Discussions revealed that the age of adolescents, marital status and marital norms, Christian values, and rights-based values influenced adolescent fertility control. In this section, we present findings according to 4 main themes: 1) age and fertility control, 2) marriage, contraception use and fertility control, 3) Christianity and fertility control and finally, 4) health, rights and fertility control.
Age and fertility control
Adolescents believed in their parents’ advice, including how to control their fertility. On the other hand, the parents also felt it was their duty to advise their children on what to do generally, including how to control their fertility. The basis for this belief was that parents had been through similar experiences when they were adolescents themselves. When a guidance and counselling teacher was asked what she would say to her daughter if she found out she was sexually active, this is what she said:
“(…) look at your age. You are still very young. Why can't you wait until such a time that society (…) [can accept your decision] or you've completed your education, then we bless you? You get married in there right away. You go and start your home. Why can't you wait until such a time? When you rush my daughter, you crash…always. Follow what the elders say because they have been through it. Abstain from sex. You can enjoy [sex] for maybe one or two minutes, but after that, what happens? You become pregnant and this is what leads to (…) early pregnancy. When you are not ready to have a child, you have it. Why? Because you have indulged in unprotected sex.” (Interview- Teacher- Guidance and Counselling; Christian and Parent)
Since this information came in the form of advice, or guidance, the young people were compelled to obey because they trusted their parents. Adolescents were supposed to follow this advice, citing the obligation to listen to parents and other adults in general, because they ‘knew better’, had been through all those experiences before. Besides, it was overall viewed as respectful. An adolescent girl who was asked why she listens to her mothers’ advice said; “(…) it’s having faith because they have been through life; she knows all things (…) (Adolescent girl, 18 years, Completed school, Chongwe).
However, the discomfort of the sex and fertility control topic between parents and their children also shaped how information or advice was packaged. The young people were unable to find out more from their parents due to the instructional nature of the information. An adolescent boy had this to say, “Guardians are very restrictive people and can never allow their child to start involving themselves into sexual activities when they are young”. (R3, FGD, Boys, 15 to 19. In-School, Lusaka).
While young people could trust their parents’ advice, they also felt the unmet need to make their own decisions and that their parents did not understand their experiences adequately, with the absence of an opportunity to address these unmet needs, or to have discussions rather than receive instructions. They thus opted for other sources such as other family members and peers. Despite the need for more information from their parents, the adolescents were expected to obey their parents’ advice, as ‘well-mannered’ children should.
“We don’t talk to our parents about this because our parents are very much strict when it comes to these things. We fear that if they know that we are found with condoms, they will start thinking that we are involving ourselves in bad things.”
(R8 FGD, Boys, 15 to 19. In-School, Lusaka)
Parents also felt obligated to talk to their children about fertility control, but it was also generally felt that fertility control discussions were beyond them, to an extent. They strongly contended against many other information sources, including what was termed as ‘bad information’ that the young people were exposed to from peers, entertainment, and social media, in addition to their advice. In the end, they felt that young people choose their influencers, and their parents hoped that their decisions would not lead to negative outcomes such as unintended pregnancy.
Respondent 1: (...) this is how these children are, even if you discipline them, they don’t behave.
Interviewer: She really disappointed you?
Respondent 2: (...) she was just saying that we do discipline children, it’s just that others don’t behave no matter how much effort you put to discipline them.
Respondent 1: Others do listen when an elderly person gives them advice; they have even completed school but some children, never listen (fall pregnant). (FGD, Mothers to adolescents, Lusaka)
While most parents were expected to provide information to the young people, information and guidance were exerted beyond parental relationships. Most of the other older people in the communities also provided ‘guidance and advice’ to adolescents, and this was widely accepted. Also, the community played a role in influencing the fertility control decisions of the young people, by sharing their opinions. Adolescents felt watched and continuously monitored by their communities.
“(...) if people know that you are abstaining in your community they will really accept you and you will be an example for other girls who don’t practice abstinence. Parents (including other adults in the community) will be like, have you seen that child, she has good behaviour and she completed school and she doesn’t do bad things, you have to be like her.” (R3, FGD, Girls, 15 to 19. In School-Afternoon, Lusaka)
On the other hand, and keeping in mind this view of adolescents by older people in general, the packaging of information was also grounded in the influencers’ varying opinions and values; traditional marriage values, Christian values and rights-based values. It was common to find teachers and health workers who were faced with conflicting roles; since they were also parents to adolescents themselves. For instance, all teachers were tasked to provide SRH information to young people, regardless of the subjects that they taught. However, this role also interacted with how they packaged information for their children if they had any or other roles they played in the community. While SRH information is provided in schools, how it was implemented was impacted by the values and beliefs of teachers or health workers.
“(...) so you are talking about encouraging them to use SRH services or to cope up (stay abstinent). As a parent, the right time for them is when they have grown up and can stand on their own. Then, as a guidance counsellor, if I meet my daughter saying things like that, I can tell her not to engage herself in these sexual relationships before her right time, if anything, she should focus on her education. That is in my path as a parent. Focus on your education. Do not ever engage in any sexual relationships either at home or school (...) especially girl children should not start indulging into sexual relationships because once they start their attention in class will be disturbed. You know they are just sexual relationships (mere sexual relationships). They go with it and a lot of things, negative things can happen. Once they start they know that, okay, this is what I will get and you know as they continue having sexual relationships, problems begin (...)” (Interview- Teacher- Guidance and Counselling; Christian and Parent)
Marriage, contraception use, and fertility control
While discussions against adolescents’ access to services cited the right time that access would be acceptable: when they were older, financially stable, or married, some exceptions were noted for adolescents who were married. This is because marriage was associated with being independent, and the most justifiable reason why a person was supposed to access contraception. It was generally expected and acceptable to engage in sexual activity and to have children when married. They linked contraception to a later time when they were married and stable, capable of starting a family. When asked if adolescents were too young to use contraception and when the right time to use contraception was, an adolescent said:
“I think the right time to use contraception (...) it is when you feel like uh when you see that your life is stable (…) Yes, that is the right time I think to use contraceptives. Maybe when you are married and you have your own home and you have your own house.” (R3, FGD, Girls, 16 to 17. In and Out of School, Chongwe)
However, it also meant that in-between adolescence and marriage, adolescents were not supposed to use contraception, leaving them vulnerable to teenage pregnancy. However, having had a child increased autonomy over their lives and the expectations from the health workers and the community for the young people to access contraception information and services. In the rural areas, marriage was outright seen as an empowerment tool for not only the young person but for her family as well. Marriage or having a child allowed the adolescent to access contraception, and to also be treated as an adult in the community.
“There are those like young girls in the villages where they have no option rather than getting married (not socio-economically empowered). They just take it like, in villages, a girl is a source of income, and so like if she gets married, they will get some money so the girl will be forced to get married by the parents (…)” (R2, FGD, Girls, 15 to 19. In and Out of School, Chongwe)
Christianity and fertility control
Adolescent fertility control discussions were also strongly influenced by Christian beliefs. Over 98 per cent of Zambians are Christians [8]. While marriage qualified access to fertility control information and services, sex before marriage was viewed as a sin, as most of the adolescents had heard this from their homes, their other relatives, from church and in schools. During a discussion about deciding to engage or not engage in sex, and when asked why she felt it was expected of her, in particular, to be abstinent, an adolescent girl said:
“Because of my tradition first of all. I feel like as Zambians, we are not expected to have sex until we are married and also because I am Adventist [Christian denomination] so it’s like [that means] sex before marriage isn’t a good thing at all. (Adolescent girl, 18 years, Christian, Completed secondary school, Lusaka).
Christian views of abortion as a sin, especially for adolescents, were very common among the discussants. The magnitude of the sin of abortion was great because it was viewed as murder in the wake of an existing sin- engaging in sex before marriage. This level of sinfulness and the murder made having an abortion upsetting to the adolescent, and the rest of the community, primarily since abortions were negatively associated with witchcraft or wizardry. When asked about situations when abortions take place, an adolescent girl said:
“Abortion mostly is done when like you get pregnant by mistake. Mostly you find a situation whereby you are pregnant and you are not ready to keep that child. So people go to the clinic to abort and kill the child, but it’s very bad. As Christian, we are not supposed to do that”. (R10, FGD, Girls, 15 to 19. In School-Afternoon, Lusaka)
It was only acceptable to practice abstinence. Moreover, failure to do so left the adolescents with multiple explanations for their ‘bad’ behaviour. When asked if young people could abstain, an adolescent boy said;
“It is possible because we can’t say us as Christians we cannot abstain. You don’t have to be committing adultery, so it is possible to abstain.” (R8, FGD, Boys, 15 to 19, In School, Lusaka).
In another discussion with adolescent girls, an adolescent said:
Facilitator: Ok, what is the reaction that our community makes when they see a young person who is not abstaining from sex?
R5: They criticize the person who does not abstain and they a lot of bad things about the person who cannot abstain. They even start talking about parents that they did not teach her properly and things like that even when parents are not the causes of that (FGD, Girls, 15 to 19. In School-Morning, Lusaka)
It was noteworthy that during the discussions with the young people, there was also a tendency for some discussants to justify their own opinions with religious messages attached to them. When this happened, it was also not very easy for the discussants to question this opinion. As such, religiosity attached to opinion was more acceptable and more dominant than any other discourse or opinion related to adolescent fertility. For instance, asked whether young people should receive SRH information or not one adolescent said;
“I think in most of the time we lack knowledge because even in the bible it is written my people perish because of lack of knowledge. I think the best way to avoid pregnancies and abortions is about awareness. I think there should be a policy where like people should be visited in their homes to learn about these things.” (R7 FGD, Girls, 15 to 19, In School-Morning, Lusaka)
Another adolescent said:
“I think the best thing is to abstain. Even in the bible, it is written in books Ecclesiastes that do whatever you do in the time of your youth but remember you will be judged alone on what you do. So you have to abstain.” (R3, FGD, Girls, 15 to 19, In School-Morning, Lusaka)
Adolescents who shared their opinions regarding what is right or wrong, according to the bible or concerning God, were less likely to be questioned or opposed compared to those that did not speak with this religious authority. When religion was attached to service provision, adolescents were not supposed to receive services because they were not supposed to be sexually active before marriage.
While the religious discourse was persuasive at the individual and community level, it was present and dominant structurally too, since Zambia was declared a Christian nation in the constitution. The Ministry of National Guidance and Religious Affairs, MNGRA held the mandate of enforcing national values and operationalizing the declaration in the country; indicating the influence of Christian values at a national policy level. National values included: morality and ethics, patriotism, democracy, dignity (inclusion), governance, and development. Despite the strong religious emphasis mainstreamed by the MNGRA, it was also noted that inclusion and dignity were highlighted in the national values. Therefore, it was noted as essential to consider the health needs of young people, with particular consideration for their specific needs. There was also an emphasis on promoting these values within the smallest unit that the young people were part of (family or home) and the need to extend those values at that community and national levels as well. When asked about how to package messages for young people, a policy implementer said:
“(...) from the perspective of the ministry [MNGRA] (...) the basis is the family. It starts with the family, then we have a community and then we have a society. So when it comes to talking about such issues [SRH], our emphasis is that it has to start from the family. The parents should be able to talk to their children about some of these issues before they go to school. Because everything we are doing (...) it starts with the family. [Policy Implementer, MNGRA, Lusaka]
Health, rights and fertility control
Few adolescents (and from Lusaka district) viewed access to contraception and abortion as a right; in that, they felt they needed to know about contraception and abortion for them to make better decisions.
Facilitator: I am going to read a statement to you guys and you have to tell me how you feel about this statement, “Adolescents are too young to know about contraceptives. The right time to talk about these things will come in future when they are older.” How do you feel about this statement?
R1: For me, I feel it’s wrong because we have to be learning about things. If we don’t learn now, we will be ignorant about these things so if we learn, it will help us know them. Most teenagers are having sex anyhow so I feel we have to learn about these things.
Interviewer: So you feel that everyone has to know about contraceptives and family planning?
R1: Yes
Interviewer: Anyone else?
R7: For me… I would say we need to know about family planning because it will give us self-control and let us know where we are supposed to stand and give us dignity…on what we should and what we should not do.” (FGD, Girls, 15 to 19, In School-Morning, Lusaka)
The Ministry of Health, MoH, noted that young people had the right to receive SRH information and services. Also, it was noted that efforts to provide adolescent-friendly services were made, but had been primarily reactive; focusing on the sexually-active adolescents, rather than all the adolescents. When asked about the health sector response to adolescent fertility, a health policymaker said:
“(…) it depends on who is supporting adolescent health programs... but as a ministry [MoH], we have realized that our messaging in the recent past has focused more on the sexually-active adolescents who are only 38 per cent of the adolescents. According to the Zambia Demographic and Health Survey of 2014, 32 per cent of adolescents are sexually active, meaning 62 per cent (…) are not sexually active. So we have tried (…) to become more comprehensive so that we do not leave out the majority 62 per cent [abstinent adolescents]. So our new approach is to make our messaging more comprehensive and to even re-orient our adolescent health spaces (…)” Policy maker-Adolescent Health, Ministry of Health, Lusaka.
The young people also acknowledged that the services were available in some settings. It was noted, however, that there was a focus on those who were pregnant or sick rather than all the adolescents who went to the health facilities. Also, adolescents who tried to access service from health facilities felt that there was an insufficient response for them without any form of adversity linked to their quest for SRH services. An adolescent girl said;
“Services are offered but these people who work in clinics are not serious. All they care about are just sick people because when I am watching T.V., I see other countries like in America they are very serious about these things but in Zambia, it seems like we have got low services and they don’t pay attention. The only time they will concentrate on is when they take you that you are pregnant. So services are not really there” (R10, FGD, Girls, 15 to 19. In School-Afternoon, Lusaka)
More recently, the use of social media to disseminate information and engage with adolescents has been introduced. However, the need to increase demand and to reach those who are not accessible via these platforms was noted. Historically, the role of the MoH in ensuring youth-friendly services for adolescents has been emphasised. These services were provided with some support from the Ministry of General Education, MoGE through the provision of CSE in schools. While acknowledging that the services could be improved, the MoH emphasized that services were the last resort; an indication that the adolescent had not been reached before they sought medical care. Therefore, a shift in focus from the health services but rather to reach adolescents in their homes and communities was emphasized, to promote healthy behaviours rather than leaving the adolescents vulnerable to early pregnancy or diseases.