“Motherhood Is Hard”: Exploring the Complexities of Unplanned Motherhood Among HIV-Positive Adolescents in South Africa

Abstract

For any woman, pregnancy and giving birth are major life-changing experiences. This period is argued to indicate a shift from girlhood into womanhood. However, this experience takes on new meaning when the woman is very young—an adolescent, who is still in school—and learns that she is HIV-positive. For such adolescent, becoming a mother, just like living with HIV/AIDS, involves moving from a known, current reality to an unknown, new reality. To understand how HIV-positive adolescent mothers grapple with the demands and responsibilities of unplanned motherhood while living with HIV, this study explores the complexities of their experiences in South Africa. Drawing on qualitative methods, this study examines their meaning to motherhood while meeting their personal health needs. Through in-depth interviews conducted among 10 HIV-positive adolescent mothers living in Johannesburg, this article presents an empirical study of their narratives and how they negotiate these complexities in their unplanned new realities. Emerging themes from the interview transcripts were identified, coded, and analyzed thematically following an interpretivist approach. From the interviews conducted, it is evident that HIV-positive adolescent mothers perceive unplanned motherhood as difficult and this negatively affects their future childbearing decisions. Given the importance of motherhood and adolescents globally, this article advocates for feminist policies that would facilitate larger transformative narratives. It also recommends the implementation of relevant policy that would alleviate the difficulties of HIV-positive adolescent mothers generally.

Keywords

motherhood adolescence HIV/AIDS support fertility decisions feminism South Africa

Background

In human developmental stages, adolescence is commonly regarded as the most dynamic stage. This is because this stage is associated with varying physical, cognitive, social, and emotional changes that shape and define the individual (Steinberg, 2014; World Health Organisation [WHO], 2016). Experiences during adolescence significantly influence the unique characteristics and maturation of individuals. One of the major characteristics attributed to the adolescent stage is good health. However, many adolescents are faced with the challenges of high-risk behaviors that often lead to unplanned pregnancy and sexually transmitted diseases like HIV and AIDS. Thus, this stage brings forth contradictory realities: the prospect of strong bodies but simultaneously, the likelihood of life-threatening infections and unplanned motherhood.

Reiteratively, unplanned pregnancy and its link to HIV and AIDS are two unintended consequences of unprotected sexual intercourse among adolescents. Studies on adolescents’ health have shown that adolescents in sub-Saharan Africa, particularly young women, represent a key grouping at the highest risk of HIV acquisition (Doherty et al., 2018; Harrison, Colvin, Kuo, Swartz, & Lurie, 2015; Harrison et al., 2016; Jewkes, Vundule, Maforah, & Jordaan, 2001; Mchunu, Peltzer, Tutshana, & Seutlwadi, 2012; Mkhwanazi, 2009; Pettifor et al., 2005). About 35% of pregnancies among adolescents in sub-Saharan Africa are argued to be unplanned suggesting the likelihood of risky sexual activities (Mchunu et al., 2012).

The continuing occurrence of HIV and unplanned pregnancies among adolescent girls in sub-Saharan Africa has various drivers. Some of these drivers are identified as structural drivers—economic, social, and a lethal mix of legal factors (Fleischman and Peck, 2015); they might also include peer pressure to engage in sexual intercourse, lack of parental guidance, inadequate education and limited knowledge of safe sex, socioeconomic factors, and exploitation by older men (Ehlers, 2003). Adolescent pregnancy is also associated with coercive sexual practices such as rape and the inability to insist on the use of condoms, while gender inequality and restrictive gender roles offer a problematic context in which forced practices thrive (Morrell, Bhana & Shefer, 2012). Transactional sex, which involves the exchange of gifts or money for sexual indulgence, is also another factor (Mchunu et al., 2012).

This research highlights unplanned motherhood and its link to HIV and AIDS among adolescents as a crucial issue in South Africa that needs relevant attention. This is not because adolescents should not become mothers or ignore their sexuality but rather because of the “unplanned” nature of their motherhood. Becoming a mother “accidentally” and living with HIV are major formative experiences for an adolescent, and this may have significant implications on the health and future of both mother and child. Evidence from research has identified gaps in literature on HIV-positive adolescent motherhood in Africa and South Africa, in particular. The study referred to in this article sought to unravel the complexities of unplanned motherhood among HIV-positive adolescent mothers and their coping strategies through drawing out aspects of their personal experiences as they confront their new reality.

Adolescence, Unplanned Motherhood, and HIV/AIDS

Adolescence is one of life’s crucial evolutions that involve both biological and psychosocial transformations. Globally, adolescents constitute one out of every five people with a population of over 1 billion (Shisana et al., 2014; UNAIDS, 2013). Despite the differences in conceptualization (that is often based on culture and contexts), adolescence is accepted globally as the transition from childhood into adulthood (Seibold, 2004). To explore the concept of adolescence within a broad contemporary South Africa, this study uses an expanded chronological definition from the early to the late substage of 10 to 24 years (United Nations Children’s Fund, 2009; WHO, 2016).

Adolescence is characterized by significant changes, both emotionally and socially accompanied by rapid physical growth and development. In the course of adapting to these changes and different psychosocial developments, adolescents are faced with peer pressure and increased interest in the opposite sex, which often leads to early sexual activity and sex experimentation (Lerner & Steinberg, 2004; Mushwana, Monareng, Richter, & Muller, 2015; Pettifor et al., 2005; Shaffer & Kipp, 2007; Steinberg, 2014). This behavioral and psychosocial development inherent in adolescents is linked to high rates of unplanned pregnancy and sexually transmitted infections like HIV and AIDS. This is reflected in a number of studies that show that about 90% of all new sexually transmitted infections are from sub-Sharan Africa, particularly eastern and southern Africa, and an estimated 16 million unplanned pregnancies occur among adolescent girls annually (Gyesaw & Ankomah, 2013; WHO, 2016).

Over the past decade in South Africa, unplanned pregnancy and its link to HIV and AIDS have been a crucial issue demanding the serious attention of policy-makers. It has been concerning that before the age of 20, nearly one-third of all women have children in South Africa (Morrell, Bhana & Shefer, 2012). For any woman, pregnancy and giving birth are major life-changing experiences (Bhana, Morrell, Shefer and Ngabaza, 2010). This experience takes on new meaning when the woman is very young—an adolescent, who is still in school—and learns that she is HIV-positive. For such an adolescent, becoming a mother, just like living with HIV and AIDS, involves moving from a known, current reality, to an unknown new reality.

Consistent with past research on motherhood in South Africa, adolescent motherhood falls within the groups of individuals that are construed as “problem” due to factors like personal development needs and lack of resources: both emotional and material (Kruger, 2006; Morrell et al., 2012). Motherhood is mostly perceived as stressful due to higher risk of psychological distress, low self-esteem and efficacy, unattained educational and occupational goals, and sometimes loneliness (Mulherin & Johnstone, 2015; Parekh & de la Rey, 1997; Thompson & Peebles-Wilkins, 1992; Yelland, Sutherland, & Brown, 2010). Comparatively, adolescent girls tend to suffer poorer mental health due to the psychological effects of early motherhood, putting these adolescent girls at high risk of anxiety and postpartum depression compared with older mothers (Darvill, Skirton, & Farrand, 2010; Yelland et al., 2010). In contrast, research also shows that some teenage mothers also experience positive mental and emotional experiences, for example, when motherhood contributes to their self-esteem and maturity or helps them to be focused and gives them meaning in life (Seamark & Lings, 2004; Seibold, 2004; Spear & Lock, 2003). For some authors, motherhood could serve as a “catalyst for positive identity change” (of affected adolescents) which leads them to become driven and wanting to serve as “good role models for their child” (Mulherin & Johnstone, 2015, p. 297).

To uncover the dynamics surrounding adolescent sexuality, reproduction, and parenting, it is important to also explore the complex and intersecting issues of emotions, reason, pragmatism, and impulse that are linked with social economics and domestic backgrounds—and how they shape the present and future (Harrison et al., 2016; Mantell et al., 2006; K. Naidoo, 2015; P. Naidoo, Chirinda, Mchunu, Swartz, & Anderson, 2015). These challenges affect both the young mother’s stage of adolescent development and the ability to manage with future motherhood. Adolescent mothers are faced with two major challenges: that of meeting the needs of the child and satisfying or taking account of their own adolescent needs (Gyesaw & Ankomah, 2013). Studies in Swaziland and South Africa show that adolescent mothers endure much stress in contending with the new responsibility of caring for their newborns (Dlamini, 2002; Kaufman, de Wet, & Stadler, 2001). The conditions of these adolescent mothers are worsened if the fathers of their children or men who impregnated them are unwilling and unable to assume responsibilities for their children’s upbringing (Chigona & Chetty, 2008). As the absence of these fathers often present social and developmental challenges for both mother and child (Morrell & Richter, 2006). Maputle and Cur (2006) maintain that both social-psychological and physiological changes occur in the lives of these expectant mothers: They have to assume new roles and have less time to adapt to various changes taking them from puberty to motherhood, with its various demands. However, with social support within and outside of their social networks, most HIV-positive adolescents are able to cope with personal and lifestyle issues, stigmatization, and tasks at hand, during pregnancy and motherhood postpartum.

As already suggested, HIV-positive adolescent mothers and their children represent two groups that are vulnerable to a multiplicity of issues such as financial hardship, stress, stigma, mother-to-child-infection and discrimination. They are both at crucial points in their life stages and can move either toward stability and a progressive set of survival strategies or toward poverty, dependency, and retrogression. At the 2016 Durban AIDS International Conference, the Minister of Health announced at a media briefing that mother-to-child transmission and the plight of adolescent mothers should be key concerns to be addressed in future research. This reinforces the importance of probing issues in this broad area of concern.

Constructive assistance given to HIV-positive adolescent mothers could go a long way to help with their transition. Atuyambe et al. (2008) argue that supportive social relationships, especially from family members, assist women to grapple with the demands of adolescent motherhood. Financial, material, and emotional supports from family members and social support in general reduce the sudden burden of an unexpected child (Atuyambe et al., 2008). These supports combined with assistance from health care providers also play a part in improving the life of the adolescent mother. While there is a considerable number of studies on the experiences and adaptive strategies of “older” mothers during pregnancy (Chigona & Chetty, 2008; DeVito, 2010; Ehlers, 2003; Gyesaw & Ankomah, 2013; Kaufman et al., 2001; Maputle, Lebese, & Khoza, 2015; Maputle & Cur, 2006; Morrell, Bhana, & Shefer, 2012; Seibold, 2004; Taplin, 2009), there is a paucity of data on the experiences and adaptive methods of adolescent mothers living with HIV and AIDS in South African contexts.

Using a sociological lens and in consistence with past works and arguments on adolescence, motherhood and HIV and AIDS, this study demonstrates, through the use of vignettes, the experiences and survival strategies of selected adolescent mothers living with HIV and AIDS, by examining their challenges postnatal. There are notable studies on teenage pregnancy, motherhood, contexts of unprotected sex, HIV/AIDS, unsafe abortion, fatherhood, and family planning, but few have been conducted on the life experiences and understanding of the concept of motherhood of HIV-positive adolescents as they transit from girlhood into womanhood, and the impact of pregnancy and HIV and AIDS on their lives and survival strategies in South Africa.

Theoretical Constructs

The theoretical structure of this study was guided by social constructionist and feminist thinking. The social constructionist framework examines and describes the influence of social practices and experiences on human reality and how these experiences are socially fabricated (Berger & Luckmann, 1966; Schwandt, 2003). Specifically, social constructionism connotes the shaping of reality based on experiences and interaction with others. The relevance of this framework to this study is supported by the fact that it is rooted in human experiences across human history and social background. These experiences are generated from the data from the in-depth interviews of selected participants in this study. Effectively, this theory indicates that the definition of unplanned motherhood-while-living-with-HIV is socially made and remade based on the experiences of the adolescents. Despite individual prior desires for motherhood, their experiences significantly influenced their perception of motherhood and subsequently transformed their future fertility intentions. Consequently, the complexities this group experiences is inevitably fabricated by social and health-related factors.

There are, on the contrary, different categories of experiences and power that are best understood through feminist intervention. To truly comprehend the complexities of the institution of motherhood for HIV-positive adolescent mothers, there is a need to broaden our awareness and understand, through questioning, their very sort of power and experiences that the society might have taken for granted. Feminist theory emerged and asserted itself through language that adequately represents women and fosters their political visibility in the society (Butler, 1990). Feminism challenges patriarchal ideologies and creates a common ground to define the concept of “woman.” Studies by international feminist researchers on gender and development work have shown that women and girls are faced by challenges at different stages in their lives. These challenges form part of their experiences, which shape their outlooks and responses to life. From the feminist standpoint, one of the pillars is women defining themselves and giving voice to their everyday experiences (Collins, 2000). In line with this, this article highlights the positioning of a group of young women at the intersection of multiple forms of symbolic identities—they are all female, HIV-positive, adolescents, economically insecure, and recipients of public health care. Their experiences build and define their social identities and the ability to manage new and unplanned responsibilities. Thus, it is important to probe the experiences and perceptions of this selected group to ascertain what they are encountering on a daily basis, and how they can empower themselves and take control of their lives. Despite the wide range of research and exploration of ethical concerns associated with HIV prevention and treatment in South Africa, it is evident from existing literature that a qualitative study that gives a detailed account of the experiences and strategies of adolescent mothers living with HIV/AIDS is greatly needed. Through a sociological and gendered lens, an attempt at closing this gap in knowledge is made.

Research Method

Despite planning and then attempting to interview HIV-positive adolescent mothers between the ages of 10 and 24 years, the data for this article were eventually taken from individual semistructured in-depth interviews of 10 willing HIV-positive adolescent mothers aged 16 to 24 years, as at the year of the birth of their children. While there were possible participants aged 10 to 15, they were not willing to be interviewed, nor were their families receptive to the idea that they would be subjects of research. Purposive sampling was used to focus selectively on the central phenomena and provide relevant answers to the investigative issue of how adolescent mothers grapple with unplanned motherhood while living with HIV and AIDS, through qualitative research (Bryman, 2004; Creswell, 2012; Miles & Huberman, 1994). The participants shared the following characteristics: race (black African), age (16-24), gender (female), marital status (unmarried), health status (HIV-positive), and maternal status (at least 2 months experience of being an HIV-positive mother) (Patton, 2002; Patton, 2015).

Data collection took place at Helen Joseph Hospital, specifically Themba Lethu Clinic. Themba Lethu Clinic is a primary health care facility that provides treatment, care, support, and caters for HIV and AIDS and tuberculosis patients in Gauteng. Interviews were conducted between May and December 2017. The purpose of the study and relevant process involved were properly explained to each participant in English language (or specific South African language, where necessary), and informed consent and audio recording consent were obtained from all participants both verbally and in writing. All interviews were tape-recorded (audio) and lasted approximately 60 min.

The in-depth interviews focused on participants’ backgrounds and life transitions, the coping strategies while grappling with personal health needs, expectations and realities of motherhood, social support, challenges of unplanned motherhood, stigma, and future fertility decisions. Some of these questions are as follow: Please tell me about your thoughts and feelings when you learned that you were pregnant and about to become a mother? How would you describe your current experience of motherhood? What are some of the challenges you face as a very young mother who is living with HIV? When you compare your experience of being a mother to what you have heard about motherhood, do you think there is a difference? In case you would get pregnant again what would you want to be different? What would you wish you would have known the first time? The interviews were subsequently transcribed, and an interpreter’s assistance was employed to translate some native languages used by participants to express their experiences. Data were then coded using ATLAS.ti 8.0 in a two-stage process and thematically analyzed following an interpretivist approach. The first stage involved relevant codes and quotations. Each coding of the interview transcripts was followed by thorough data quality check for validity and accuracy. The second phase coding involved collation of all emerging themes which arose from Stage 1 coding of the 10 interview transcripts. This process revealed the dominant themes in the data collected.

Table 1.

Participants’ Demographic Characteristics.

Pseudonyms	Age (as at delivery)	Age of child(ren)	Marital status	Health status	Status of child
Lily	21	3 & 1 years	Partnership	HIV positive	HIV positive
Holly	24	2 months	Single	HIV positive	HIV negative
Ivy	19	4 months	Single	HIV positive	HIV negative
Jasmine	20	5 months	Single	HIV positive	HIV negative
Daisy	17	5 years	Single	HIV positive	HIV negative
Poppy	17	7 & 2 years	Partnership	HIV positive	HIV negative
Rose	16	6 years	Single	HIV positive	HIV negative
Alyssum	22	7 months	Single	HIV positive	HIV negative
Iris	19	3 years	Single	HIV positive	HIV negative
Violet	17	5 years	Single	HIV positive	HIV negative

Ethical Clearance

Before the commencement of data collection (interviews and field notes), three approvals were obtained for this research. The first was from the university faculty ethical committee. The second approval was obtained from the Themba Lethu Clinic in Johannesburg, while the final approval was obtained from the Gauteng Department of Health. For each approval, the proposal of this research was officially and thoroughly scrutinized to avoid ethical issues and protect the interest of participants due to the sensitivity of the topic, as it involves vulnerable adolescents who are mothers and also living with HIV/AIDS.

Findings and Discussion

The existing literature reveals that adolescent mothers with unexpected and unplanned pregnancies struggle to deal with their responsibilities, keeping up with their roles, withstanding stigma, and keeping in place support systems (Chohan & Langa, 2011; Gyesaw & Ankomah, 2013; Morrell et al., 2012). These issues in the literature resonated among the HIV-positive adolescent mothers I interviewed in this research. However, for HIV-positive adolescent mothers, additional complexities are presented. From the systematic analysis of data, three important themes are discussed in this article. The first theme—reality of unplanned motherhood while living with HIV—documents their experiences that are shaped by unplanned motherhood and their HIV-positive status, thus defining their reality as mothers. This theme discusses the challenges and the impact on their lives. The second theme—coping with the unplanned reality and drawing on a support system—examines the coping strategies employed by this group of individuals in surviving their unplanned reality and sustaining their support system. The last theme—future fertility decisions—examines the impact of these adolescent girls’ experiences on subsequent childbearing intentions and future decisions as they journey through life.

Reality of Unplanned Motherhood While Living With HIV

Despite sex education in school and awareness of the risks involved in unprotected sex and being generally knowledgeable about sexual and reproductive issues, all the participants reported that their pregnancies were unintended. The reality of unplanned motherhood while living with HIV was clearly reflected in the experiences and troubles encountered by the participants in the postpartum period. First, accepting and living simultaneously with both health and motherhood responsibilities was identified by the adolescent mothers as difficult. The majority of them expressed shock when they learnt about their pregnancy. For those who knew about their HIV status before the pregnancy, the shock was minimal. However, for those who found out about their HIV status and pregnancy at the antenatal clinics, it was overwhelming. On her first visit to the clinic after she summoned the courage to register for ante natal, Iris reflected that

I went there (clinic) they (nurse) actually took the urine samples to check whether you are really pregnant or you are not . . . then they do HIV testing and then this other guy, like he was HIV counsellor came there and then took my blood and then put them in the HIV testing kit . . . tester . . . he showed me two bars and then he said that I am HIV positive . . . eyoh . . . I couldn’t believe it and I still don’t believe it now . . . I couldn’t believe it (silence) (crying) . . . I felt overwhelmed like I’m pregnant and on top of that I am infected with HIV and I didn’t know who it (father) was.

Iris’s narrative presents an overwhelming sense of unpreparedness and despair. It also affirms the arguments of most studies that highlight the risky sexual behaviors of most adolescents that often lead to unplanned pregnancy and sexually transmitted infections (Fleischman & Peck, 2015; Lerner & Steinberg, 2004; Morrell et al., 2012). While many of the participants expressed their disbelief at the discovery of their pregnancy, the challenges of taking care of their health needs and protecting the baby during the pregnancy also depicts the difficulties experienced. Other narratives, like the compulsory and uninterrupted daily use of Antiretroviral theraphy (ARV), further established the impact the sudden transition had on their unplanned new world. Alyssum, who learnt about her status few months before she got pregnant claims that meeting the challenges of her personal health needs was challenging:

The pill . . . oh! You don’t wanna know. With the pregnancy it was horrible at first for about three months I couldn’t cope but I had to push . . . Ya . . . sleepless night, late . . . (sighs)

The above extract demonstrates the narrative that shows that despite the multiple forms of symbolic identities like being a female, mother and health status, which has socially constructed their new reality, these adolescent mothers push against boundaries through psychological resilience and physical strength. For example, the data show participants “sacrifice” through the consistent use of ARV to prevent mother to child transmission. However, the experience during pregnancy is insignificant compared with experience after delivery as the birth of a child impacted the meaning and definition of motherhood in the lives of these participants. As shown by their experience and subsequent complexities, most participants expressed difficulties when they were asked to conceptualize motherhood. Given the demands of motherhood and that of living with HIV, mothering for these adolescent mothers comes as difficult, hard and a roller coaster. As such, Rose admits that

Motherhood is hard. Motherhood is very hard and if you are still young, it’s like maybe five times like the work . . . So basically being a mom while you are still young is very hard, you need all the help you can get . . . it’s hard for like adults and for us (HIV-positive adolescents) yoh it’s something else . . . cos even when they (baby) get sick, you don’t know what to touch and how to behave . . . you are just confused . . . so it’s very hard.

Evident in the above narrative is a comparative discourse on the definition of motherhood as planned and unplanned (an overwhelmed HIV-positive young girl) perspective. The responsibilities presented by this role show the huge challenges faced by participants. Also, Poppy states that

Motherhood is difficult. It is difficult because you are playing a role of a doctor, a mother, a sister, and friend . . . like every support base . . . you have to be a comfort, you have to be everything to the child. Yes . . . you have to do everything and still honour going to schools and meetings whatever . . . So, it is a difficult job being a mother because you will be working 24/7, there is no off.

The above extract demonstrates dyad narratives. First, the narrative shows the hegemonic patriarchal discourse which depicts the complexity of a lonely journey through motherhood. It presents how the responsibilities of motherhood, while living with HIV, are solely borne by the participants. Given their explicit gendered experiences of motherhood, it is evident through these participants’ narratives that masculine dominance reflected through the persistence of absent fathers or limited support contributed immensely to their difficulties. Their inexperience and their health status made the situation challenging. For Poppy,

you know being a young mother it’s . . . iyoh! . . . it’s quite a roller coaster ride . . . there are certain things you come across and you don’t know how to deal with them . . . Motherhood is very challenging . . . especially if you are a single parent and positive . . . It was not easy because the adjustments are quite difficult because at seventeen you are basically still a child.

While the responsibilities of motherhood are challenging, most of the adolescent mothers described these challenges as a major limitation to connecting with their babies. Iris expressed her difficulty in bonding with her baby:

It was very difficult. I couldn’t bond with my child, like I felt like the child resented me or something I didn’t know what was happening. But I always struggled like with him, I don’t wanna lie. Whenever he cries, I also just cry . . . But yohhh sleepless nights cos my mother like she couldn’t like do almost everything for me, I had to do some things for myself and it was not easy . . . it was not easy.

She continues by reporting the emotional responsibility that comes with the unintended situation:

sometimes you get overwhelmed and maybe you start snapping at everything and there are those moments when you just say obviously, I did ruin my life or something like that or maybe I would be out there doing things but am busy stuck here with a baby or something like that.

Some of the participants reported the psychological effect of the responsibilities of unplanned motherhood and that of their health. They perceived these responsibilities, coupled with that of their health, as a major setback. This made them resent their babies. According to Violet,

I will always feel like I robbed myself of my childhood and at times I will resent my child, I would hit my child so badly and even though she couldn’t hear what I was saying but I will always tell her that I regret being with her.

From the foregoing, it is evident that all the participants experienced dilemmas with coping—given their youth and HIV status. For some, this negatively impacted their relationship with their children. Findings from elsewhere corroborate the experience of participants in this study (Chigona & Chetty, 2008; Morrell et al., 2012).

Support System as a Coping Mechanism

As argued by Atuyambe et al. (2008), support given to adolescent mothers shapes their future and advancements. This theme discusses the findings under the support system, which to a large extent helps interviewees cope with their new reality. To avoid ambiguity, the term support is conceptualized as financial, emotional/ psychological, and physical assistance. The findings show that most of the participants’ mothers play a paramount role regarding child care. Other members of the family also contribute to this support to enable the completion of some participants’ education and career advancement. In South Africa, especially among the black African communities, support from the baby’s maternal grandmother is considered an acceptable practice and a norm in the society (Chohan & Langa, 2011; Jewkes, Morrell, & Christofides, 2009). This thus shows synergy between the literature and the findings in this study that the mothers of the adolescents, that is, the maternal grandmother of the child, are the most enabling support of adolescent mothers. This is reflected in Iris’s narrative:

In terms of support, I would say my mother gives more of the support because she is more like the only the person, not like the only person I have in my life, just that others are there but they don’t know what I have been through, they are just seeing “the me” that they know and they have always known. But my mum has always been very supportive of me.

Also, Poppy narrated that

I cope because I have my parent, my mum to support me, help me . . . Yes . . . and my junior (younger) sister, and she is there.

Violet also reported that her parent plays an important role in supporting her in every aspect:

I do have . . . Now I have a very powerful supporting structure from my parents, my mum, she’s such a wonderful soul, she is a caring person. . .she would die for that child . . . so they are like best friends.

However, when asked about how participants survive economically, majority of them claimed that their financial support comes from the Child Support Grant (CSG). Lily said,

I can say I survive with the grants money and some help from people . . . Yah.

For Iris:

. . . we do get financial support from . . . I was mostly relying on the social grant and the father was not supportive also.

Also, Alyssum reported that

I applied for child grant and my family is supporting my baby.

Emotionally, most of the interviewees were able to face the challenges by accepting the responsibilities. Alyssum explained that through “acceptance,” she was able to take the first steps and move far from the first challenges encountered with her unplanned reality:

I was shocked. I wasn’t expecting it, but then I had to accept the pregnancy, I told myself it takes 9 months . . . I was able to accept my HIV status, so I had to accept that I’m a mother. Had I not accepted the fact that I’m pregnant and that I’m HIV positive things wouldn’t be this way . . . probable I would be dead right now.

From this theme, most participants enjoy social support from their immediate family members while some rely on the child support grant financially. It is also important to mention that as adolescents, these mothers need more support to cope and grow with the challenges that come with adolescence, as the addition of motherhood and HIV increases and highlights the multiple complexities these mothers face in their daily lives.

Future Fertility Decisions

As discussed in the literature, reproduction and childbearing begin at early ages in many sub-Saharan African countries, and this often continues until menopause (Morrell et al., 2012). Particularly in South Africa, early childbirth is a common occurrence despite the significant decline in fertility rates. This decline in the childbirth rate is linked to social problems and economic difficulties, changes in marriage and paternity patterns, and significance of education and career advancement (Benton & Newel, 2013; Roberts, Williams, & Buchanam, 2013). For HIV-positive adult women, studies show that factors like gender inequalities, structural and socioeconomic vulnerability, mother-to-child transmission, sexually transmitted infections, and so on, influence fertility intentions and decisions (Asfew & Gashe, 2015; UNAIDS, 2013). However, this theme examines the influence of some of these factors on the subsequent fertility decisions of HIV-positive adolescent mothers.

For participants in this study, a virtual “agreement” emerged on the decision to stop childbearing or delay subsequent pregnancy and childbirth. Despite medical interventions, such as prevention of mother-to-child transmission, some perceive another pregnancy and childbirth as detrimental due to their health and immune status. The fear and likelihood of perinatal transmission, despite a wide spectrum of knowledge on mother-to-child transmission, also emerged. This is exemplified by Iris’s statements when asked about her future fertility decision and plan:

No! No! No! No! . . . that one I can’t (silence) I just can’t . . .

No maybe if it was just like normal person, maybe I would but now . . . Yeah but still I have this disease in me, so I feel like getting pregnant would just . . . I don’t know, make things worse or what . . . haiii, I can’t (whispers) . . . I can’t.

However, for the few who still have the desire to have more children, some important conditions would be considered before the birth of another child. The major conditions and requirements mentioned by these few young mothers before they would choose to have another child are financial security, completion of studies, present father, supportive husband, and employment goal. Rose explained that

yes I do . . . kids are adorable . . . ya they are . . . I do plan to have them but I just don’t want . . . I’m gonna have them at the right time this time . . . ya . . . when I get older and when I have the resources that I need.

For Rose, the presence and the participation of a future partner is very important. This she believes would contribute immensely to the positive upbringing of any child that comes from such a union:

I would want the father to be positive and . . . like have a positive relationship with the child like the father to be involved . . . I would want him and I to be like in that thing together . . . I would want to be working . . . I would want to be staying in a house . . . like I would want my kids now to experience like the mother and father’s love in that home.

At first Lily was adamant that a future child birth was definitely undesired but after second thoughts, she said there is a possibility but not anytime soon, mostly because of her financial constraints. However, she said based on the availability of some resources:

Ahnahn . . . not now . . . well maybe in the future, maybe ten years . . . Eish . . . by that time I must be married and own my house, have my own job, car . . . live a better life, a good life. I must be able to buy good pampers for my . . . hem . . . nappies for my child, good milk for him, food . . . healthy food . . . I know I can’t afford all that now.

For Violet the combination of a responsible partner and time spent with the child would make her change her mind about a future fertility decision:

If I get pregnant, I would say providing for my kids . . . if (laughs) I do get pregnant and spending more time with my kid because working shift is time consuming . . . you hardly spend time with your kid . . . I want to have a child with someone who I know that would be responsible, someone who I know will be there for the kids emotionally not just financially and I want someone who will be a father figure . . . Ya . . . to the child. So, I wouldn’t want to repeat the same mistake.

In sum, the main reasons for most of these adolescent fertility decisions were negative perceptions of their health status and bodies, non-participating partners, challenges to the support system, and the need for an increased standard of living in an environment of economic uncertainty. This shows the broad difficulties encountered by HIV-positive adolescent mothers in South Africa. Absent fathers, lack of socioeconomic means, and personal health issues stood out as the most important factors that influenced their future fertility decisions. These personal attitudes toward future childbearing decisions demonstrate that these adolescent mothers find motherhood challenging and difficult. However, despite unfavorable contextual factors and social obstacles it is important to highlight that these adolescent mothers displayed agency and autonomy through acceptance, resilience, optimism about their children, and especially the struggle to regain control over their lives. Although many similarities marked them, they differed in terms of age and maturity, ethnicity, and other social identities. In line with Glenn et al’s (1994) viewpoints on mothering, there is no one model of mothering—Mothering is not inborn or inherent but shaped by contextual and circumstantial realities. Some of the adolescent mothers felt more confident than others, some had strong support; others did not. Some reflection on the similarities and differences is important and should be evident in relevant policies and structural interventions for this group of individuals.

Limitations and Strength of the Study

Some important limitations are noteworthy in this article. Most of the very young HIV-positive adolescent mothers approached in this study were not willing and declined outright to be interviewed, despite my explaining the privacy and confidentiality clause. They stated that by granting the interview and sharing their personal experiences they felt “exposed.” Others said that by being interviewed they would be going back the sad memory lane they have tried so hard to forget. Hence, the sample size of this research was eventually small and more selective than planned. On a positive note, once they agreed, no participants dropped out during the interviews. However, due to the sensitive nature of this topic, some of the participants were not comfortable and may not have been totally responsive to talking about the details of their experiences. While it is clear that the study participants were not representative of all HIV-positive adolescent mothers in South Africa, the findings presented in this article highlight the usefulness of the study as it provides valuable insights into young mothers’ experiences that can be studied further in future studies.

Conclusions and Policy Recommendations

This article contributes to a burgeoning literature on motherhood, HIV, and adolescents’ sexual reproductive health. While previous studies have examined teenage pregnancies, unplanned pregnancies among teenagers in South Africa, fatherhood, and other adolescent-related topics, this study has sought to connect two key areas of scholarly interest: HIV-positive and adolescent mothers. This article investigates how they grapple with their personal health needs while juggling unplanned responsibilities of motherhood. Generally, it is evident from the findings of this study that HIV-positive adolescent mothers find it difficult to cope with the challenges of motherhood, and their personal and health needs. The most eminent challenges include but are not limited to psychological and economic difficulties.

The vignettes referred to draw meaning from the adolescents’ general experiences but most especially from the narratives around being the sole player without the presence of their children’s father. While one does not want to overemphasize the need for masculine involvement in assisting women with their unexpected predicament, there should be policy interventions that emphasize men’s parental roles and domestic responsibilities. The adolescents’ narratives show a hegemonic male-centered South African context—one that releases men from child-rearing obligations but compels that women struggle with it on a daily basis, devising strategies to survive through sheer display of their agency. There is an overwhelming sense of disadvantage, both emotional and socioeconomic.

Following feminist research, advocacy for research on women, and where possible with women, has encouraged a scrutiny of the conditions shaping women’s lives. There are some inferences for policy-makers and practitioners working with HIV-positive adolescent mothers in South Africa. First, the finding that HIV-positive adolescent mothers find their unplanned reality difficult yet still forge ahead despite structural barriers and challenges suggests a need to respond in a way that looks beyond their risky sexual practices and behaviors. It is imperative to not focus only on teaching responsible sexual reproductive decisions and practices but also aim to create emancipatory knowledge and provide relevant resources that would assist young mothers to build their lives progressively. Considering the connection between unplanned adolescent motherhood and socioeconomic disadvantages and poverty, it is highly recommended that programs that improve skills acquisition and development, educational attainment, and opportunities for sustainable resources should be implemented for adolescent girls in South Africa. This may help reduce the financial and emotional difficulties that are linked to unplanned motherhood among adolescents living with HIV.

Overall, despite the emotional and practical limitations faced by the participants, the spirit in which they managed and accepted their unplanned new realities demonstrates that unintended motherhood does not necessarily mean the end of happiness, education, and future ambition—but rather the beginning of redirecting and self-constituting a meaningful future. Future policy and research endeavors thus need to construct and interrogate new images of the adolescent, HIV-positive mother.

Footnotes

Acknowledgements

We would like to appreciate professor Naidoo Kammila for all her valuable comments and efforts to improve the article. We are most grateful to all the adolescent mothers who willingly participated in this research. Thank you for sharing your personal and important stories. We also extend my sincere thanks to Sello Mashamaite and some members of staff at the Helen Joseph Hospital, Thembelethu Clinic. Thank you all.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

Ethical Clearance

ORCID iD

Adeagbo Morolake Josephine

Author Biography

Adeagbo Morolake Josephine is currently a doctoral researcher in the department of Sociology at the University of Johannesburg, South Africa. Her primary research interests are in Gender Studies, Sexuality, motherhood, HIV/AIDS. She is also passionate about adolescence, maternal health and race.

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