Swedish teenager perceptions of teenage pregnancy ...

Acta Obstet Gynecol Scand 2005: 84: 980–986 Printed in UK. All rights reserved

Copyright # Acta Obstet Gynecol Scand 2005

Acta Obstetricia et Gynecologica Scandinavica

ORIGINAL ARTICLE

Swedish teenager perceptions of teenage pregnancy, abortion, sexual behavior, and contraceptive habits – a focus group study among 17-year-old female high-school students MARIA EKSTRAND1, MARGARETA LARSSON1, LOUISE VON ESSEN2 AND TANJA TYDEŃ1,2 From the 1Department of Women’s and Children’s Health, and 2Department of Public Health and Caring Sciences, Uppsala University, Uppsala, Sweden

Acta Obstet Gynecol Scand 2005; 84: 980–986. # Acta Obstet Gynecol Scand 84 2005 Background. Sweden has the highest abortion numbers among the Nordic countries. Since 1995, the abortion rate among teenagers has increased by nearly 50%. We therefore undertook a study where the overall aim was to gain a deeper understanding on which factors female teenagers believe may explain the increasing numbers of teenage abortions. Teenagers’ perceptions of teenage pregnancy, abortion, sexual behavior, and contraceptive habits were investigated. Methods. Six focus group interviews with 17-year-old Swedish girls were conducted. The interviews were tape-recorded, transcribed verbatim, and analyzed by manifest content analysis. Results. Negative attitudes toward teenage pregnancy and supportive attitudes toward abortion were expressed. Risk-taking behaviors such as negligence in contraceptive use and intercourse under the influence of alcohol were suggested as main reasons behind the increasing numbers of abortions among Swedish teenagers. The contemporary, sexualized, media picture was believed to influence adolescents’ sexual behavior, and liberal attitudes toward casual sex were expressed. Girls were perceived as more obliged than boys in taking responsibility for contraceptive compliance and avoidance of pregnancy. The apprehension that hormonal contraceptives cause negative side-effects was widely spread, and the participants were found to have a somewhat limited knowledge of abortion. The majority were unsatisfied with the quality of sexual education provided by the schools. Conclusion. Possible reasons for increased abortion numbers among teenagers in Sweden could be liberal attitudes toward casual sex in combination with negligence in contraceptive use, use of alcohol followed by sexual risk-taking, fear of hormonal contraceptives, and a deterioration of sexual education in the schools. Key words: attitudes; teenage pregnancy; abortion; sexual risk-taking; contraceptives Submitted 17 May, 2004 Accepted 20 December, 2004

Sweden has a long tradition of an open attitude toward teenage sexuality. Sexual education has been compulsory since 1955, and there are youth clinics in every town with contraceptive counseling free of charge. In the early 1990s, the #

Acta Obstet Gynecol Scand 84 (2005)

Swedish school system was profoundly reformed, and sexual education changed from having been a core subject to becoming an overarching topic, supposed to be included in other subjects (1). National evaluations have shown a wide variety

Teenager perceptions on reproduction

Abortions/1000 women - 19 years

in the quality of sexual education in Swedish schools (2,3). Sweden has the highest abortion numbers among the Nordic countries. In 2003, approximately every fourth pregnancy was terminated, resulting in an abortion rate of 20/1000 women (age span 15–44 years) (4). Since 1995, the abortion rate among teenagers has increased by nearly 50%. In 2002, the abortion rate among teenagers was the highest for 7 years, reaching 25/1000 women (age span 15–19 years; Fig. 1) (4). Sexual behavior among high-school students in Sweden has been investigated in some studies (5–7). Students were asked, among other things, about age at first intercourse and their use of contraceptives. The age at coitarche had remained unchanged compared with 10 and 20 years earlier, whereas the use of contraceptives at first intercourse had increased (6). Contraceptive habits among women (14 years and older) requesting abortion in three Swedish counties showed, on the other hand, that half of the teenagers in that study did not use any contraceptives at the time of conception. Taking the risk, trusting safe periods, having unplanned sex, and being under the influence of alcohol were mentioned as reasons for not using contraceptives. The most common reasons for pregnancy termination were low age, financial concerns, and a desire to postpone childbearing in favor of education (8). The overall aim of this study was to gain a deeper understanding on which factors female teenagers believe may explain the increasing numbers of teenage abortions. Teenagers’ perceptions of teenage pregnancy, abortion, sexual behavior, and contraceptive habits were investigated.

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Materials and methods The study had a descriptive and qualitative design using focus group interviews. Focus group interviews are particularly appropriate when collecting data on previously unexplored areas (9) with regard to perceptions, feelings, and believes. Focus groups capitalize on the interaction within a group to elicit rich experimental data (10,11). The group process can help people to explore and clarify their views in ways that would be less easily accessible in a one-to-one interview. When group dynamics work well, the participants work alongside the researcher, taking the research in new and often unexpected directions.

Sample and data collection Six focus group interviews with 17-year-old female highschool students (n ¼ 42) were performed in 2003, in Uppsala, a medium-sized university town in Sweden. Each group contained six to eight participants. The Swedish school system is based on public schools where the absolute majority of all students attend independently of socioeconomic backgrounds. By including six of seven high schools and classes from both theoretical and vocational study programs, a sufficient variety with regard to the participants’ background characteristics is believed to be ensured. A semistructured topic guide covering questions about attitudes and knowledge concerning teenage pregnancies, abortion, sexual behavior, and contraceptives was used. A pilot study was performed in a group with a composition similar to that in the above-mentioned focus groups. No adjustments were made.

Procedure Female nursing students, functioning as research assistants and trained in performing focus group interviews, contacted the headmasters of six high schools and informed them about the study. After their approval, two classes in each school were selected for participation. The class teachers were given oral and written information about the project. The research assistants thereafter distributed written information and application lists to the students in the classrooms. The students were informed that participation was voluntary and that data would be treated confidentially. Students who accepted participation were asked to write their name and telephone number on the application lists. The lists were collected by the research assistants who thereafter contacted the first four names on each list. Of 48 contacted students, 42 turned up. The interviews lasted between 25 and 60 min and were held in Swedish, in the school buildings during school hours. Each student was offered a movie ticket in return for participation. Each interview was monitored and audiotaped by two female research assistants who alternated between the role as moderator (leading the discussion) and observer. Before the data analysis started, the interviews were transcribed verbatim by the first author. The transcripts and quotations were translated into English and thereafter examined by a native-speaking translator. The study was approved by the research ethics committee at the Faculty of Medicine at Uppsala University.

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Data analysis

15 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 Year

Fig. 1. Development of teenage abortions in Sweden.

The focus group data were analyzed by manifest content analysis. This method is suitable when identifying core meanings such as predominant patterns or themes that #


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emerge through interview transcripts (9). The first author initially read the transcribed text in order to get a feeling for the essence of the material. The analysis was then performed in the following steps: 1) Words and sentences containing information relevant to each interview question were identified by the first author. In the process of categorizing data, the following aspects were taken into consideration: frequency of comments (the number of times a topic surfaced in the discussion), extensiveness of comments (how many people talked about the same issue), intensity of comments (voice volume, speed, and emphasis on certain words), and interactions within the groups. 2) Preliminary categories were created by the first author. 3) The content and boundaries of each category were discussed and defined by all authors. Changes and redefinitions of the categories were made in an ongoing creative process. 4) All recording units with information relevant to the interview questions were referred to mutually exclusive categories, which in turn were referred to themes by the first author. The raw data were thoroughly gone through by all authors. The first author categorized all recording units and, in order to strengthen the credibility, the second author assigned all recording units to the categories created by the first author. A comparison of the two categorizations of all recording units was made using the Kappa method (12) showing a Kappa value of 0.92.

Results

The interaction between the participants was vivid and led to rich discussions in all groups except in one in which the participants seemed to be rather shy and not so talkative. This interview was also the shortest. In general, all participants made themselves equally heard. In two groups, a couple of girls somewhat dominated the discussion. Areas of agreement were common, but the overall impression was that participants did not hesitate to pose comments of dissent. The content analysis resulted in six themes: negative attitudes toward teenage pregnancy, supportive attitudes toward abortion, sexual risktaking behavior, reproductive trends in society, responsibility regarding pregnancy and contraceptives – a girls’ issue, and limited knowledge about abortion and contraceptives. Quotes that capture the participants’ knowledge, experiences, and attitudes are presented. The group numbers are presented in brackets following the quotes. Negative attitudes toward teenage pregnancy Most groups claimed that they would support and respect the decision if a friend who had become pregnant would decide to continue the pregnancy. However, this did not necessarily #


mean they would agree with the decision: ‘‘I would support her, but it would be a tragedy!’’ (G: 2), ‘‘If she decided to keep the baby, I would ask her if she really had thought it through and how she plans to solve the situation’’ (G: 1). Several groups mentioned that teenage pregnancies easily cause rumors and that teenage mothers are looked down upon. Even if the participants realized that they all could become pregnant, several of them still considered pregnant girls were to be ‘‘whores’’ (G: 1) or ‘‘not able to take care of themselves’’ (G: 1). Most groups stated that not having an abortion in a situation of teenage pregnancy by most people is considered a bad decision.

Supportive attitudes toward abortion An obvious right. The vast majority expressed supportive attitudes toward abortion using terms such as ‘‘an obvious right’’ (G: 3), ‘‘right in a situation of distress’’ (G: 6), and ‘‘good to have as an option if the baby is unwanted’’ (G: 1). Interactions during the discussions were often complementary, but diverse opinions occurred. One girl did not find abortion to be the obvious choice, even in case of rape. The same girl referred to abortion as ‘‘killing of a child’’ (G: 3). All groups underscored that one should not abuse abortion as a method of birth control. A few girls described abortion as something people might consider shameful or even a taboo. Abortion was perceived as emotionally painful and something that the woman might regret. Reasons for induced abortion among teenagers. If becoming pregnant as a teenager, almost all girls would request an abortion. However, a few were hesitant, reasoning that it depends on the kind of relationship with the partner. Most girls felt too young and incapable of providing the baby with an economically secure environment, other reasoned that having a child would force the girl to quit school, making it difficult to get a higher education, or that a baby in one way or another would jeopardize the future: R1: ‘‘I would choose to have an abortion, because, I mean, you want to finish school and then you have to have the money to be able to take care of the baby.’’ R2: ‘‘Yes, you should definitely have the option to choose an abortion.’’ R3: ‘‘Maybe you’re just too young. . .to be able to take care of it. . .a child.’’

Teenager perceptions on reproduction R2: ‘‘Exactly, or if you feel like the child is going to ruin your future, if you just started an education. . .or if it is just a bad time!’’ (G: 5)

Sexual risk-taking behavior ‘‘It will not happen to me.’’ All groups expressed liberal attitudes toward casual sex. ‘‘One night stands’’ were perceived as a natural element in young people’s sexual lives. Sexual risk-taking was considered a major reason behind the increasing abortion rates. Negligence, absentmindedness, and carelessness were mentioned as the most common reasons for not using contraceptives. Several groups confirmed that, in the heat of the moment, it is easy to ignore the consequences or underestimate the risks of unprotected sex: ‘‘You simply don’t use protection, thinking that nothing is going to happen to you’’ (G: 4), ‘‘A lot of girls think: It won’t happen to me. If I have unsafe sex one single time, it doesn’t matter, I won’t get pregnant’’ (G: 3). The emergency contraceptive pill. In some groups, the emergency contraceptive pill (ECP) was mentioned as a reason for increased abortion rates as well as an excuse for not using regular contraceptives: ‘‘I believe the number of abortions have increased, at least partly because of the morning-after-pill. People think – what the heck, there are morning after pills, and they might use it as a regular contraceptive, several times a month’’ (G: 1). Also mentioned was that the intention to use ECP might fail for various reasons: ‘‘People don’t bother using a condom, thinking they might as well take a morning-afterpill . . . and then perhaps it’s too late, or it doesn’t work or whatever . . . ’’ (G: 2). One group questioned the efficacy of ECP, mentioned its side-effects and the risk of not using it correctly: R1: ‘‘But, it’s not like 100% safe either . . . Plus, there are a lot of hormones in morning-after-pills, right? They aren’t good for you.’’ R2: ‘‘I took it once, and at that time they told me not to use it more than three times a year.’’ R3: ‘‘Yeah, that’s what they told me too . . . ’’ R1: ‘‘But still, you can take it every weekend!’’ (G: 4) Alcohol, discomfort, embarrassment, and high cost: causes for not using the condom. Several groups described the influence of alcohol as a reason for not using the condom. Other groups stated that the condoms unpopularity mainly depend on it being ‘‘uncomfortable’’ to use. A

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few girls mentioned embarrassment as a cause for not using the condom: ‘‘Especially if it is a one-night-stand it’s hard to be the one suggesting that a condom should be put on . . . it might be awkward if the guy doesn’t want to. It’s hard to stand up for it’’ (G: 2). Several groups found contraceptives in general and condoms in particular to be too costly for young people and were of the opinion that condoms should be subsidized. Reproductive trends in society Media picture. Several groups believed that young people’s sexual behavior has changed over the years. In one group, the contemporary media picture was mentioned as an explanation of young people’s attitudes to sex and sexuality: ‘‘The way the media puts it is that everyone should have sex! Basically everything is about sex . . . commercials . . . everything. Of course, people start living by it . . . and people get careless’’ (G: 2). Changed attitudes toward sexuality and family planning. One group discussed whether more open attitudes toward sexuality in society could explain increased abortion numbers. Some meant that attitudes in society now are liberal enough to let people choose abortion without making them feel ashamed or socially unaccepted: ‘‘Hopefully a lot of young people that earlier decided to keep the baby, would instead choose to have an abortion these days . . . since the permissive attitudes in society have reached young people, telling them that it’s OK’’ (G: 1). Changed attitudes toward the nuclear family and a shift in the traditional gender roles were also believed to influence the abortion decision among teenagers: ‘‘These days girls obtain professional careers more often than they did before. Their future holds other things than just staying at home with the children’’ (G: 4). Different opinions were expressed as to whether a liberal abortion policy makes people negligent in the use of contraceptives. However, the majority did not think so. Responsibility regarding pregnancy and contraceptives – a girls’ issue Girls’ responsibility. Initially, the general norm for all groups seemed to be that preventing pregnancy should be the mutual responsibility of both the boy and the girl. However, later in the discussions, it became clear that girls perceive themselves as more obliged than boys in taking responsibility for avoiding a pregnancy: #


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R1: ‘‘I think both are responsible.’’ R2: ‘‘Although, I think it easily turns out to be the girls’ responsibility . . . ’’ R3: ‘‘Yeah, the guy isn’t exactly the one who becomes pregnant!’’ R2: ‘‘I think the girl is more aware of what can happen if you have unsafe sex. Guys are more like . . . whatever . . . ’’ (G: 5) Responsibility depending on the kind of relationship. In most groups, the girls seemed to agree that the responsibility for contraceptives in practice depends on whether you are in a stable relationship or if it is a ‘‘one-night-stand’’: ‘‘Oral contraceptives and implants are used if you’re in a stabile relationship, because then you don’t have to worry about venereal diseases and stuff’’ (G: 1). According to several groups, should girls take responsibility for contraceptives, especially at occasional sex: ‘‘You can’t rely on someone you might not even know to take responsibility for not making you pregnant’’ (G: 2).

Limited knowledge about abortion and contraceptives The majority of the groups discussed health risks in connection to legal abortion. Several were uncertain of how great the risks really are, but voiced worries about the risk of becoming sterile. One group expressed an unclear picture of legal abortion and had different opinions on what an abortion means: R1: ‘‘Most people only know that the baby is taken out, not how it’s actually done!’’ R2: ‘‘I read something about that and it was very, very scary.’’ R3: ‘‘Well, I heard that you can get a pill – if it’s just a few weeks . . . and that, I must say, didn’t sound so bad . . . ’’ R2: ‘‘Yeah, but you like . . . bleed. . .!’’ R3: ‘‘Yeah, yeah, that’s true, you probably won’t feel great for a day or two, but still . . . ’’ R2: ‘‘But you feel bad emotionally!’’ R4: ‘‘What does this bleeding do, by the way?’’ R1: ‘‘See, no one has a clue really, what you actually do, what an abortion really means . . . ’’ (G: 3) On the other hand, a few girls thought that they had a very clear picture of how an abortion is performed: ‘‘When you know how it’s done how they cut off the arms and legs and suck out the brain . . . it’s sickening, it’s brutal!’’ (G: 5). Fear of side-effects regarding hormonal contraceptives. A common apprehension was that hormonal contraceptives cause negative side#


effects and damage to the body, especially during puberty. Influence of unreliable information sources regarding contraceptives was described as a considerable and confusing problem: R1: ‘‘The weird thing is that the pills used to be a lot stronger than they are today.’’ R2: ‘‘Exactly! More hormones and stuff. I don’t get why people are so scared?’’ R3: ‘‘But still, a lot of people are saying that you eat more, get bigger breasts, and all kinds of stuff. . .you gain weight, get mood swings . . . ’’ R4: ‘‘I think people are scared of taking the pill now when there has been so much in the media about blood clots and stuff.’’ R3: ‘‘Yes, that’s right . . . ’’ R1: ‘‘There are so many myths and stories floating around that you can’t keep track of what the risks really are.’’ (G: 2) Unsatisfactory sexual education at school. Media and friends, but also youth clinics and parents, were mentioned as providing young people with knowledge regarding sex and sexuality. None of the groups viewed the school as a main source of information. On the contrary, all groups found the sexual education at school to be unsatisfactory: ‘‘The school could do 100% better!’’ (G: 5), ‘‘Young people don’t get information about contraceptives at school’’ (G: 5), ‘‘You get so much information everywhere else, it’s only in the school that they are a bit negligent’’ (G: 6). Many thought this might, at least partly, explain the increasing numbers of abortions among teenagers. All groups expressed high expectations on the sexual education that the schools should provide. Several girls stated that the schools still have the highest reliability in comparison with other sources of information about sexual matters.

Discussion

Focus group interviews were used to collect qualitative data on attitudes and knowledge concerning teenage pregnancy, abortion, sexual behavior, and contraceptive habits. The findings illuminate the participants’ opinions and concerns on these matters. We believe that the participation rate was positively affected by performing the interviews in the school buildings on school hours. This may have enabled students who most likely would not have turned up otherwise to participate. The credibility of the data is believed to be ensured by having young, female moderators with a non-authoritarian approach performing the interviews.

Teenager perceptions on reproduction The participants often expressed opinions from a third person perspective. This may illustrate that the subjects of debate were not always self-experienced and/or may be a way for the participants to express personal opinions in a less threatening way. Especially, intense dialogues occurred when participants talked about sexual education and hormonal contraception, which we assume indicate that they had personal experiences with these issues. Negligence in contraceptive use, in combination with liberal attitudes toward casual sex and a general delay in childbearing in favor of education and career was suggested as reasons for the increasing abortion numbers among Swedish teenagers. Despite the fear of unwanted pregnancy, sexual intercourse under the influence of alcohol seemed to appear rather frequently. This was also mentioned as one of the main reasons for sexual risk-taking. Other factors suggested to explain risky sexual practices were a ‘‘false’’ trust in ECP and a tendency to underestimate the risks in connection with unprotected sex. Condoms were embarrassing for some and uncomfortable for others. The attitudes toward casual sex were liberal. Sexual experimentation and crossing boundaries are normal parts of adolescents’ sexual development (13). However, teenagers engaged in careless sexual behavior are at risk for unwanted pregnancy. Although the use of contraceptives at first intercourse has increased over the past two decades (6), studies have shown that teenagers occasionally fail in contraceptive compliance, especially during casual sex (14–17). ‘‘Safe sex’’ is a complex issue, linked to social norms and context. The adoption of a protective behavior also depends on the characteristics of the relationship (18). As found in this study, asking a new partner to use a condom can be difficult due to fear of ruining an intimate situation. This is of course particularly unfortunate at occasional sex, when the use of protection is of great importance. The participants sometimes underestimated the risks involved with unprotected intercourse. Comments such as ‘‘It will not happen to me’’ were often mentioned. Similar findings were demonstrated in a previous Swedish study in which teenagers were found to calculate the risks involved with unsafe sex based on probability or the partner’s reputation (14). However, calculation of risks often diminishes when positive emotions, such as liking, trust, or love occurs (19). The groups were of the opinion that the focus on sex in media could lead to riskier sexual behavior. Today, messages connected with sexuality and pornography are widely spread and easily

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accessible through media, films, Internet, etc. It has been shown that a majority of teenagers have consumed pornography and that pornography may influence people’s sexual practices (7,20). The reasons behind the negative attitudes toward teenage pregnancy were mainly that the teenagers felt too young, wanted to finish school, and were not yet financially self-supportive. Similar results were found by Larsson et al. (8). The girls considered themselves to be more obliged than boys in taking responsibility for contraceptives and avoidance of pregnancy. Whether or not these findings hold true for a larger population is an interesting question for further research. An analysis of official documents within the area of Swedish sexual politics demonstrates that women have been the constant objects for influence and change and have come to face greater expectations than men regarding contraceptive compliance (21). In light of our results, we believe it to be important to arm adolescents with necessary skills in attempting to achieve sexual equity between the genders. An important finding was the massive dissatisfaction concerning the sexual education provided by schools. The participants had, in fact, limited knowledge not only about risks regarding hormonal contraceptives, but about abortion as well. An explanation may be that these issues are not given enough priority in the education. Few schools have plans and guidelines for sexual education, with the consequence that students get different standards of education (2,3). Our results indicate that the students have high expectations on sexual education provided by the school and that the school still is considered the most reliable information source regarding sexuality. To provide a better understanding of the increasing abortion numbers among teenagers, we believe future research would benefit by including teenage boys’ perspectives on reproductive behavior. It is also important to strive for a deeper knowledge regarding factors behind sexual risk-taking.

Limitations A few limitations of the present study have to be pointed out. The focus group interviews were performed by four research assistants who alternated between the role as moderator and observer. This may imply that the interviews were performed in slightly different ways. However, this may also be a strength of the study as it may have contributed to detecting as much as possible of the investigated phenomena. The #


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persons who performed the interviews did not take part in the data analysis. This may be related to a risk that important interactions were not considered in the analysis and presentation of the results. However, the interviews were audiotaped and the verbal interactions have been given attention in the data analysis.

Conclusion

Negligence in contraceptive use, in combination with liberal attitudes toward casual sex was suggested as reasons behind the increasing number of abortions among Swedish teenagers. Girls seem to bear the main responsibility for pregnancy prevention at the same time as many fear negative side-effects of hormonal contraceptives. Sexual education in the school was found to be unsatisfactory and media appeared to have a great impact on young people’s sexual behavior. In order to prevent teenage abortions, efforts must be made to reinforce the trust of young girls in reliable birth control methods. Schools generally need to establish higher quality of sexual education, in which abortion should be given priority.

Acknowledgments This study was funded by grants from the Swedish National Institute of Public health.

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Address for correspondence: Maria Ekstrand Department of Women’s and Children’s Health Uppsala University Uppsala, Sweden e-mail: [email protected]