant adolescents therefore they
could also find peers.
o Giving opportunity for adolescents to return back to school after
delivery.
 Providing vocational skill training which meet with market requirement and
opportunities in Indonesian context which enable adolescents to develop
their skill would also benefit for adolescents in accessing employment.
However, sufficient funds to apply their skill is also required.

7.7.2 Recommendation for research

Future research to evaluate changes in practice shaped by policy suggested
above would enable refinement of services targeted for adolescents. For example
evaluation of SRH education via different modes e.g. smart phone application,
 226

online sources, evaluating care pathway for pregnant adolescents and their
partners; and evaluating programmes of school inclusion for pregnant
adolescents and their partners. Further research related to appropriate models of
maternal care services and parenting support for adolescents in Indonesia is
needed in order to provide evidence for developing specific maternity and
parenting support for adolescents.

7.8 Disseminations of the research

A part of this research has already been disseminated in some conferences listed
below.

1. A Astuti, J Hirst and K Bharj Exploratory study of Indonesian Adolescents’

Reproductive Practices and their Experiences during Pregnancy and Early
Parenthood: Methodology, Methods and Research Design: poster
presentation Annual Conference of Faculty of Medicine, University of Leeds
(2014).
2. A Astuti, J Hirst and K Bharj Exploratory study of Indonesian Adolescents’
Reproductive Practices and their Experiences during Pregnancy and Early
Parenthood: Methodology, Methods and Research Design: poster
presentation: poster presentation Post Graduate Research Conference,
School of Healthcare, University of Leeds (2014)
3. A Astuti, J Hirst and K Bharj Experiences of pregnant adolescents and their
partner in Indonesia and other low-lower and middle-upper middle: A
systematic review: oral presentation Post Graduate Research Conference,
School of Healthcare, University of Leeds (2015)
4. A Astuti, J Hirst and K Bharj Experiences of pregnant adolescents and their
partner in Indonesia and other low-lower and middle-upper middle: A
systematic review: oral presentation ICM Asian Pacific Regional, Yokohama,
(Japan 2016)
5. A Astuti, J Hirst and K Bharj Exploratory study of Indonesian Reproductive
Practices and their Experiences during pregnancy: poster presentation
Sexual Reproductive and Infant Psychologic Annual Conference, Leeds
(2016)
 227

6. A Astuti, J Hirst and K Bharj Exploratory study of Indonesian Reproductive

Practices and their Experiences during early parenthood: poster presentation
Triennial International Conference ICM, Toronto, Canada (2017)

Further dissemination will include publication in peer-reviewed journals i.e.

synthesise of study 2 and 3 and also qualitative systematic review ( study 1).
Presenting the summary of the key findings and recommendations of this
research to policy makers including the Indonesian Ministry of Research,
Technology and Higher Education, Indonesian Ministry of Health, Indonesian
Midwifery Association, Indonesian Ministry for Social Affairs, Indonesian Ministry
of Religious Affairs, Indonesian Ministry of Women’s Empowerment and Child
Protection, Indonesian Ministry of Youth and Sports, and the National Population
and Family Planning Board (BKKBN); international and local NGO’s which
focused on adolescent pregnancy and SRH; and researcher and academic
people across universities in local Indonesian and international.

7.9 Conclusion
Adolescent pregnancy and parenthood is considered a public health issue,
particularly when it happens in countries with limited support for pregnant
adolescents and young parents. This research has engaged to explore
Indonesian adolescents’ reproductive practices and their experiences during
pregnancy and early parenthood by conducting exploratory qualitative research
including a qualitative systematic review, an in-depth study of Indonesian
adolescents’ experiences during pregnancy, and an in-depth study of Indonesian
young parents during their early parenthood. This research also has ethical
considerations which have been implemented during the research process and
the ethical approval was obtained from SHREC and also the Indonesian ethical
board. The rigour of the study was maintained by considering credibility,
transferability, dependability and confirmability during the process of this
research.

Findings shows that power relations in society strongly influence adolescents’

experiences during their unplanned pregnancy and their early parenthood.
Therefore, the concept of Foucault related to power relations in society has been
used as a lens to discuss the findings, counter and debate the adolescents’
 228

experiences during pregnancy and early parenthood. Implications and

recommendations for policies, practices and research were also drawn to offering
thoughts based on the current evidence that may be beneficial for giving an
alternative way of thinking about adolescent pregnancy and parenthood.
Disseminations of this research includes presentations of findings in international
and local conferences which was attended; a plan for publications of findings in
peer-reviewed journals; and a plan of presentations of findings and
recommendations for Indonesian policy makers, local and international NGO’s
and academic people.

7.10 Reflection after the process of data collection

Researcher can confirm that the trainings which attended before data collection
(detail in Chapter 1) were beneficial to help researcher applied research theories
into practice. For example, at the beginning of the process of data collection,
researcher always read training courses’ materials attended to challenges that
may be found during the interviews; and identified strategies to overcome them.
The researcher found that some participants were open and willing to talk freely,
but some were less willing to talk. The training courses’ materials therefore were
really beneficial on developing skills on data collection such as how to encourage
people to talk during interviews.

This research was the researcher’s first experience of conducting research under
supervision from an overseas institution as all previous research were under
Indonesian institution, therefore learnt about the ethical review process between
the University of Leeds and Indonesian institutions. The detailed process of
ethical application, ethical review and ethical approval were a benefit to develop
research skills, particularly explaining to the reviewer how the data collection will
be applied in an Indonesian context. In addition, in terms of engaging in the
research field, the researcher gained very positive feedback for conducting
research and for accessing a private meeting room for interviews. There was an
assumption that participant recruitment may be challenging. However, there were
adolescents who voluntarily participated in study 2 and 3. It may be because of
they wanted to shared their experiences. During interviews with participants, I
expected that female participants would be more open because there was no
 229

gender differences, so I expected the usual openness between females within

the community. There were some male participants who were less willing to talk,
but, I also found that some male participants also talked freely and openly, as
well as being able to take time to discuss their views with the researcher. It may
because of participants’ characters or it may be because they have opportunity
to share their real experiences through their pregnancy and early parenthood
period.

As this was the first experiences of conducting qualitative research, I was really
surprised by the extensive amount of data. I assumed that transcribing would not
take a lot of time but then during the process I learnt that the transcription process
was time-consuming in qualitative research. Additionally, as interviews were
conducted in Bahasa Indonesia, English translations took time and needed to be
discussed with the supervisory team and prepared for the thesis. I also learnt
from the research findings about the experiences of adolescents being pregnant
and parents that were not thoroughly understood before data was collected. The
researcher had assumed that female adolescents were the most burdened
people when pregnancy due to premarital sexual relationship occurred, but
surprisingly the findings show that male adolescents also experienced a feeling
of being burdened, life difficulties and challenges as well. Furthermore, the
researcher was also surprised that some adolescents also mentioned that they
preferred to live independently, rather than live with their parents. In fact, before
the research has conducted, I assumed that married couple whom living with their
parents were in the very comfort zone as they being supported by their parents.
Moreover, I also assumed that the findings would be unique and very different
with other previous research. However, after data analysis, writing-up as well as
exploring theory of power I found that there are similar situations can also be
found globally and seems applicable and relevant in other countries. For
example, how power of culture influences people and family’s perspectives and
behaviour as well as individual self-regulation.

7.11 Summary
This chapter has presented an overview of the research aim, integrated
discussion of the main findings, strengths and limitations, and originality of the
 230

studies. Furthermore, implications of the research, recommendations,

disseminations, conclusions of the overarching research as well as reflection
after data collection process have also been provided.
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Population Studies. 5(3), pp.329-347.
Appendix A : Proof of ethical approval
 Appendix B : Example of Search Outline
1. ASSIA
((adolescent* OR (teen* OR teenager*) OR (youth OR young father*) OR
(young mother* OR young parent*) OR (young boy* OR young girl*)) AND
(pregnant* OR pregnanc* OR primigravida* OR antenatal OR prenatal)) AND
(experience* OR perspective* OR perception* OR view*) : 418
2. Medline
3. # Searches
Results
▲
1 adolescent*.mp. [mp=title, abstract, original title, name of substance word, subject 959115
heading word, keyword heading word, protocol supplementary concept word, rare
disease supplementary concept word, unique identifier]

2 teen*.mp. [mp=title, abstract, original title, name of substance word, subject 15096
heading word, keyword heading word, protocol supplementary concept word, rare
disease supplementary concept word, unique identifier]

3 teenager*.mp. [mp=title, abstract, original title, name of substance word, subject 7103
heading word, keyword heading word, protocol supplementary concept word, rare
disease supplementary concept word, unique identifier]

4 young girl*.mp. [mp=title, abstract, original title, name of substance word, subject 1686
heading word, keyword heading word, protocol supplementary concept word, rare
disease supplementary concept word, unique identifier]

5 young boy*.mp. [mp=title, abstract, original title, name of substance word, subject 814
heading word, keyword heading word, protocol supplementary concept word, rare
disease supplementary concept word, unique identifier]

6 young mother*.mp. [mp=title, abstract, original title, name of substance word, 536
subject heading word, keyword heading word, protocol supplementary concept
word, rare disease supplementary concept word, unique identifier]

7 young father*.mp. [mp=title, abstract, original title, name of substance word, 66

subject heading word, keyword heading word, protocol supplementary concept
word, rare disease supplementary concept word, unique identifier]

8 young parent*.mp. [mp=title, abstract, original title, name of substance word, 132
subject heading word, keyword heading word, protocol supplementary concept
word, rare disease supplementary concept word, unique identifier]

9 youth.mp. [mp=title, abstract, original title, name of substance word, subject 31573
heading word, keyword heading word, protocol supplementary concept word, rare
disease supplementary concept word, unique identifier]

10 1 or 2 or 3 or 4 or 5 or 6 or 7 or 8 or 9 968063

11 pregnant*.mp. [mp=title, abstract, original title, name of substance word, subject 79141
heading word, keyword heading word, protocol supplementary concept word, rare
disease supplementary concept word, unique identifier]

12 pregnanc*.mp. [mp=title, abstract, original title, name of substance word, subject 364377
heading word, keyword heading word, protocol supplementary concept word, rare
disease supplementary concept word, unique identifier]
3. # Searches
Results
▲
13 primigravida*.mp. [mp=title, abstract, original title, name of substance word, 1620
subject heading word, keyword heading word, protocol supplementary concept
word, rare disease supplementary concept word, unique identifier]

14 antenatal.mp. [mp=title, abstract, original title, name of substance word, subject 16090
heading word, keyword heading word, protocol supplementary concept word, rare
disease supplementary concept word, unique identifier]

15 prenatal.mp. [mp=title, abstract, original title, name of substance word, subject 84305
heading word, keyword heading word, protocol supplementary concept word, rare
disease supplementary concept word, unique identifier]

16 11 or 12 or 13 or 14 or 15 387236

17 experience*.mp. [mp=title, abstract, original title, name of substance word, subject 483619
heading word, keyword heading word, protocol supplementary concept word, rare
disease supplementary concept word, unique identifier]

18 perspective*.mp. [mp=title, abstract, original title, name of substance word, subject 137146
heading word, keyword heading word, protocol supplementary concept word, rare
disease supplementary concept word, unique identifier]

19 perception*.mp. [mp=title, abstract, original title, name of substance word, subject 209981
heading word, keyword heading word, protocol supplementary concept word, rare
disease supplementary concept word, unique identifier]

20 view*.mp. [mp=title, abstract, original title, name of substance word, subject 213419
heading word, keyword heading word, protocol supplementary concept word, rare
disease supplementary concept word, unique identifier]

21 17 or 18 or 19 or 20 947762

22 10 and 16 and 21 1564

23 limit 22 to yr="2004 -Current" 886

Appendix C : World Bank Classification List
 Appendix D : Example of Pre Screen Tool Framework Used

Title/ Author/ Year STUDY DESIGN

OUTCOME (QUALITATIVE
(EXPERIEN STUDIES AND
Population EXPOSURE
CE, STUDIES
(ADOLESCENTS) (PREGNANCY)
PERSPECTI REPORTED CONCLUSION (INCLUDE,
VE, VIEWS) EXPERIENCE IE; BACKGROUND OR
SURVEY REJECTED)
Yes No Yes No Yes No Yes No
Aboriginal Adolescents’ Pregnancy in Eastern Used as background as the
Taiwan (Tsai and Wong, 2004)     data collected in 2002.
Meanings attributed to fatherhood Abstract was in English but
by adolescents (Sampaieo et al, 2014) full papers was in
    Portuguese
The timing of marriage and childbearing among
Used as background as the
rural families in Bangladesh: Choosing between
    data collected in 2002.
competing risks (Schuler et al, 2005)
Adolescent Pregnancy in Argentina: Evidence-
Used as background as the
Based Recommendations for Public Policies
    data collected in 2003.
(Gogna et al, 2008)
Appendix E : Example of the data extraction of
qualitative findings
Standard data quotesion form
Article 1
Title : Relationships, perceptions and the socio-cultural environment of pregnant teenagers in Soshanguve
Secondary School
Author: Maholo et al (2009)
Country:
South Africa
Aims of study
To determine the teenagers’ patterns of relationships, perceptions towards their pregnancy and lives and describe the role
of their socio-cultural environments in their pregnancies.
Ethics – how ethical issues were addressed
Written permission to conduct the study was sought and obtained from the Ethics Committee of Tshwane University of
Technology and authorities of the healthcare centres in Soshanguve. Rights of participants were respected throughout the
study. Informed consent, anonymity, confidentiality were also maintained. Participants were informed about their rights to
withdraw at any time of the study without any victimisation whatsoever.
Study setting
The study was in sub urban areas. The majority of participants (83.3%; n=25) were in the 17-20 year age group. Most were
pursuing their studies at secondary schools in Soshanguve while some had just left school due to their pregnancies. Almost
all the participants (96.7%; n=29) were primigravidae with most (70.0%; n=21) having had their menarche at the age of 14
or younger.
Theoretical background of study
Nursing health promotion
Sampling approach
30 participants identified from Primary Healthcare (PHC) catchment area of Soshanguve. There is no statement related to
reason of using methodology and methods of this study.
Participant characteristics
There is inclusion of criteria to be participants. However, the author did not mention how they were selected and why they
were selected. Author also did not explain how many participants were excluded and criteria for exclusion. The following
points are inclusion criteria of participants:
 Between 14-20 years of age
 Willing to participate
 Using specific PHC clinic for antenatal or post natal care
 In a Soshanguve secondary school or had left school within the preceding six months due to pregnancy
Data collection methods
Semi structured interview with specific themes to be explored and it is audio recorded. The interviews were in a private room
at the Primary Healthcare Clinic. The role of author in the data collection is not stated in the article. The role of the author
was as a main researcher. In this study, author did not explain how data saturate.
Data analysis approach
Data were analysed by using open coding and the template analyzed style. Descriptive analysis was used to identify themes
and subthemes. An acknowledged approach to qualitative data analysis is using the template which the narrative data are
applied. The units of the template for the study were the themes of the interview. An independent coder was involved to
reduce bias and a consensus meeting was held between the researcher and the independent coder to determine inter-coder
variability.
Key themes identified in the study (1st order interpretations)
Experience of menarche, relationships, knowledge and perceptions about their pregnancies, socio-cultural norms and
teenagers’ environment and vision of the future.
Data quotes related to the key themes
 Experience of menarche
a. Knowledge and perception about menstruation
 “ I started to menstruate at 13 years. I knew nothing about menstruation. I was embarrassed and
reported to my mother. She just said I must menstruate because I am a girl and added that I must go to
the clinic for prevention because if I can sleep with a boy, I will fall pregnant”.
b. Emotional responses to menstruation
“ I still remember when I started to menstruate at 14 years. I was so anxious and even felt like committing
suicide. What made matters worse was I was going to write an examination at twelve o’clock that day
and I just did not know what to do. I was uncomfortable throughout the exam and just passed by luck.
 Relationships
a. Age of sexual debuts and durations of relationships
21 participants initiated sexual relationships from 15-17 years of age, 10 participants had their sexual
debuts at 14 years of age. 21 participants started their sexual debuts when they had started
menstruating.
b. Knowledge and perceptions about relationships
“ I just felt ready for the relationship and to love someone intimately. I was never pished into having sex,
but I wanted to experience it”.

“ I started to fall in love when I was 15 years old. I was surprised to discover that I am pregnant after
three months of the affair.”
c. Partners and outcomes of the relationships that resulted in these pregnancies
“ Since I started, this is my third boyfriend. I separated with the first one because he was having an
extra affair. He claimed to be having a lot of homework and suddenly had excuses to see me. We
separated without notifying each other. The present one is responsible for this pregnancy but he denies
the pregnancy saying that he does not believe the pregnancy is his. My family went to meet his parents
but his mother protected him saying he has a child already with another girl. He also refused to
acknowledge that pregnancy”.
 Knowledge and perceptions about their pregnancies
a. Knowledge related to pregnancy and information received during antenatal-care
“I don’t know anything about pregnancy. I just got to know that I am pregnant after telling my friend that
I have missed my period. I even took some purgatives to cleanse my stomach as I was feeling sick”
Another stated:
“I know that a person fall pregnant after sexual contact. That’s the only thing I know and after there is no
menstruation during pregnancy.”
b. Knowledge and perception about contraceptives
“The pills need extra carefulness. I used Nur Isterate once and felt dizzy and developed sores on my
buttocks. My face was swollen and I decided not to use it any more. I also know condoms prevent illness
and pregnancy. I once used them and my partner started to refuse them as he felt they were too tight
for him.”
“I am not sure whether my partner forgot to use a condom or not.”
 Socio-cultural norms and teenagers’ environment
a. Reactions from family members
“My parents said according to their culture, they accept my baby, but emphasized that I should have
matured first and completed my studies.”
“My mother always says that the old initiation schools for both girls and boys were helpful in teaching
and preparing youth for adulthood. Now things have changed and it is not easy to talk to your children
about all these sexuality issues.”
b. Individual beliefs
“ I am now happy as I wanted a baby desperately. My boyfriend is 28 years and is working and supports
me and my baby.”
“I should have listened to my mom when she advised me to use contraceptives to protect myself. I
refused as I did not want her to know that I was having a boyfriend and that we were engaging in sex. I
have a baby and I can hardly provide anything for her. I depend on my family for everything”
 Vision of the future.
“ I can now advise teenagers to abstain or use condoms. The best thing is to abstain.”
“if they are pregnant they must eat the right diet and test for HIV to save their children. They must never do
abortion because the baby has the right to live as they are also living”
Author explanations of the key themes (2nd order interpretations)
 Experience of menarche
a. Knowledge and perception about menstruation
The findings indicate parents’ inappropriate communication with their daughter about the developmental
changes and realities of life. Mother could share false or vague information with their daughter regarding
sexuality issues.
b. Emotional responses to menstruation
Expressing emotional experiences towards menstruation is natural and acceptable. It becomes a
concern when young girls are not adequately informed or prepared for menstruation as they become
negative and may not know what to do or how to behave. Lack of appropriate information may also lead
to adolescents’ vulnerability to risky sexual behaviors. From the study, it became evident that mothers
or grandmothers provided statements or instruction without explanations.
 Relationships
a. Age of relationships
From the findings, it appears as though the length of relationships did not influence the initiation of sexual
relationships. Almost all participants were involved in relationships, though not necessarily with the
fathers of their babies, at the time of the study.
b. Knowledge and perceptions about relationships
 From the most participants, being in a relationship implied having a sexual relationship. Some
participants were able to choose whether to take the relationship to a sexual level or not. However, some
participants were reportedly harassed and beaten by their boyfriends for refusing to engage in sex.
c. Partners and outcomes of the relationships that resulted in these pregnancies
All participants admitted to having multiple partners thought not all were sexual partners
 Knowledge and perception about their pregnancies
a. Knowledge related to pregnancy and information received during antenatal care
It is important that adolescents are informed about pregnancy and the changes taking place within their
bodies during pregnancy so as to take necessary steps and obtain antenatal healthcare. Participants
who had attended antenatal clinics indicated that they were informed about what to report during the
pregnancy, the importance of antenatal visits, post natal check ups and HIV prevention of mother to
child.
b. Knowledge and perceptions about contraceptives
Though condoms are still an option, both parties must take joint responsibility for their consistent and
correct use. Additionally, consistent condom use must be the responsibility of both ad not be left to males
only.
 Socio cultural norms and teenagers environment
a. Reactions from family members
The findings indicated that parents or family members were concerned about their adolescents
becoming pregnant but not all understood their own roles in preventing the possibility due to limitation
and cultural barriers.
b. Individual belief, practices and reactions regarding pregnancy
Pregnant teenagers and teenage mothers had mixed feelings about their pregnancies. Some were
relived expressing joy and acceptance of their babies, whilst others regretted feeling worthless and
betrayed
 Vision in the future
Most participants intended to return to school, leaving their babies with their grand mothers. Some felt hopeless,
discourage and desperate. One of the participant stated that she would not go back to school because she had
added another responsibility to her mom who is helpless. One of the participants saw a problem in coping with
studies and caring for a baby at the same time.
Recommendations made by authors
 Both pedagogical and andragogical educational strategies must be used to educate adolescents, families and
communities regarding sexual issues
 Educational content should include the menarche, reproductive functions, reproductive health, sexuality and
sexual relationships and contraception.
 The variability of the socio-cultural environment of adolescents in South Africa must receive attention to prepare
the future registered nurse to deal with adolescents.
 Evidence must be gathered to use as a starting point of interventions, informing adolescents, families and
communities about adolescent pregnancies.
 The recommended early age of then at which education should commence needs to be considered so that
intervention are timely to enable adolescents to make informed decisions about their pregnancies.
Assessment of study quality: B
Article 2:
Title: Experiences of pregnancy and motherhood among teenage mothers in a suburb of Accra Ghana: a qualitative
study
Author: Gyesaw and Ankomah (2013)
Country
Ghana
Aims of study
To explore experiences of adolescent mother during pregnancy, childbirth and care of their newborns
Ethics – how ethical issues were addressed
Written informed consent and verbal consent were sought from participants. Permission was also obtained from parents and
guardians. Participants were assured of confidentiality. Ethical approval for the study was given by the Ghana Health Service
ethical review board.
Study setting
The study was conducted in Ga East Municipality, a suburb of Accra, Ghana’s capital city. There was a mixture of participants
who understood and spoke both Ga and Twi and a mixture of Christians and Muslims. In terms of parity, the participants
were all mothers of at least one child
Theoretical background of study
Public health particularly Sexual Reproductive Health
Sampling approach
54 participants were identified from healthcare facilities and community level. A nurse volunteer compiled a list of adolescent
mother and some mothers were traced who in turn by using snowballing techniques. In community level, community
gatekeepers were employed to ensure that the study included teenage mothers who may not have attended health facilities.
Snowballing techniques sampling employed to recruit next potential participants. The identified study participants were visited
at home by the female co-author. A brief explanation of the study objectives was given to both parents and other adult
guardians. The home visits were done to help establish rapport and build confidence among parents, guardians, and the
investigator. During the home visits, dates and venues for focus groups and indepth interviews were also discussed. Upon
arriving at a consensus, telephone calls were made to each of the participants to confirm the time, place, and date for the
discussion or interview. The author mention about research design, however, there is no justification why exploratory
qualitative study was used.
Participant characteristics
Adolescent mothers aged 14-19 years living alone or with their parents or guardians. There is no statement related why the
participants selected and how many adolescents were exluded.
Data collection methods
Focus group discussions consist of 6-9 participants each group for about an hour and recorded. A moderator is a nurse who
previously had experiences on working with adolescents and a note taker was also employed in every session of FGD. With
regard to the in depth interviews, six respondents were recruited from the health facility during special clinic days set aside
for mothers, while three respondents were recruited from the community to reflect mothers who do not have access to health
facilities. An interview guide, based on topics similar to the focus group discussions, was used to conduct the in depth
interviews. In this study, author did not explain how data saturate.
Data analysis approach
Thematic analysis was used to identified sub themes and themes from the transcription. Coding was done manually based
on key words and phrases developed from the data. The codes were then grouped together under higher order headings.
These themes were categorized according to experiences in relation to pregnancy, childbearing and childcare and parental
view reactions. The researcher then sorted the data thematically by clustering together material with similar content. At this
stage, the researcher employed creative and analytical reasoning to determine categories of meaning.
Key themes identified in the study (1st order interpretations)
 Reasons for becoming pregnant
 I am pregnant
 Reactions from parents
 Partner reaction
 Option of abortion
 Adolescents in labor
 First sight of the baby
 Caring for the baby
Data quotes related to the key themes
 Reasons for becoming pregnant
a. Transactional sex
“I was in school and I had to pay my exam fees….I needed money. Then this boy expressed interested
in me. He helped me on more than two occasions, which landed me with a pregnancy” (17 years old)
“I was in school and my mother said she had no money for me. The man said he would take care of me,
but then there was a pregnancy, then a child and then this second pregnancy” (17 years old)
“He lured me into getting pregnant. He conned me with sweet talk and gifts” (15 years old)
“My mother has money but she does not give me any, not even basic needs for a normal girl. Then I
went to watch TV and met my boyfriend who promised to look after me…..then I became pregnant.” (18
years old)
b. Adolescent sexual experimentation
“I was very stubborn. I had no financial problems. I created that problem. I could have turned down the
boy’s proposal, but I did not. He became my boyfriend and made me pregnant.” (19 years old)
c. Lack of sex education
“We were both young and had just started a relationship, we didi not know anything. We were
experimenting, which resulted in the pregnancy.” (16 years old)
d. Wanted to be adolescent mom
“My boyfriend made me pregnant. I was aware of everything. I was aware of it. I just wanted. I am ready.”
(19 years old).
 I am pregnant
“ I was not expecting anything. I did not know I was pregnant. It was my mother who realized I was pregnant
because I was vomiting all the times but still menstruating” (16 years old)
“I did not know, but when I realized it, it was very late. It was 6 months old and I was still menstruating” (17 years
old)
“I started vomiting and spitting, then realized something was inside.” (19 years old)
“ I was living with my auty, who realized that my attitude towards the usual household chores had changes. It was
not until two months later when my menses was not coming that I accepted I was pregnant.” (16 years old)
“When the month came for me to have my menses, it did not come and when the time elapsed for about two days,
I went to get a pregnancy test. The result come out positive.” (19 years old)
“When I was to have my menses that month, it did not come and I knew what was wrong.” (17 years old)
 Reactions from parents
“ I was living with my mother before the pregnancy and she really reprimanded me for getting pregnant. Mother
was really upset and depressed. She fumed at me that she spent millions on your education and now this has
happened.”
 “My dad was very angry. He did not talk to me for about three months. My mother had to go to talk to him on my
behalf before he forgave me.” (18 years old)
“My parents were very upset with me because they thought with the pregnancy that I would not go back to school.”
“ My mother had no problem as she needed grandchildren. She had no problem at all.” (19 years old)
 Partner reaction
“My partner was calm with the news. He said he was going to inform his family. Later, my Dad sent a delegation
to his people. They readily accepted (the pregnancy).” (19 years old)
“My partner wanted to marry me but I had been preventing him because I wanted to complete my apprenticeship.
This made it easy for him.” (18 years old)
“He denied responsibility for the pregnancy”. (15 years old)
 Option of abortion
“My mother warned me not to abort, that she would support me until I delivered.” (16 years old)
“My parents wanted me to abort the pregnancy, but when we went to check the gestation of the pregnancy, it was
too old for an abortion.” (16 years old)
“My partner was strongly against abortion. He told me that, where he comes from, it is taboo to commit abortion
and whoever tries it dies.” (18 years old)
“I told my partner and he asked me what I wanted to do. He brought me some medicine for an abortion, but the
pregnancy, wouldn’t abort. He even went to the extent of giving me akpeteshie (local gin), but still no abortion.”
(19 years old)
 Adolescents in labor
“ I toileted too much during labor. So when I delivered, I said Oh Thank god.” (19 years old)
“Labor was difficult and painful. I kept crawling on the floor. Whoever says that labor is easy is lying.” (18 years
old)
“I had stomach upset…it was labor. I had to walk for about 3 miles to the health center. I was a good decision, as
my mother had gone to work. Five minutes after getting there, I delivered. The least bit of delay and I would have
delivered on the way.” (18 years old)
 First sight of the baby
“After delivery when my son was handed over to me, I looked into his face. I remembered the suffering and said
Wow I want give birth again. I was teased until I left the health facility.” (18 years old)

“ I had no regret about carrying the pregnancy to term. I was very glad to have had the baby. Even sometimes
when I am at home and I look at my baby. I become so happy because there are people out there, who have
money, who want what I have but cannot.” (19 years old)
“ I had no regret for having the baby…so relieved. The baby was shown to me; I was alive to see my child.” (16
years old)
“ I was hurt with regard to my education. I was so glad when I saw my baby, I had no regret…no one can tell what
the child will do for me in the future.” (18 years old)
 Caring for the baby
“My mother took the child from me so I could go back to school. With regards to caring to care for the child, it is
my mother’s duty.” (14 years old)
“I was not feeling well after delivery so it was my mother who did everything for us. She only brought her to me to
suckle.” (18 years old)
“My aunty has been so good to my child and myself. She bought the baby’s clothes and all that the baby needed,
she got them.” (16 years old)
“I had no problem at all. My boyfriend provided for all our needs and my mother also helped in caring for the baby.”
(16 years old)
“My partner was and continues to be supportive in the care of the child.” (19 years old)
Author explanations of the key themes (2nd order interpretations)
 Reasons for becoming pregnant
a. Transactional sex
For about half the young mothers, the sexual encounters that resulted in their pregnancy were the result of
transactional sex. Many narrated the financial challenges they faced and how they felt they could exchange
sex for material gains; many of their parents and other relatives could not or would not provide the basic
needs of adolescents.
b. Adolescent sexual experimentation
A few of participants accepted responsibility and admitted that they became too difficult for their mothers
control. They want their own way experiment by engaging sex. They felt it was a stage in the life of an
adolescent, a period where most adolescents turn rebellious and do not listen to counsel. They preferred to
explore and take advice from peers and not from parents.
c. Lack of sex education
In each discussion group, there were young adolescents who mentioned that they were naïve and did not
know anything about the implications sexual relationship; they did not know they could become pregnant.
d. Wanted to be adolescent mum
A few of adolescents mentioned that they chose to become pregnant and that they had always wanted to
have children early in life. They explained that they wanted to prove they were mature and felt pregnancy
enhance their societal value, because it is socially demanded that pregnant women be respected.
 I am pregnant
The majority of participants did not know they were pregnant and did not expect their pregnancy. A few of them
were still menstruating during the first semester. It was their parents and guardians who first noticed the pregnancy.
Many of the participants, however, knew they were pregnant after missing their menstrual period.
 Reactions from parents
The greatest fear of most of the participants was that of how their parents would react upon hearing about the
pregnancy. The majority of respondents indicated their parents or guardians were not happy on learning that they
 were pregnant. To many parents, the pregnancies came as a surprise. Parental reaction varied. Nearly all parents
were upset and some were shocked. However, in a rare situation parent had no problem accepting the pregnancy.
 Partner reaction
Most of the participants mentioned the reactions of their partners when they told them of the pregnancies were
positive. In a few cases, however, partners flatly denied they were responsible for the pregnancy.
 Option of abortion
More than half of the participants noted that abortion was discussed as a way out. While nearly all parents advised
the teenagers not to consider abortion, others mentioned parents who wanted to facilitate abortion. Many reported
that while their partners were against abortion for fear of complications that might lead to death, a few others tried
unsuccessfully to abort the pregnancy.
 Adolescents in labor
Almost all the participants testified to the pain that came with labor.
 First sight of the baby
Most of the participants had no regrets about carrying the pregnancy to term. Upon seeing the newborn for the
first time, nearly all participants mentioned that the pain and suffering vanished.
 Caring for the baby
Regarding the level of care the adolescent mothers gave to their newborns, nearly all the adolescents had some
assistance from their family in caring for their child. In nearly all cases, the young mothers were supported by their
mothers or other older family members. Many admitted that because they lacked parental skills, they could not
have coped on their own.
Recommendations made by authors
Solutions to the holistic problems of the adolescent mother cannot be found in the activities of a single individual or service.
The solutions can only be found through the coordinated effort of a multidisciplinary and intersectoral team. The role of school
health nurses should be expanded to providing information on pregnancy and its risks, contraceptive use, abortion and its
complications, and early childbirth and its consequences. There is also a need for health educators to focus on local high-
risk groups and high-risk behavior. In addition, teenagers should be taught assertive interpersonal skills development, such
as negotiating and refusal skills in programs that allow young people to practice these skills. Special programs should be
initiated
Assessment of study quality: A
 Appendix F : Quality Assessment of the study by
using Critical Appraisal Skills Programme
(CASP)
List of Questions:
Screening Questions
1. Was there a clear statement of the aims of the research?
Consider: what the goal of the research was; why it is important; its relevance.
2. Is methodology appropriate?
Consider: if the research seeks to interpret or illuminate the actions and/ or
subjective experiences of research participants.
Detailed Questions
3. Was the research design appropriate to address the aims of the research?
Consider: if the researcher has justified the research design (eg have they
discussed how they decided which method to use)
4. Was the recruitments strategy appropriate to the aims of the research?
Consider: if the researcher has explained how the participants were selected; if
they explained why the participants the selected were the most appropriate to
provide access to the type of knowledge sought by study; if there are any
discussions around recruitment (e.g. why some people chose not to take a part)
5. Were the data collected in a way that addressed the research issue?
Consider: If the setting for data collection was justified; If it is clear how data were
collected (e.g. focus group, semi-structured interview etc.); If the researcher has
justified the methods chosen; If the researcher has made the methods explicit
(e.g. for interview method, is there an indication of how interviews were
conducted, or did they use a topic guide)?; If methods were modified during the
study. If so, has the researcher explained how and why?; If the form of data is
clear (e.g. tape recordings, video material, notes etc.); If the researcher has
discussed saturation of data
6. Has the relationships between researcher and participants been adequately
considered?
Consider: If the researcher critically examined their own role, potential bias and
influence during: (Formulation of the research questions, data collection,
including sample recruitment and choice of location); How the researcher
responded to events during the study and whether they considered the
implications of any changes in the research design
7. Have ethical issues been taken into consideration?
Consider: If there are sufficient details of how the research was explained to
participants for the reader to assess whether ethical standards were maintained;
If the researcher has discussed issues raised by the study (e.g. issues around
informed consent or confidentiality or how they have handled the effects of the
study on the participants during and after the study); If approval has been sought
from the ethics committee
8. Was the data analysis sufficiently rigorous?
Consider: If there is an in-depth description of the analysis process; If thematic
analysis is used. If so, is it clear how the categories/themes were derived from
the data?; Whether the researcher explains how the data presented were
selected from the original sample to demonstrate the analysis process; If
sufficient data are presented to support the findings; To what extent contradictory
data are taken into account; Whether the researcher critically examined their own
 role, potential bias and influence during analysis and selection of data for
presentation.
9. Is there a clear statement of findings?
Consider: If the findings are explicit; If there is adequate discussion of the
evidence both for and against the researcher’s arguments; If the researcher has
discussed the credibility of their findings (e.g. triangulation, respondent validation,
more than one analyst); If the findings are discussed in relation to the original
research question
10. How valuable is the research?
Consider: If the researcher discusses the contribution the study makes to existing
knowledge or understanding e.g. do they consider the findings in relation to
current practice or policy, or relevant research-based literature?; If they identify
new areas where research is necessary; If the researchers have discussed
whether or how the findings can be transferred to other populations or considered
other ways the research may be used
Article/ Grade Quality Assessment
Article 1 Aim of study stated clearly in this article, the use of qualitative
exploratory was fit with the aim of study. The process of study mainly
Title : Relationships, addressed ethical issues ie confidentiality, dependability, credibility and
perceptions and the socio- trustworthiness. The author also provides the role of author in every
cultural environment of step of study. Data analysis was also presenting in very structured way
pregnant teenagers in with quotes original data from participants. Discussion,
Soshanguve Secondary recommendation and conclusion also addressed the aim of study.
School However, there are information missed from the article particularly in
Author: Maholo et al (2009) terms of methods ie: there is no explanation related to reason for using
exploratory qualitative approach no other approach such as
Grade B phenomenology, grounded theory, ethnography etc. In terms of
recruiting participants, author was not providing information of how
many potential participants identified and how many of those were
excluded and why excluded. In terms of data collection, author was not
stating about saturation and triangulation.
Article 2 This study is very strong in the way of description of background of
study, aim, ethical consideration, recruitment of participants, discussion
Title: Experiences of of how data analyse and grouped into themes. The role author is clearly
pregnancy and motherhood mentioned in every step of study process. However, there are several
among teenage mothers in a flews in terms of methods ie there is no explanation of reason of using
suburb of Accra Ghana: a exploratory qualitative study. there is also no information of how many
qualitative study potential participants identified and how many participants included.
Author: Gyesaw and Data saturation and triangulation also have not been discussed.
Ankomah (2013)

Grade B
Article 3 This study is very strong in the context where adolescent pregnancies
occurred. The participants inclusion was also limited to prima gravidae
Psychological Health and pregnant adolescents who live in sub urban area. Aim of study stated
Life Experiences of Pregnant clearly and the objectives of research were presented very obviously.
Adolescent Mothers in However, the ethical consideration were not fully addressed. Though,
Jamaica author mentioned related to confidentiality, gaining consent, there is no
Author: Wilson-Mitchell explanation related to institution which approved ethical. Author also
(2014) was not providing information related to their role in every step of the
process. Information related to ethical standards was also missed.
Grade: B
Article 4 This study was presenting very strong qualitative research. Aim of
study, background and specific objectives were created and further
Title: Northeastern Thai addressed carefully in in discussion and conclusion. Reason for using
Adolescents’ Perceptions of qualitative approach also stated clearly. Ethical approval gained from
Being Unmarried and committee, consent gained before interview, confidentiality addressed
Pregnant by anonymity and interview in a private room. Credibility of the research
Author: Muangpin et al were addressed by using professional independent interpreter and
(2010) coder. Author’s role specifically was explained in every step of study.
Article/ Grade Quality Assessment
Recruitment and selecting process were transparently displayed.
Grade A Triangulation and saturation were also considered. Proses of data
analysis through rigorous efforts in order to improve validity of study.
Reflexivity was gained from participants feedbacks. Discussion and
conclusion of study were also relevant with information and themes
emerged.
Article 5 The aim of this study was stated clearly. Process of collecting data was
also provided structurally. Data analysis also was presenting in briefly
Title: Lived experiences of in a right order. However, flews were appeared in methods. There is no
early pregnancy among discussion related to why the study approach was employed. Ethical
teenagers: A issues and ethical approval were not stately mentioned. Sampling
phenomenological study approach was not discussed, criteria for inclusion and exclusion was
Author: Pogoy et al (2014) also not provided. Potential participants’ number was not presented and
how many of those selected was also not displayed. Other sources in
Grade: C data collection sort of field notes was no discussed. Discussion of the
themes emerged was also very limited and recommendation was not
explicitly mentioned. Author’s role also was not clearly stated in every
step of study process.
Article 6 The aim of study stated clearly, objectives were mentioned obviously,
background and study setting were very strong and well explained.
Title: One foot wet and one Author present efforts to maintain ethical consideration ie
foot dry: transition into confidentiality, dependability, credibility and trustworthiness. Ethical
motherhood among married approval was gained from institution. However, several flews were
adolescent women in rural found ie in sampling approach, all participants identified were agreed to
Vietnam participate, strong power relation therefore may influence participants
Author: Klingberg-Allvin et al decision. Authors’ are midwife who is working in the place of study.
(2008) There is no explanation of specific task of each author. There is also no
discussion related to place of interview. In the process of data collection
Grade: B professional coder or interpreter was also not mentioned.
Article 7 This study mentioned aim and objectives of study very clear. In terms
of background, author provide brief explanation of study setting.
Title: Becoming a mother: Permission and consent were gained before interview held. However,
teenage mothers’ flews were found in methods of study. Author was not providing any
experiences of first information ethical approval. The way of gaining permission and
pregnancy consent was not discussed. In terms of recruiting participants, there is
Author: Maputle (2006) no explanation of how they are identified and how they were
approached. There is no specific information related numbers of
Grade: C potential participants and how many of them and why they were
excluded. Inclusion and exclusion criteria were not mentioned. In terms
of data collection, there is no discussion of whether information have
been anonymous or not, there is also no information of where interview
run and who did interviewed of participants. Other sources such as field
notes were also not discussed. Author also was not stating whether
they used professional independent coder or not during data analysis.
The process of data analysis also have been limited presented.
Author’s role during the process of study was also not mentioned in
every step of study. There is no original information quoted in this article
then I contacted author and the quotations of participants was sent by
email.
Article 8 The study is really strong with the explanation of study setting related
to cultural community perception related to adolescents pregnancy. Aim
Title: Experiences of teenage and objectives are also stated clearly. Ethical consideration was
pregnancy among Xhosa considered well with the strategies of gaining consent, ethical approval,
families confidentiality, dependability, credibility and trustworthiness. Sampling
Author: James et al (2011) approach and how to recruit them was also provided. Data collection
process was also considering other sources ie memo and field notes.
Grade : B Data analysis process was presented rigorously and the author’s role
was mentioned in every step of the process. Discussion and
recommendation of the study also addressed the aim of study.
However, in terms of interview, author mentioned that mostly
participants chose to be interviewed in their houses. In this case, author
was not discussion about researcher safety have been addressed.
Article/ Grade Quality Assessment
Article 9 This study is very strong on background and study setting of study.
Ethical consideration mainly addressed and ethical approval had been
Title: Existential gained from ethical committee. The aim of study was mentioned clearly
phenomenology as a with objectives in order to achieve the aim. However, in terms of
possibly to understand methods there are several flews ie: there is no inclusion and exclusion
pregnancy experiences criteria for recruiting participants, only 4 participants were agreed to be
teenagers included in this study, there is also no information related to place of
Author: Jorge et al (2006) interview, whether interview recorded or not, whether other sources
(field notes and memo) were considered or not. Data analysis process
Grade: C was also not provided transparently. Author’s role was not discussed in
the step of study. Discussion of study was limited and there is no
recommendation of the study.
Article 10 The background and study setting were clearly mentioned in this study.
Aim of study clearly stated, sampling approach and data collection were
Title: Pregnancy provided in reasonable order. Ethical issues were considered and
Stigmatization and Coping author provide structured step on the process of study. However, there
Strategies of Adolescent is no statement related of ethical approval from any boards. In terms of
Mothers in two Yoruba data collection, this study included participants which had experience
Communities. South western of adolescent pregnancy regardless when the pregnancy was occurred.
Nigeria Author also was not discussing their role in the process of study.
Author: Melvin et al (2009)
Grade: B
Article 11 This study is very strong in background and study setting. Aim and
objectives was clearly mentioned. Original data provided. Ethical
Title: Adolescent approval was not gained since there is no ethics committee. Therefore
Pregnancies in the Amazon instead of this permission was gained from the local authority. However,
Basin of Ecuador: a right and in terms of methodology and methods, there are flews disappeared.
gender approach to girls Reason for using qualitative interview was not discussed. Consent from
sexual and reproductive participant was not discussed and there is no explanation of
health approaching participants. In terms of recruiting participants, there is no
Author: Goicolea (2009) discussion related to inclusion and exclusion criteria. Place of interview
and the process of interview were also not provided. Data analysis
process was also not presented transparently. The author presented
Grade: D theory of content analysis but does not provide the way he/ she analyse
his information from participants. Discussion of study was also limited
and the recommendation of the study was very broad and practically
influence by research evidence. Author’s role was also not stated during
process of study.
 Appendix G Excluded studies
Having D grade
a. Adolescent pregnancies in the Amazon Basin of Ecuador: A right and
gender approach to girls’ sexual and reproductive health/ (Goicolea,
2009)
GOICOLEA, I. 2009. Adolescent pregnancies in the Amazon Basin of
Ecuador: A right and gender approach to girls’ sexual and reproductive
health. Doctoral thesis, UMEA University.
 Appendix H : Example of coding, organising and development of analytical themes
No Participants’ Information Coding Previous themes
Study 1 “I knew nothing about menstruation. I was embarrassed and reported Experience of menarche and
to my mother. She just said I must menstruate because I am a girl and  Lack information about menstruation menstruation
added that I must go to the clinic for prevention because if I can sleep  Embarrassed
with a boy, I will fall pregnant”.  Support from parent to prevent pregnancy

Study 1 “I was so anxious and even felt like committing suicide. What made Experience of menarche and
matters worse was I was going to write an examination at twelve  Desperate in menarche menstruation
o’clock that day and I just did not know what to do. I was  Uncomfortable in menarche
uncomfortable throughout the exam and just passed by luck.
Study 5 We never had sex education in school. I don’t know anything about it Causes and effects
 Lack information pf sexual education
Study 7 I felt something like a snake playing inside my abdomen (noga e Inadequate information/
ragaraga ka mo dimpeng  Lack information of pregnancy knowledge related physiological
 Sign of pregnancy changing during pregnancy
Study 7 My breasts were enlarged and full. I was worried and I d id n ’t know Inadequate information/
what’s happening  Lack information of physical changing during knowledge related physiological
pregnancy changing during pregnancy
 Sign of pregnancy
Study 7 I was always wet and my mother said I have premature rupture of Inadequate information/
membranes (motse o thobegile)  Lack information of pregnancy complication knowledge related physiological
 Sign of complication changing during pregnancy
Study 7 I have observed thick lines on my abdomen and my umbilicus was Inadequate information/
protruding  Lack information of physical changing during knowledge related physiological
pregnancy changing during pregnancy
 Sign of pregnancy
Study 7 I was always ill with dizzy spells, didn’t know the cause Inadequate information/
 Lack information of physical changing during knowledge related physiological
pregnancy and emergency condition changing during pregnancy
 Sign of pregnancy
 Categorising and charting
1. Theme: I am pregnant
1.1 Unplanned 1.2 Conception, pregnancy and psychological 1.5 I wanted a baby 1.8 Preserve or terminate
pregnancy changing pregnancy
Study 1 I was surprised to I started to menstruate at 13 years. I knew nothing about I just felt ready for the I even took some purgatives to
discover that I am menstruation. I was embarrassed and reported to my relationship and to love cleanse my stomach as I was
pregnant after three mother. She just said I must menstruate because I am a someone intimately. I was feeling sick”
months of the affair girl and added that I must go to the clinic for prevention never pushed into having
because if I can sleep with a boy, I will fall pregnant sex, but I wanted to
experience it
I still remember when I started to menstruate at 14 years. I
was so anxious and even felt like committing suicide.
What made matters worse was I was going to write an
examination at twelve o’clock that day and I just did not
know what to do. I was uncomfortable throughout the
exam and just passed by luck.
I don’t know anything about pregnancy. I just got to know
that I am pregnant after telling my friend that I have
missed my period
I have missed my period.
 Appendix I Participants information sheets,
information leaflet and consent form

School of Healthcare, University of Leeds

Information Sheet for Parent of Young Women/ Young Men
A study about experiences during pregnancy of young women and young men
This information sheet is for parents of adolescents wishing to participate in a study of young
women’s and young men experiences.
What is the purpose of this study?
This study plans to explore young peoples’ experiences around the time of pregnancy so that I
can understand what it is like to be a young person during this time in Indonesia. This knowledge
will help us to improve health and social services for young people.
Who is doing the study?
I am Andari Wuri Astuti and I am undertaking this study as part of my PhD study at the University
of Leeds in England. Dr Janet Hirst, Associate Professor and Dr Kuldip Bharj, Senior Lecture at
the University of Leeds are supervising this study.
Why have I been approached to this study?
You have been approached because your son or daughter wishes to take part in this study and
who has been given a copy of the full information sheet giving details of the study.
What will be involved if I allow my daughter/ son take part in this study?
If you give permission for your daughter/ son to participate in the study, she/ he will be invited to
talk to me during her pregnancy/his girlfriend pregnancy. Ideally, I would like to talk to her/ him
between now and the time of birth of their baby. For example, in the next week or so, between
now and the time of birth and near by the expected time of birth. I anticipate each time of our talk
it will last for about one hour. I will audio-record the interview, so I do not have to write notes at
the same time. The interview will take place in one of meeting rooms of the public health centre
or in the midwifery private clinic.
What are the advantages and disadvantages if my daughter/ son taking part?
There is no obvious direct benefit to your daughter/ son for taking part in this study. Your
daughter’s / son’s views will help us understand what it is like for young people when being
pregnant/ their girlfriend is pregnant in Indonesia. This knowledge will help us to improve health
and social services for young people.
Do I have to give permission for my daughter/ son to take part?
It is up to you to decide whether or not to give permission for your daughter/ son to take part. If
you do decide to give permission for your daughter/ son to take part, you will be given an
opportunity to ask for further clarity on any aspect of the study and be asked to sign a consent
form. If you do decide to not give permission for your daughter/ son to take part of this study, it
will not affect your daughter’s / his girlfriend’s care.
Can I withdraw my daughter/ son from the study at any time?
You are free to withdraw your daughter/ son from taking part of the study at any time before or
during the interview. You can also withdraw the information provided during interview up to 24
hours after each interview without giving a reason. After 24 hours of each interview, your
daughter’s/ son’s name will be removed and the information given by your daughter/ son will have
not being identifiable and cannot be linked to your daughter/ son. Your daughter/ son will have an
opportunity to stop or have rest at any time during the interview and she/ he will be able to choose
whether to continue or have another interview appointment. You can also withdraw your
daughter/son and not permit her/ him to complete the three interviews. Should any issues arise
during or following the interview/s then please contact your daughter’s / his girlfriend’s midwife or
you can also contact me.
Will the information obtained in the study be confidential?
Only I will have access to your daughter’s/ son’s personal details and these will be kept
confidential and securely scanned on to a password protected computer. I will remove your
daughter’s/ son’s detailed information such as name, address, and contact details after the
interview. All information that is given during the interview will be kept confidential; only my
academic supervisors and I will have access to the audio recording. The audio recording of our
talk will be typed-up (transcribed) and then audio recording will be deleted. The transcription will
be held in a password protected secure network of the University of Leeds until for 3 years, after
which, it will be securely and irreversibly deleted from the device on which it is stored. If there are
any issues raise to break the law, I will discuss with supervisors.
What will happen to the results of the study?
Some quotations will be used from everyone who takes part in this study; these will not be
associated with real names as I will give everyone a false name to ensure that people cannot be
identified. The result of the study will form part of my PhD thesis and the result will be published
in scientific journals and be presented at conferences.
What you are being asked to do?
I will need your permission to agree for your son or daughter to take a part in this study. If you
agree, please fill in the consent form, sign it and then return it to me using one of following ways:
 Scan and email to me at the email address that set up specifically for this study
[email protected]
 Photo Screen Shoot and send it to this WhatsApp contact number which has been
specifically set up for this study: 081931774579
 Ask your son or daughter to bring it on interview appointment date
Who has reviewed this study?
Ethical approval has been granted by the School of Healthcare Research Ethics Committee and
Indonesian Local Ministry of Health (state project reference number and date).
If you agree for your son or daughter to take part to this study and/ or would like more
information about the study please contact:
Andari Wuri Astuti
PhD Student
University of Leeds
LS2 9UT, Leeds, UK. Telp : 081931774579 or email [email protected]
Supervisors :
1. Dr Janet Hirst
University of Leeds
LS2 9UT, Leeds, UK. Telp : 0113 3431281 or email [email protected]
2. Dr Kuldip Bharj
University of Leeds
LS2 9UT, Leeds, UK
Telp : 0113 3431235 or email [email protected]
 School of Healthcare, University of Leeds
Participant Information Sheet for Young Women
A study about experiences during pregnancy of young women and young men
You are being invited to take part in the above named study but before you decide, please read
the following information.
What is the purpose of this study?
This study plans to explore young women’s experiences around the time of pregnancy so that we
can understand what it is like to be a pregnant young woman in Indonesia. This knowledge will
help us to improve health and social services for young people.
Who is doing the study?
I am Andari Wuri Astuti and I am undertaking this study as part of my PhD study at the University
of Leeds in England. Dr Janet Hirst, Associate Professor and Dr Kuldip Bharj, Senior Lecture at
the University of Leeds are supervising this study.
Why have I been asked to participate?
You have been invited in this study because you are aged 19 or under, an Indonesian resident
and pregnant.
What will be involved if I take part in this study?
If you choose to participate in the study, you will be invited to talk to me during your pregnancy.
Ideally, I would like to talk to you three times between now and the time of birth of your baby. For
example, in the next week or so, between now and the time of birth and near by the expected
time of birth. I anticipate each time we talk it will last for about one hour. With your permission I
will audio-record our talk so I do not have to write notes at the same time. The interview will take
place in one of meeting rooms of the public health centre or in the midwifery private clinic.
What are the advantages and disadvantages of taking part?
There is no obvious direct benefit to you for taking part in this study. Your views will help us
understand what it is like for young people when pregnant in Indonesia. This knowledge will help
us to improve health and social services for young people.
Do I have to take part?
It is up to you to decide whether or not to take part. If you do decide to take part you will be given
this information sheet to keep and be asked to sign a consent form. If you do decide to not take
part to the study, it will not affect your care.
Can I withdraw from the study at any time?
You are free to withdraw at any time before, during the interview and you can also withdraw the
data up to 24 hours after each interview without giving a reason. After 24 hours of each interview,
the information you have given will have been anonymised, analysed and cannot be linked to you.
You can also stop or have rest at any time during the interview. If you wish to continue, or have
another interview appointment, you may do so. You can also withdraw and not complete the three
interviews. If we discuss anything that is upsetting to you and you wish to talk about this further,
myself or your midwife will be available to talk with you should you wish.
Will the information obtained in the study be confidential?
Only I will have access to your personal details and these will be kept confidential and securely
scanned on to a password protected computer. I will remove all your detailed information such as
name, address, and contact details after study project. All information that is given during the
interview will be kept confidential; only my academic supervisors and I will have access to the
audio recording. The audio recording of our talk will be typed-up (transcribed) and then audio
recording will be deleted. The transcription will be held in a password protected secure network
of the University of Leeds until for 3 years, after which, it will be securely and irreversibly deleted
from the device on which it is stored. If there are any issues raise to break the law, I will discuss
with supervisors.
What will happen to the results of the study?
Some quotations will be used from everyone who takes part; these will not be associated with
real names as I will give everyone a false name to ensure anonymity. The result of the study will
form part of my PhD thesis and will be published in scientific journals and be presented at
conferences.
Who has reviewed this study?
Ethical approval has been granted by the School of Healthcare Research Ethics Committee and
Indonesian Local Ministry of Health (state project reference number and date).
If you agree to take part, would like more information or have any questions or concerns
about the study please contact:
Andari Wuri Astuti
PhD Student
University of Leeds
LS2 9UT, Leeds, UK. Telp : 081931774579 or email [email protected]
Supervisors :
3. Dr Janet Hirst
University of Leeds
LS2 9UT, Leeds, UK. Telp : 0113 3431281 or email [email protected]
4. Dr Kuldip Bharj
University of Leeds
LS2 9UT, Leeds, UK. Telp : 0113 3431235 or email [email protected]
 School of Healthcare, University of Leeds
Participant Information Sheet for Young Men
A study about experiences during pregnancy of young women and young men
You are being invited to take part in the above named study but before you decide, please read
the following information.
What is the purpose of this study?
This study plans to explore young men’s experiences around the time of their wife’s or girlfriend’s
pregnancy so that we can understand what it is like to be a husband or a boyfriend during this
time in Indonesia. This knowledge will help us to improve health and social services for young
people.
Who is doing the study?
I am Andari Wuri Astuti and I am undertaking this study as part of my PhD study at the University
of Leeds in England. Dr Janet Hirst, Associate Professor and Dr Kuldip Bharj, Senior Lecture at
the University of Leeds are supervising this study.
Why have I been asked to participate?
You have been invited to take part in this study because you are aged 19 and under, an
Indonesian resident, and have a girlfriend or wife who is pregnant.
What will be involved if I take part in this study?
If you choose to take part in the study, you will be invited to talk to me during your girlfriend’s or
wife’s pregnancy. Ideally, I would like to talk to you three times between now and the time of birth
of your baby. For example, in the next week or so, between now and the time of birth and near
by the expected time of birth. I anticipate each time we talk it will last for about one hour. With
your permission I will audio-record our talk so I do not have to write notes at the same time. The
interview will take place in one of meeting rooms of the public health centre or in the midwifery
private clinic.
What are the advantages and disadvantages of taking part?
There is no obvious direct benefit to you for taking part in this study. Your views will help us
understand what it is like for young people when their girlfriend or wife is pregnant in Indonesia.
This knowledge will help us to improve health and social services for young people.
Do I have to take part?
It is up to you to decide whether or not to take part. If you do decide to take part you will be given
this information sheet to keep and be asked to sign a consent form. If you do decide to not take
part in this study, it will not affect your wife’s or girlfriend’s care.
Can I withdraw from the study at any time?
You are free to withdraw at any time before, during the interview and you can also withdraw the
data up to 24 hours after each interview without giving a reason. After 24 hours of each interview,
the information you have given will have been anonymised, analysed and cannot be linked to you.
You can also stop or have rest at any time during the interview. If you wish to continue, or have
another interview appointment, you may do so. You can also withdraw and not complete the three
interviews. If we discuss anything that is upsetting to you and you wish to talk about this further,
myself or your girlfriend’s/ wife’s midwife will be available to talk with you should you wish.
Will the information obtained in the study be confidential?
Only I will have access to your personal details and these will be kept confidential and securely
scanned on to a password protected computer. I will remove all your detailed information such as
name, address, and contact details after study project. All information that is given during the
interview will be kept confidential; only my academic supervisors and I will have access to the
audio recording. The audio recording of our talk will be typed-up (transcribed) and then audio
recording will be deleted. The transcription will be held in a password protected secure network
of the University of Leeds until for 3 years, after which, it will be securely and irreversibly deleted
from the device on which it is stored. If there are any issues raise to break the law, I will discuss
with supervisors.
What will happen to the results of the study?
Some quotations will be used from everyone who takes part; these will not be associated with
real names as I will give everyone a false name to ensure anonymity. The result of the study will
form part of my PhD thesis and will be published in scientific journals and be presented at
conferences.
Who has reviewed this study?
Ethical approval has been granted by the School of Healthcare Research Ethics Committee and
Indonesian Local Ministry of Health (state project reference number and date).
If you agree to take part, would like more information or have any questions or concerns
about the study please contact:
Andari Wuri Astuti
PhD Student
University of Leeds
LS2 9UT, Leeds, UK.
Telp : 081931774579 or email [email protected]
Supervisors :
5. Dr Janet Hirst
University of Leeds
LS2 9UT, Leeds, UK
Telp : 0113 3431281 or email [email protected]
6. Dr Kuldip Bharj
University of Leeds
LS2 9UT, Leeds, UK
Telp : 0113 3431235 or email [email protected]
 School of Healthcare, University of Leeds
Information Sheet for Young Mother
A study about experiences of early parenthood of young women and young men
You are being invited to take part in the above named study but before you decide, please read
the following information.
What is the purpose of this study?
This study plans to explore young mother’s experiences as young parents so that we can
understand what it is like to have a baby for young mother in Indonesia. This knowledge will help
us to improve health and social services for young people.
Who is doing the study?
I am Andari Wuri Astuti and I am undertaking this study as part of my PhD study at the University
of Leeds in England. Dr Janet Hirst, Associate Professor and Dr Kuldip Bharj, Senior Lecture at
the University of Leeds are supervising this study.
Why have I been asked to participate?
You have been invited in this study because you are Indonesian resident, had pregnancy in aged
19 or under and have first child aged between 3 months and 1 year old.
What will be involved if I take part in this study?
If you choose to participate in the study, you will be invited to talk to me. I would like to talk to you
for about one hour. With your permission I will audio-record our talk so I do not have to write notes
at the same time. The interview will take place in one of meeting rooms of the public health centre
or in the midwifery private clinic.
What are the advantages and disadvantages of taking part?
There is no obvious direct benefit to you for taking part in this study. Your views will help us
understand what is like for young people as parent Indonesia. This knowledge will help us to
improve health and social services for young people.
Do I have to take part?
It is up to you to decide whether or not to take part. If you do decide to take part you will be given
this information sheet to keep and be asked to sign a consent form. If you do decide not to take
part of this study, it will not affect your care.
Can I withdraw from the study at any time?
You are free to withdraw at any time before, during and you can also withdraw your data up to 24
hours after interview without giving a reason. After 24 hours, the information you have given will
have been anonymised, analysed and cannot be linked to you. You can also stop or have rest at
any time during the interview. If you wish to continue, or have another interview appointment, you
may do so. If we discuss anything that is upsetting to you and you wish to talk about this further,
myself or your midwife will be available to talk with you should you wish.
Will the information obtained in the study be confidential?
Only I will have access to your personal details and these will be kept confidential and securely
scanned on to a password protected computer. I will remove all your detailed information such as
name, address, and contact details after study project. All information that is given during the
interview will be kept confidential; only my academic supervisors and I will have access to the
audio recording. The audio recording of our talk will be typed-up (transcribed) and then audio
recording will be deleted. The transcription will be held in a password protected secure network
of the University of Leeds until for 3 years, after which, it will be securely and irreversibly deleted
from the device on which it is stored. If there are any issues raise to break the law, I will discuss
with supervisors.
What will happen to the results of the study?
Some quotations will be used from everyone who takes part; these will not be associated with
real names as I will give everyone a false name to ensure anonymity. The result of the study will
form part of my PhD thesis and will be published in scientific journals and be presented at
conferences.
Who has reviewed this study?
Ethical approval has been granted by the School of Healthcare Research Ethics Committee and
Indonesian Local Ministry of Health (state project reference number and date).
If you agree to take part, would like more information or have any questions or concerns
about the study please contact:
Andari Wuri Astuti
PhD Student
University of Leeds
LS2 9UT, Leeds, UK.
Telp : 081931774579 or email [email protected]
Supervisors :
7. Dr Janet Hirst
University of Leeds
LS2 9UT, Leeds, UK
Telp : 0113 3431281 or email [email protected]
8. Dr Kuldip Bharj
University of Leeds
LS2 9UT, Leeds, UK
Telp : 0113 3431235 or email [email protected]
 School of Healthcare, University of Leeds
Participant Information Sheet for Young Men
A study about experiences of early parenthood of young women and young men
You are being invited to take part in the above named study but before you decide, please read
the following information.
What is the purpose of this study?
This study plans to explore young men’s experiences as young father so that we can understand
what it is like to have a baby for young people in Indonesia. This knowledge will help us to improve
health and social services for young people.
Who is doing the study?
I am Andari Wuri Astuti and I am undertaking this study as part of my PhD study at the University
of Leeds in England. Dr Janet Hirst, Associate Professor and Dr Kuldip Bharj, Senior Lecture at
the University of Leeds are supervising this study.
Why have I been asked to participate?
You have been invited in this study because you are Indonesian resident, have wife or girlfriend
who had pregnancy in aged 19 or under and have first child aged between 3 months until 1 year
old.
What will be involved if I take part in this study?
If you choose to participate in the study, you will be invited to talk to me. I would like to talk to you
for about one hour. With your permission I will audio-record our talk so I do not have to write notes
at the same time. The interview will take place in one of meeting rooms of the public health centre
or in the midwifery private clinic.
What are the advantages and disadvantages of taking part?
There is no obvious direct benefit to you for taking part in this study. Your views will help us
understand what is like to be young father in Indonesia. This knowledge will help us to improve
health and social services for young people.
Do I have to take part?
It is up to you to decide whether or not to take part. If you do decide to take part you will be given
this information sheet to keep and be asked to sign a consent form. If you decide not to take part
of this study, it will not affect your wife’s care.
Can I withdraw from the study at any time?
You are free to withdraw at any time before, during and you can also withdraw the data up to 24
hours after interview without giving a reason. After 24 hours, the information you have given will
have been analysed, anonymised and cannot be linked to you. You can also stop or have rest at
any time during the interview. If you wish to continue, or have another interview appointment, you
may do so. If we discuss anything that is upsetting to you and you wish to talk about this further,
myself or your wife’s midwife will be available to talk with you should you wish.
Will the information obtained in the study be confidential?
Only I will have access to your personal details and these will be kept confidential and securely
scanned on to a password protected computer. I will remove all your detailed information such as
name, address, and contact details after study project. All information that is given during the
interview will be kept confidential; only my academic supervisors and I will have access to the
audio recording. The audio recording of our talk will be typed-up (transcribed) and then audio
recording will be deleted. The transcription will be held in a password protected secure network
of the University of Leeds until for 3 years, after which, it will be securely and irreversibly deleted
from the device on which it is stored. If there are any issues raise to break the law, I will discuss
with supervisors.
What will happen to the results of the study?
Some quotations will be used from everyone who takes part; these will not be associated with
real names as I will give everyone a false name to ensure anonymity. The result of the study will
form part of my PhD thesis and will be published in scientific journals and be presented at
conferences.
Who has reviewed this study?
Ethical approval has been granted by the School of Healthcare Research Ethics Committee and
Indonesian Local Ministry of Health (state project reference number and date).
If you agree to take part, would like more information or have any questions or concerns
about the study please contact:
Andari Wuri Astuti
PhD Student
University of Leeds
LS2 9UT, Leeds, UK.
Telp : 081931774579 or email [email protected]
Supervisors :
9. Dr Janet Hirst
University of Leeds
LS2 9UT, Leeds, UK
Telp : 0113 3431281 or email [email protected]
10. Dr Kuldip Bharj
University of Leeds
LS2 9UT, Leeds, UK
Telp : 0113 3431235 or email [email protected]
 School of Healthcare, University of Leeds

Parent Consent Form

Title of Study: A study about experiences during pregnancy and early

parenthood of young women and young men

Please confirm agreement to

the statements by putting
your initials in
the box below
Yes No
I have read and understood the parent information sheet
I have had the opportunity to ask questions and discuss
this study
I have received satisfactory answers to all of my questions
I have received enough information about the study
I understand that I am/ we free to withdraw my son or
daughter from the study before or during interview or I can
also withdraw the information provided during the interview
up to 24 hours after each interview without any
requirement to explain my decision; this will not affect my
son’s/ daughter’s care
I understand that the interview will be audio-recorded.
I understand that any information provided, including
personal details, will be kept confidential, stored securely
and only accessed by those carrying out the study.
I understand that any information given may be included in
published documents but all information will be
anonymised.
I agree for my son/ daughter to take part in this study
Parent Signature …………………………………………………………
Date
Name of Parent
Researcher Signature ………………………………………………………..
Date
Name of Researcher:
 School of Healthcare, University of Leeds
Participant Consent Form
Title of Study: A study about experiences during pregnancy and
early parenthood of young women and young men

Please confirm agreement

to the statements by
putting your initials in
the box below
Yes No

I have read and understood the participant information sheet

I have had the opportunity to ask questions and discuss this
study
I have received satisfactory answers to all of my questions
I have received enough information about the study
I understand that I am free to withdraw from the study before
or during interview or I can also withdraw the information
provided during interview up to 24 hours after each interview
without any requirement to explain my decision; this will not
affect my wife/ or my care

I understand that my interview will be audio-recorded.

I understand that any information I provide, including personal
details, will be kept confidential, stored securely and only
accessed by those carrying out the study.
I understand that any information I give may be included in
published documents but all information will be anonymised
and I cannot be identified.
I agree to take part in this study
Participant Signature …………………………………………………………
Date
Name of Participant
Researcher Signature ………………………………………………………..
Date
Name of Researcher
Appendix J : Poster for participants’ recruitment in
English version