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Background: First birth before 18 years has declined in Uganda unlike repeat adolescent birth (=second or more births before age 20 years). We explored the circumstances of and motivators for repeat adolescent birth in Eastern Uganda. Methods: Between January and March 2020, we conducted a qualitative study involving 70 individual in-depth interviews with purposively selected respondents – 20-25-year-old women with and without repeat adolescent birth, their partners, and parents, in the communities of Teso sub-region. We conducted latent content analysis. Results: Four major themes emerged: poverty, vulnerability, domestic violence, and demotivators. Sub-themes identified under poverty were: “limited provisions”, “peasantry”, “large families”, “dropping out of school”, “alcohol abuse”, and “broken family structure”. Vulnerability included “marital entrapment” and “partner coercion”. Demotivators included: “abandonment”, “stern warning”, “objection to marriage”, and “empowerment”. Extreme poverty resulted in inadequate provision of basic needs leading to unprotected sexual activity in a bid to secure financial support. Following the first birth, more than three quarters of the women with repeat adolescent birth reported increased economic distress that forced them to remain in unwanted marriage/union, often characterized by partner coercion, despite wanting to delay that repeat birth. Women without repeat adolescent birth avoided a second birth by empowerment through: an economic activity, contraception use, and resumption of schooling. Conclusion: Repeat adolescent birth in Uganda is premised around attempts to address the economic distress precipitated by first birth. Many women want to delay that repeat birth but the challenges robbed them of their reproductive autonomy. Beyond efforts to prevent first birth, programs need to address economic empowerment, ensure contraceptive access, and school re-integration for adolescent mothers in order to prevent shortly-spaced repeat births.
We employed a qualitative study design using in-depth interviews (IDIs) among respondents in the communities and locations of Soroti and Katakwi districts in Teso sub-region, Eastern Uganda. The in-depth interviews were chosen because we needed to obtain personal experiences regarding this very sensitive topic – adolescent birth [40]. Further, for this study, we used the Standards for Reporting Qualitative Research (SRQR) reporting guidelines for qualitative studies [41]. The districts of Soroti and Katakwi are inhabited by the Iteso – an ethnically homogenous Nilo-Hamite population. Soroti district was selected on account of being the commercial hub and Katakwi represented the other districts in the region. Soroti district is the central hub for Teso sub-region. Katakwi represents the other districts. Soroti district has 10 sub-counties and 26 parishes, Katakwi has 9 sub-counties and 46 parishes. According to the Uganda National Housing and Population Census (NHPC) Survey in 2014, most of the people reside in rural areas; 247,187 (83.3%) in Soroti and 156,943 (94.4%) in Katakwi. Of the total population in these districts, 92,761(55.8%) in Katakwi and 163,542 (55.1%) in Soroti were aged less than 18 years. In 2016, Teso sub-region had the highest childbearing rates with 31.4% of the adolescent girls 15–19 years having started childbearing, compared to the national average of 24.8% [10]. In the two districts, we employed purposive sampling to select the participating sub-counties and subsequently four parishes with most adolescent pregnancies in each of the participating sub-counties based on guidance provided by the Assistant District Health Officer, Maternal Child Health in each district. In Soroti district, we purposively recruited respondents from Katine, Gweri, Arapai and Asuret sub-counties for the rural category and from Eastern, Municipal and Northern Divisions for the urban category. In Katakwi respondents were from: Usuk, Magoro, Toroma and Kapujan sub-counties for the rural category and, Central Division for the urban category. Study participants were: 1) women age 20–25 years with or without repeat adolescent birth following first birth < 18 years of age, 2) spouses/partners of women with repeat adolescent birth, and 3) parents of women with or without repeat adolescent birth. The parents and partners were largely unrelated to the women interviewed. We recruited them from their homes/communities using purposive sampling. To identify target respondents, the Assistant District Health Office introduced us to the sub-county village health teams (VHT) coordinator who subsequently linked us to the parish coordinator. Within the parishes, the VHT coordinator mobilized other VHT members to work with us. We briefed the VHT members on the selection criteria which they used to identify potential respondents. Being level I of the health care system and knowledgeable about their village community members, we chose village health teams (VHTs) led by the sub-county coordinator, as the contact point to identify and recruit target respondents. The study team confirmed eligibility of the potential respondents and ensured informed written consent was sought. Interview guides capturing participants’ socio-demographic characteristics as well as interrogating the circumstances informing first and repeat/non-repeat adolescent birth were developed, pre-tested and accordingly adjusted with input from non-participating communities in Soroti (Table 1). These were translated into Ateso by two bilingual research assistants. To ensure consistency of information, these guides were back translated into English by an independent bilingual social scientist with research experience. Main interview questions for the study “Circumstances of and motivators for repeat adolescent birth in Eastern Uganda” 1. Please share with us the circumstances under which you/your partner/your daughter had the first childbirth? Probe: About upbringing, schooling, employment, marriage/union, living alone, age at conception and childbirth, contraception use/non-use, living alone, etc) 2. After the first pregnancy was confirmed until the repeat adolescent pregnancy and birth, please tell us about what happened to you/your partner/your daughter. Take us through the events. Probe: for marriage/union, who she lived with, where she gave birth, who was caring for her, contraception use/non-use, schooling, employment/work, etc *Partner: inquire if the first and repeat childbirths from this lady are all his. If only the repeat birth, explain the circumstances and motivators for it. 3. Help us understand, from your perspective, what influenced you/your partner/your daughter to have another child before age 20 years? Probe for: Economic, social, personal desire, marriage related, family support, peer influence, community, and reproductive health services related factors. 5. Of all the things you have shared with us, which was the biggest influencer for you/your partner/your daughter to have another child before age 20 years? Probe for reasons/influencers. Summarize the reasons eg 3. 1. Please share with us the circumstances under which you/your daughter had the first childbirth? Probe: About upbringing, schooling, employment, marriage/union, living alone, age at conception and childbirth, contraception use/non-use, living alone, etc 2. After the first pregnancy was confirmed until the age of 20 years, please tell us about what happened to you/your daughter. Take us through the events. Probe: for marriage/union, who she lived with, where she gave birth, who was caring for her, schooling, contraception use/non-use, employment/work, etc 3. Help us understand, from your perspective, what influenced you/your daughter not to have another child before age 20 years? Probe for: Economic, social, personal desire, marriage related, family support, peer influence, community, and reproductive health services related factors. We collected the data between 06th January 2020 and 20th March 2020. The principal investigator (DA) together with four trained research assistants fluent in both English and Ateso conducted and audio recorded all the interviews in safe and convenient spaces for the respondents to the point data saturation was attained – no further new answers to the questions received. The interviews lasted approximately 1 h following completion of the informed consent processes. Interview recordings were transcribed and translated verbatim Ateso into English ensuring no alteration in meaning. Three of the authors (DA, SM, and LA) read the transcripts several times while agreeing on areas that needed more clarity. We conducted Latent content analysis was conducted using the approach by Graneheim and Lundman [42]. We embarked on analyzing the text in each transcript and interpreted the underlying message. We generated codes using framework analysis which we then grouped data into sub-themes and themes. Emerging themes were explored in subsequent interviews until thematic saturation was reached. For the demographic characteristics, the mean age of the women at first birth was expressed as a mean whereas other parameters were left as total numbers. Data collection was conducted by bilingual trained experienced research assistants. These data collectors transcribed interviews together with the principal investigator. Each proof-read their transcripts. For purposes of checking concordance, we sampled out six audio recordings from women with and without repeat adolescent birth (3 from each), had two people independently transcribe them and compared the transcripts.
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