Discussion
The aim of this study was to explore stigmatising attitudes related to adolescent pregnancy, abortion and contraception among PAC providers in a low-resource setting. The results show that PAC providers’ views are characterised by a conflict between human rights and societal norms. The providers expressed a pragmatic view on adolescents’ human rights, such as the rights to life, autonomy, equality, education and the highest attainable standard of healthcare. The participants also communicated a general resistance to provide abortion services and contraceptive counselling, mainly reflecting societal norms such that adolescent sexual activities and thus contraceptive use and abortion are immoral and irresponsible.
An important advantage of the study design was the mixed methods approach which allowed triangulation. This technique facilitates validation and reliability of the data through cross-verification of the quantitative and qualitative data sources. Moreover, triangulation helps to obtain a deeper and more complete understanding of the studied phenomenon, particularly in sensitive objectives.26 A limitation of this study was the small sample size for the questionnaire-survey, which did not allow comparisons between subgroups of the sample. Given the small sample size, the CUSS was only qualitatively validated; however, because statistics confirmed the suitability of the data and internal consistency reliability of the scale, we provided summaries of the individual item responses and overall qualitative findings. A larger study by which to validate the scale is in progress within this research project, and this will allow us to use this scale quantitatively to test for differences in the future. Considering the sensitive nature of this study, the main purpose of the questionnaires was to explore if and how abortion and contraceptive use stigma is articulated among PAC providers. The dichotomisation grouped scores 3–5 as stigmatising attitudes and scores 1–2 as non-stigmatising attitudes. Score 3 stands for ‘unsure’, which means that a provider choosing this score did not take a stand against the given statement. Therefore, score 3 was considered a stigmatising attitude. By the mixed methods design, qualitative results could confirm the findings in the questionnaires and support the reliability of these results.
Owing to the limited time and financial resources, we conducted only two FGDs with only physicians and midwives. Nevertheless, the prior qualitative validation of the scales and the quantitative questionnaires supported to monitor and achieve data saturation. Trustworthiness of qualitative research is based on the concepts of credibility, dependability and transferability.25 Credibility was gained by the purposive sampling, which generated a heterogeneity within the sample in terms of age, sex, occupation and work experience. Bringing together a diverse group of people was considered advantageous to maximise the exploration of different perspectives in the group. However, the gender and hierarchy mix within the FGDs must be considered in this context since it might have affected the outcome of the discussions. Voluntary participation is a possible weakness because the participants might have stronger opinions, either positive or negative, compared with the average population.27 Nevertheless, FGDs have shown to facilitate such discussions since sharing the same experience might contribute to a deeper discussion from different perspectives.27 Most important, the goal was not to generalise the findings, but rather to indicate transferability through consistency with other studies conducted in various contexts.12 13 17 28 29 The consistency and accuracy were further strengthened by the heterogenic research team, with personnel experienced in quantitative and qualitative research within this objective and context. The dependability was fortified by conducting the two FGDs simultaneously to avoid participants interacting with each other in between the FGDs.
Worldwide, providers of sexual and reproductive health services are dealing with controversial issues such as sexuality, abortion and contraception.30 This study sheds light on the conflict between adolescents’ human rights against the norms and beliefs in society. Most providers in this study opined that a woman who has had an abortion should be treated equally to everyone else, but they still had negative stereotypes about women who abort. Furthermore, it is important to note that these providers are currently offering PAC services and have been trained in youth-friendliness, hence are likely to have more liberal attitudes than other healthcare providers.
In Kenya, as in many other contexts, women who seek to terminate a pregnancy challenge the ideals of womanhood that originate in conservative gender roles and intend to control female sexuality and compulsory motherhood.11 In the FGDs, the providers indicated young women’s lack of autonomy as one of the greatest challenges to provide sexual and reproductive health services to young women. Three out of 10 PAC providers considered an adolescent woman too young to decide whether to use contraception, a finding in accordance with previous studies of East Africa.13 28 Many of the PAC providers accentuated increased male awareness and involvement as an important measure towards improved sexual and reproductive health for women.
Participants of the FGDs consistently used terms such as sin, immorality and promiscuity, which reflected their society’s religious values and cultural beliefs. Young women seem to be multiply stigmatised when seeking abortion or contraceptive counselling, since having sex at a young age, having an abortion and continuing a pregnancy are equally unacceptable in the community. Previous studies have also shown that providers have social-based and moral-based restrictions regarding abortion and contraception, especially for young unmarried women.12 17 One explanation for these restrictions could be that, as the providers display themselves as a part of the community, they are also carriers of the existing norms. Religion is identified as one of the most important factors influencing providers’ attitudes and actions.17 Consequently, when policies are unclear, religious norms rather than scientific evidence seem to dictate the guidelines. In Kenya, an estimated 40% of the national health services are provided by faith-based organisations, most of them Christian, and many of those work in partnership agreements with the Ministry of Health.31 Providers in faith-based organisations might tend to focus contraceptive counselling on recommendations to abstain, even though promoting abstinence is not proven to delay initiation of sexual intercourse or decrease unintended pregnancies.32 Negative health effects have been noted when religious values are mixed with national policies, most strongly documented in relation to sexual and reproductive health.30
The providers were aware that the myths and misconceptions surrounding adolescent sexuality, abortion and contraception might keep young women from seeking abortion services and contraceptive counselling. This awareness highlights that PAC providers are unprepared to deal with the ambivalence when facing adolescents with sexual and reproductive health problems. Ethical dilemmas related to sexual and reproductive health and rights, as well as evidence-based education to prevent ignorance that might generate stigmatising attitudes, are important endeavours in medical pregraduation training.33
The interpretation of the slightly liberalised Kenyan abortion law adopted in 2010 was a hot topic during the FGDs, and the providers considered the vagueness of valid indications for abortion as a severe weakness in the new constitution. However, a liberal abortion law alone may not ensure the safety of abortions. Knowledge about the law must be disseminated, and abortion policies and guidelines need to be explicit. In addition, providers must be willing to obtain training and provide quality and non-judgemental abortion and contraceptive services, as systematically provided contraceptive counselling in PAC is effective to mitigate unmet need for contraception.34 Additionally, the governments must be committed to providing the necessary resources to ensure women can access those safe services, even in remote areas,5 and YFCs were considered an important resource for adolescents.
For future research, the SABAS and CUSS could be used in a larger sample of healthcare providers in similar settings to validate the relevance and the reliability of these scales. Since our findings indicate that stigmatising attitudes and misconceptions surrounding abortion and contraceptive use among adolescents are common in this community, such study could also provide a baseline for a stigma reduction intervention among PAC providers. Future research should also include adolescents in similar studies to explore their attitudes towards abortion and contraceptive use.