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Background: Despite global and regional policies that promote the reduction of adolescent fertility through ending early marriages and reducing early child-bearing, adolescent fertility remains high in most sub-Saharan countries. This study aimed to explore the competing discourses that shape adolescent fertility control in Zambia. Methods: A qualitative case study design was adopted, involving 33 individual interviews and 9 focus group discussions with adolescents and other key-informants such as parents, teachers and policymakers. Thematic and critical discourse analysis were used to analyze the data. Results: Adolescents’ age significantly reduced their access to Sexual and Reproductive Health, SRH services. Also, adolescent fertility discussions were influenced by marital norms and Christian beliefs, as well as health and rights values. While early marriage or child-bearing was discouraged, married adolescents and adolescents who had given birth before faced fewer challenges when accessing SRH information and services compared to their unmarried or nulliparous counterparts. Besides, the major influencers such as parents, teachers and health workers were also conflicted about how to package SRH information to young people, due to their varying roles in the community. Conclusion: The pluralistic view of adolescent fertility is fueled by “multiple consciousnesses”. This is evidenced by the divergent discourses that shape adolescent fertility control in Zambia, compounded by the disempowered position of adolescents in their communities. We assert that the competing moral worlds, correct in their own right, viewed within the historical and social context unearth significant barriers to the success of interventions targeted towards adolescents’ fertility control in Zambia, thereby propagating the growing problem of high adolescent fertility. This suggests proactive consideration of these discourses when designing and implementing adolescent fertility interventions.
A case study design [29] was adopted for the study, using qualitative methods. This design allowed an in-depth exploration of adolescent fertility in Zambia. The study was set in Lusaka province [30]. Data were collected from Lusaka and Chongwe districts [30] from January 2018 to July 2019. The sites were purposefully selected for this study with Lusaka representing a more urban setting while Chongwe represented a rural and peri-urban setting. Lusaka district houses Lusaka, the capital city of Zambia. Lusaka city is situated in the Central Part of Lusaka Province and the country, with a population of 1,747,152 people. While the natural vegetation has been cleared due to urbanization, the open deciduous woodlands account for 80% of the forested areas. Economically, Lusaka is the second-largest economic centre of Zambia, notable for the diversification of production of goods and services. The city is the centre for national social amenities and most governmental and non-governmental department headquarters. The district is coordinated by the District Administration, which is made up of the Council, Office of the District Commissioner and the traditional administration [63]. Chongwe district is about 40 min away from Lusaka City. It has a population of about 182,174 people, of whom, 89,265 are female and 92,909 are male. The population density is 22.2 persons per square kilometre. Other than the Game Management Areas, Chongwe has three major vegetation types—Dry Miombo, Mopane and Savannah Woodlands, but suffers heavy deforestation due to charcoal burning, farming and other activities. This is not surprising as Chongwe is predominantly agricultural, with agricultural activities in crop production, horticulture and livestock production as the main sources of income. The district is run by the District Administration, which is made up of the Council, Office of the District Commissioner and the traditional administration under the leadership of Senior Chieftainess Nkomeshya Mukamambo II of the Soli people [63]. Both the rural and urban perspectives were captured in the study, with the inclusion of the more peri-urban views from both Chongwe and Lusaka. The Zambia Population HIV Impact Assessment (ZAMPHIA) survey showed a reduction in HIV prevalence from 13.3% in 2014 to 11.6% in 2016 [64]. Despite a high disease burden, much progress, such as the reduction in HIV prevalence rates have been made, in addition to other declining indicators such as Maternal Mortality Ratio (591/100,000 live births in 2007 to 278/100.000 in 2018), Infant Mortality Rate (70/1,000 live births in 2007 to 42/1,000 live births in 2018) [30]. Despite a record reduction in fertility within the reproductive age group from 6.1 in 1996 to 4.7 in 2018, teenage pregnancy has remained stable and constant over the last 15 years, indicating high adolescent fertility in Zambia [32]. Discussions were held in purposefully selected locations in community schools and high schools. Interviews with other stakeholders were conducted in government ministries, schools, churches, clinics, and homes. The study included a total of 25 individual interviews adolescents (15–19) and 8 Focus-Group Discussions (FGDs) of 5–8 participants were conducted in selected locations in both rural and urban settings, at community and high schools (Table (Table11). Characteristics of focus-group discussion participants Also, 8 key informants were interviewed: 3 from government ministries, alongside 2 teachers, 1 religious leader, 1 health worker, and 1 parent (Table (Table2).2). All data were collected from Chongwe and Lusaka districts. An FGD with mothers was also done. Characteristics of interview participants Purposeful sampling was employed, with snowball sampling also incorporated where there was a need for more information from participants who were not initially included in the study proposal but were additional sources of information needed to meet the study objectives. Community health workers were engaged in the selection of adolescents in Chongwe districts. These adolescents lived in the community around a community school in the district. Adolescents in Lusaka were selected by teachers at the schools that were selected. Recruitment of key informants was done via snowball or purposive sampling too. The sampling method was based on knowledge of informants included in the study. All the study participants were not economically independent as they lived with either a parent or guardian. While a few had completed secondary school, majority of the adolescents were still in school-ranging from grade 8 to grade 12 (junior and senior secondary school). Data was collected through individual interviews and FGDs, steered by discussion guides (see Additional file 1). For the adolescents, trial interviews were done first. A total of 18 interviews were conducted with adolescent boys and girls, exploring the social construction of adolescent fertility. The tools were then adjusted, for the critical perspectives that emerged from the data, using both the shared meanings and the various relationships that may reduce their access to information and services. After that, the discussion guides were revised, and more data was collected using the revised tools; to adequately document adolescents’ experiences and perceptions of fertility control in Zambia. Also, notes were taken from participants who did not consent to be recorded. Other than the formally organized discussions, additional informal discussions with various informants were done throughout the study data collection period—January 2018 to July 2019. All the audio-taped data was transcribed verbatim, and the transcripts were imported into NVivo 10 [31] for management and analysis. Initially, thematic analysis was used to analyze the data [32]. Sense-making was iterative-started during data collection through revision of tools, more data collection, translation and transcription. Critical Discourse Analysis [33] tenets were applied, drawing on social constructionist and critical perspectives to make sense of the data. Fairclough posits that discourse shapes our understanding of reality, highlighting how divergent views expressed by different actors in society can shape behaviour [33]. We started by exploring how fertility was constructed by adolescents and how the different moral influencers shaped these shared understandings. Thereafter we identified the competing discourses that influenced these shared understandings, from a postcolonial critical perspective [25]. Ethical approval was sought from Excellence in Research Ethics IRB (REF 2017-Apr-007). Informed consent was sought from all the participants before the interviews were conducted. Participation was voluntary, non-remunerable, and the researchers sought consent to record the discussions separately from consent to take part in the study. Consent from all adolescents who assented was sought from their parents or guardians, and permissions to conduct interviews were provided by the relevant authorities. Confidentiality was upheld throughout the study.
