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| Mulualem Merga1*, Kirubel Anteab1, Mezinew Sintayehu2and Hinsermu Bayu1 | |
| 1Department of Midwifery, College of Health Sciences, Mekelle University, Ethiopia | |
| 2Department of Nursing and Midwifery, School of Allied Health Science, College of Health Science, Addis Ababa University, Ethiopia | |
| Corresponding Author : | Mulualem Merga Department of Midwifery College of Health Sciences Mekelle University, Ethiopia Tel: 251-910050154 E-mail: muller1629@gmail.com |
| Received December 24, 2014; Accepted March 30, 2015; Published April 03, 2015 | |
| Citation: Merga M, Anteab K, Sintayehu M, Bayu H (2015) Challenges in Decision Making Among Homeless Pregnant Teens in Addis Ababa, Ethiopia: A Descriptive Phenomenological Study. J Preg Child Health 2:140. doi: 10.4172/2376-127X.1000140 | |
| Copyright: ©2015 Merga M, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. | |
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Background: Homeless youth are particularly at high risk for teen pregnancy; studies indicates most of homeless young women become pregnant, because circumstances in which they live and work increase their vulnerability to sexual exploitation and abuse and put them at a higher risk of unintended pregnancies, and other reproductive health problems.Generally despite declines in teen pregnancy, and births internationally, teen age, homeless girls often become pregnant, but little is known about the extent to which the traumaexperienced during the key developmental stages of childhood challenge their decision making process.
Objective: The main objective of this study was to identify challenges in decision making among homeless pregnant teens in Addis Ababa, Ethiopia.
Method:Qualitative study was conducted among street girls who were 13 to 19 years old and reported being pregnant during the study or have history of past pregnancy using focus group discussions and through individual deep interview. Study participants were selected using Snowball sampling techniqueas well as from care center.
Result: At the time of the study all most all participants had cited the difficulties of their situations and listed as worrying about further complication of their life by early parenthood ,worrying about their children’s fate of living in impoverished single-parent life, burning of their plastic shelter by police, losing their job due to pregnancy, getting pregnant from very close family, financial constraint for abortion, lack of basic needs and the traumaexperienced during the key developmental stages of childhood challenge their decision making process.
Conclusion: Homeless pregnant teensface a big challenge todecide on the fate of their pregnancy due to all traumatic factors which led them to street and pregnancy, partners’ reaction, worrying about future fate of their un-born child, and others.
| Keywords |
| Pregnant; Childhood; Poverty; AIDS |
| Introduction |
| Back ground of the study |
| A home is not just a physical space: it provides roots, identity, security, and a sense of belonging and a place of emotional wellbeing. So, homelessness is about more than roof-less-ness [1,2]. Street children exist in every part of the world and large groups of children unsupervised by adults have appeared in almost every country during some part of history. The vast majorities of these children work and live in large urban areas of developing countries, and they are the reflection of growing social tragedy in the world [1]. |
| Street children are not usually counted, not subject to census so their numbers are not known, but what certainly known is that their number is increasing for various reasons. The increasing phenomenon of street children have been linked with several related factors like economic recession, poverty, unemployment, rural to urban migration, war, political instability, natural calamities, family breakdown and violence including physical, emotional and sexual abuse, the global population growth , rapid urbanization and AIDS pandemic [3,4]. |
| While all of the above are substantive factors contributing to the existence of street children, increasing mass poverty stands out as a major factor for the existence of street children.The problem requires urgent attention as it threatens the very fabric of society. But with each passing day, it is becoming increasingly clear that many African governments of countries where the problem is most acute have been unable to give itthe attention it deserves, and have unintentionally contributed to its continuation. While one can speak of some kind of political commitment on the part of many African governments, very little is being done to address the problem of street children [5]. |
| Ethiopia, being among the poorest countries in Sub–Saharan Africa thousands of children lives under difficult circumstances and are exposed to various forms of abuse and exploitation [6]. In Ethiopia, due to different factors children are drifted to street life to support themselves or their families in major cities [7]. Over 4 million children are estimated to live under especially difficult circumstances. It is estimated that more than half a million street children (600,000) children are taking part in street life and as many as 500,000 children find themselves at an extremely high risk of becoming involved in street life in Ethiopia [8]. |
| The streets of Addis Ababa, the capital city of Ethiopia, are said to be home to a population of between 60,000 to 100,000 street children with the lower estimates originating from the Ministry of labor and social Affairs and the higher from aid agencies [9]. This report indicates that at least 25% were female. |
| Statement of the problem: The rising occurrence of mothers living on the streets of Addis Ababa has become one of the city’s most pressing social problems [9]. Like many under developed nations; challenges facing the Ethiopian children entirely, and street teenage pregnantdistinctively are diverse and immense.Girls who work and live on the streets are exposed to the street subculture such as smoking, drug, alcohol, substance and sexual abuse, engaging in sexual activities or selling sex for survival these all put them at a higher risk of unintended pregnancies [9]. Additionally trauma experienced during the key developmental stages of childhood, especially maltreatment such as sexual abuse and exploitation, has profound physiological, cognitive, and social effects on the growing young person. Such trauma can affect a teen’s ability to form emotional attachments, destroy trust in adults, and create cognitive distortions about sexuality and relationships. These can lead to risky sexual behaviors, including multiple sexual partners, unprotected intercourse, which will end up with teen pregnancy, so how teens exposed to these traumas are able to successfully cope with adversity and decide for parenthood? |
| Furthermore combining childhood, streetism, and pregnancy provokes a deep sense of unease: “…it is adults who conceive and beget children; a child cannot conceive or bear a child. Yet that is precisely what street pregnant teens were about to do” [10]. Street pregnant teens live alone in streets, without proper or reliable shelter; they had lost contact with their parents and, they did not enjoy parental protection, love and care. So, this article was concerned with this particular group of young mothers: street –involved pregnant teens and tried to demonstrate, to what extent they were challengedto negotiate and attempt to reach a decision. |
| Significance of the study |
| Based on the very little data found nationally on street girls as whole, and street teen pregnant girls particularly, I contended that not enough was done to address the problem of this special category and that indeed their challenge in decision making is remains an ignored tragedy. |
| So, the result of this study hopefully compiles a diverse wealth of potentially meaningful information from numerous pregnant teens in their experiences that can be used to create a training program for whoever works with street children, and give base-line information for decision makers such as city administration, health office, health facilities and NGOs working with the street children related issue to put appropriate solution forward. |
| Additionally this study brought the strengths of many experienced girls to the field in the aftermath of childhood trauma during FGD and helps them to cope up life by themselves by reassuring themselves by comparing what cause them to be on the street with that of their peers. Furthermore this study can help as a base for further researches. |
| Literature Review |
| Literatures have revealed that Street pregnant teens are highly concentrated in countries with struggling economies, but are also present in some developed countries. Regardless of their location, they face hardships and exploitation such as trafficking, child labor, sexual abuse, exposure to HIV/AIDS and lack of medical attention to serious health issues [11]. But studies revealed that both internationally and nationally governments, and other concerned bodies appear slow to address the problem of street pregnant. This in part stems from the fact that little is known about how these particular groups of street children experiences their pregnancy. Even with a Ministry for women and children, government departments often lack comprehensive and reliable data on let alone these hard to find group but on street children as whole [12]. Studies carried out previously indicated that the literature on street children Ethiopia is relatively small and repetitive [12]. It is therefore very difficult for effective government action without reliable and up-to date data on these special category of street children. |
| The community too tends to hide its head in the sand hoping that the problem will go away. Unfortunately the problem is not going away, but increasing to alarming proportions. |
| Only the few soft hearted or religious ones will throw a few shillings to these children leading miserable life.The problem of street children generally, and street pregnant particularly has been growing to enormous proportions before it gets the attention it deserves! This is a tragedy that cannot remain ignored any longer. Among the actions that can be taken to address the problems that street pregnant teens face, the first important step is to realize and acknowledge that the problem of this special category of street children is one of the most burning problems. A few studies that exist on the sexual behavior of street children in Addis Ababa showed that these children are more familiar to high-risk behavior and are sexually active at an early age [9]. |
| Street girls are also physically and sexually victimized by street boys too and on the streets they are prey to different forms of victimization. Empirical accounts by street girls in Ethiopia have revealed that they are victims of beatings and assault on two specific occasions: when they refuse to have sex with street boys and when they refuse to hand over their money (often) to older street boys [13]. According to a report presented by the African Child Policy Forum (ACPF), a prominent child-advocacy group, ‘‘one in every two Ethiopian girls is a victim of unwanted sexual touching [14]. |
| Additionally child prostitution has been cited amongst the most pressing problems that need to be tackled in efforts to protect the girl child in Ethiopian [15]. Poverty, desperation and the obligation to support them through sex work keeps street girls within a vicious cycle, which carries with it the high risk of unwanted pregnancy and STDs infection. Although it has been estimated that 25% of Ethiopia’s street children are girls [16], and despite the fact that there is indisputable evidence that street girls in Ethiopia are often obliged to take on commercial sex work for survival, recent information on the number of street girls engaged in it is lacking [17]. |
| Pregnancies, back street abortions, street births and street motherhood are often the outcome of commercial sex work and rape experiences [18]. Studies also indicate that homeless teenage girls are almost five times more likely to become pregnant [19] and far more likely to experience multiple pregnancies than housed teenage girls [20]. |
| Currently, street mothers in Addis Ababa are estimated at 10,000 [21]. But very little is known, however, about how they experience their pregnancies or the ways in which they negotiate difficult life circumstances during the process. The little that is known about how they conceptualize pregnancy comes from Saewyc’s study of the experiences of “out of home” young women (17 to 19 year old) who chose to be parent [13]. These women all described complicated relationships with their families of origin and with |
| Partners, encompassing violence, abandonment, no love, and no hope for a better future for themselves and their unborn children.The majority of homeless teens flee to the streets to escape their families of origin [14,21,15,16].They report traumatic childhoods characterized by neglect, physical violence, and emotional and/or sexual abuse by their family or institutional caregivers [17,25,26,18]. And others have also documented that becoming pregnant is one of the primary reason girls leave or are kicked out of their homes [21]. Many of the same risk factors that place them at risk for homelessness are strong predictors of early and unplanned pregnancies. |
| Homeless teensthat became pregnant were more likely to have experienced intra-familial incest, sexual abuse at an early age, and more severe sexual abuse than young, homeless women who do not become pregnant [22]. They were also more likely to have left their homes involuntarily, experienced homelessness at a younger age, and initiated drug and alcohol consumption earlier in life. Other factors that contribute to unintentional pregnancy and negative health outcomes among teen homeless girl include participation in survival sex [23], and barriers to regular supplies of contraceptives [24,25]. |
| The gendered patterns of intimate partner violence among homeless couples may contribute to unintentional teen pregnancy. The structural vulnerability of teens and young, homeless women engaged in sexually exploitative relationships in which they have little power to negotiate either contraception to prevent unintended pregnancy or condom use to reduce the risk of sexually transmitted infections [26]. |
| One study also asked girls of the street and girls on the street what they perceived the results ofhaving lived on the streets might be. For girls of the street, 114 responses were collected from a sample of 32 girls. Every single response contained a negative consequence of street life, most of the respondents mentioning lack of education, ill health and physical and sexual assaults. No positive aspects of life on the street were mentioned. This would seem to lay to rest the myth that street children are free spirits existing in a childhood idyll free of adult interference. It is true to say that street life is an unspeakably miserable experience for many girls of the street. For girls on the street, the responses were also primarily negative. Perhaps reflecting the additional security they enjoyed over girls of the street, this sample was less concerned with their physical wellbeing (although this remained a primary concern, mentioned by 29%). |
| The single greatest concern was that their street work would interfere with their education and consequently their prospects in life. Again, no positive aspects of street life were mentioned [11]. One study conducted in Dessie town showed that out of sexually active female street youth, 25.0% had a history of unintended pregnancy at least once prior to the study, out of which 55.5% of them reported history of induced abortion at least once [27]. Another study in Addis Ababa revealed that nearly a quarter (23%) of the girls had encountered unwanted pregnancy At the time of the survey, 90.4% of girls were ever had sexual intercourse , and the mean age at their first sexual intercourse were 14.3 years [28]. |
| In another study that was conducted in AA among the 108 street girls participated in this study, more than half (70.4%) reported that they had ever been pregnant (31.9% once and 68.1% more than one times) and almost three fifth (59.4%) of these pregnancies resulted in abortion. Nearly all (95.7%) of female respondents said that pregnancies were unwanted. Although pregnancy is prevalent this much on the street where girls are rarely found no study was yet done regarding the challenge they encounter during their decision making. |
| Also governmental and nongovernmental organizations intervention program do not tackle down to the realities of let alone street teenage pregnant who need more specific services, but street girls for whom it is also important to develop services that meet their specific needs [29]. |
| Some areas which would need to be addressed differently may include: |
| • Outreach activities need to go beyond street visits in order to find girls who are more hidden away. |
| • Shelter must be a priority because it means safety for girls. |
| • Clothing, toilettes and a place to wash are also vital to girls’ safety and self-esteem. |
| • Counseling and psychosocial activities must be adapted to deal with the impact of sexual abuse, early motherhood and involvement in commercial sex work. |
| • Family and community reintegration programmes must explicitly address the challenges of stigma, especially if girls are to return home with clear signs of sexual activity, such as being on HIV treatment or with children. |
| • Vocational training and business start-up activities must reflect the potential income from commercial sex work which can provide a relatively high standard of living. |
| • Girls will need to be encouraged to participate and may need some sort of compensation. |
| These all mean street girls generally and street teenage pregnant girls particularly need extra considerations in providing services to street children, but it is clear from research that the current service provision in Kampala and Addis Ababa is not even enough to meet the needs of girls on the streets [29]. |
| There are very few organizations targeting girl children. This is because these organizations work through the existing societal structures such as hospitals, schools, local communities and facilities from which street children are disconnected including surprisingly the street it because Girls are less visible on the streets because there is a lot of stigma from the community therefore their priority is hidden places [29]. |
| Though Study reports and other literatures on street children sexual health problems generally and pregnancy related problems particularly are very limited, even when available not comprehensive [30]. To date, too little is known about how street teens experience their pregnancies, and problems they encounter during decision making. |
| Hence undertaking a study in this area was believed to provide information on the different types of challenges street teens encounter during their pregnancy and decision making so that relevant information would be generated that could help organizations for changing the approach of services to take full advantage of pregnancy as a potential catalyst event for change in this highly vulnerable and underserved population, because when working with street children it may not be possible to find an appropriate place or time to provide information to them, so it is important to take advantage of as many situations as possible whenever in contact with street children, and among these situations pregnancy is the best gate way to help them when they become cooperative more than ever, and need help more than ever and to do this we should first assess where their problems are. |
| Objectives |
| General objective: Exploring the challenges in decision making among homeless pregnant teens in Addis Ababa, Ethiopia. |
| Specific objectives: |
| • To identify factors that challengehomeless pregnant teens during decision making |
| • To assess how street teen girls negotiate traumatic childhoods with becoming mother |
| Methodology |
| Study area |
| The study was conducted in Addis Ababa the capital of Ethiopia which has an area of 530.14 square Kilometer divided into 10 sub cities (Kefle Ketemas) with a total of 100 kebeles. Based on 2007 Ethiopian census, Addis Ababa has a total population of 2,738,248, consisting of 1,304,518 men and 1,433,730 women [31]. Addis Ababa is the largest urban area in Ethiopia and attracts many children and youth who are searching for employment. The city has a high population of street children who are engaged in the informal sectors. The research was conducted from November30, 2012 to June 6, 2013 in Arada one of the five with high concentration of street childrensub cities of Addis Ababa: (Arada, Addis ketema, Kirkos, Lideta and Bole, the sub cities). |
| Study design |
| A descriptive phenomenological study design was used in this study. Individual deep interview and more specific semi-structured questionnairewasconducted to gather relevant informationon sociodemographic characteristics, sexual behavior, and to gain an in-depth understanding of the challenges encountered during decision making by street pregnant teens girls in Addis Ababa. |
| Study population |
| The source populations for this study were all street teenage girls in Addis Ababa, and the study population was all street teenage girls who were pregnant during the study and who were with their child on the street during the study, and who were living or working independently on the street, aged 13-19 years, resided in Addis Ababa. |
| Sample size |
| Research circle wasdiscontinued after saturation of the information reached or after no more new idea was expected, so the sample size in this study was not determined before the data collection since the sample size depends on the repeatedness of information. |
| Sampling procedures |
| After selecting the site Arada one of the five sub cities with high concentration of street children in Addis Ababa, the participants were selected by Snowball sampling method because street pregnant teenagerswere less visible on the streets. |
| Sample selection |
| The study was primarily based at the GOAL ETHIOPIA: nongovernmental organization center for homeless youth providing a variety of free services like; medical, legal, social work, and life skill training services. Recruitment occurred at both this center and community levels. At this center level, from 30 November 2012 through 20 January 2013, approximately 145 women attending the center were given an informational sheet about the project. Women who were 13 to 19 years old and reported being homeless during a current or past pregnancy were recruited. All women who disclosed pregnancies during this time agreed to participate in the study were listed. From the list, some mothers were traced who, in turn, through snowball sampling, led us to other teenage mothers. |
| Inclusion criteria: |
| • Street girls who were 13 to 19 years old |
| • Street girls who had current or past pregnancy history |
| Exclusion criteria: |
| • Pregnant teens those were seriously sick and unable to respond to the questions and who could not give consent (mentally impaired) to articulate their experiences related to the phenomena that were being investigated. |
| Data collection instruments |
| Standardized questionnaire was developed after reviewing relevant literatures [32]. The questionnaire in the beginning was prepared in English and then translated into Amharic and back to English by two blind people to ensure consistency, but finally administered in Amharic, the local language. Individual deep interview, more specific semistructuredquestionnaire, tape recorder, and participant observation was used as a tool to gather relevant information on socio-demographic characteristics, sexual behavior, and to gain an in-depth understanding of the challenges encountered during decision making on pregnancy by street teenage girls in Addis Ababa |
| Data collection procedures |
| The instruments listed above were used as a tool to gather relevant information on socio-demographic characteristics, sexual behavior, and to gain an in-depth understanding of the challenges encountered during decision making by street teenage girls. The data collection was conducted within 1 month and three weeks. Upon review of the filled questionnaire, a follow-up FGD was conducted to discuss and to make the participants to explain their ideas in more detail and/or elaborate on what they have stated in the questionnaire with their peers.’ |
| FGDs was conducted with two groups consisted of 8-10 participants. Participants were selected on volunteer bases. The researcher used a non-directive style of interviewing using open-ended questions allowing the participants the freedom to control pacing and subject matter of the interview. Additionally, a more directive style of questioning was used as needed when clarification of information is important. The researcher recorded the information from the FGD by making hand-written notes, and using tape recorder. |
| In the study the FGD was used to assess validity by comparing the responses on the questionnaire with the participant’s real opinions they shared with their peer, with relatively a little bit freedom than face to face questioner. Reliability was assessed through test-retest reproducibility by interviewing some of the participants more than one occasion. Some of the questions were asked in more than one way to assess internal consistency. Acceptability was determined by asking the participants how they found answering the questionnaire during the validity testing. |
| Data analysis |
| After every focus group discussion and in-depth interview, the recorded discussions were fully transcribed and translated verbatim into English. Interviews were supplemented by observational notes that were recorded and coded. Coding of interviews and field notes was done based on key words and phrases developed from the data. Themes identified as being important when they were raised by multiple participants. These themes were categorized according to challenges in relationto partner’sreactions, current living situation, previous or current pregnancy experience, decision-making rationale regarding these pregnancies, financial constraints to access an abortion, mixed feeling about parenting, problems of accessing prenatal services, and lack of basic needs. Data collection and analysis were a simultaneous process in this research, and data analysis entails classifying teenage street girls, and the challenge they experience during decision making. |
| Study variables |
| Dependent variable: |
| • Decision making on pregnancy |
| Independent variable: |
| • Socio-demographic, and economic variable |
| • Traumatic childhood |
| • Factors led to the street |
| • connectedness to NGOs |
| • life skill training |
| • personal factors like smoking status, khat and alcohol use |
| • Parental and partner negative reaction. |
| Operational definition |
| Street children: They are children less than 18 years old, comprising on and of street children. |
| Decision on pregnancy: Determination about continuity or termination of their pregnancy. |
| Street pregnant teens: On and of girls who are 13 to 19 years old and reported being homeless during a current or past pregnancy or street teenage pregnancy is defined as a pregnancy in a young street woman who has not reached her 20th birthday when the pregnancy ends, regardless of women’s marital status or whether she is considered adult by local statutes. They are children in difficult circumstances, who struggle to survive in the city. |
| Children on the street: Those children who primarily engaged in economic activities of street. They are children of either sex falling with the age group of less than 18 years working or begging on the street, but living with their parents or visiting their parents regularly. |
| Children of the street: Children of either sex who are within the age group of less than 18 years and, who are both economically and socially engaged in street life. These children live and work on street without any kind of control or assistance from parents or relatives. |
| Risky sexual practice: children who had sex earlier than 18 years of age, or have sex with non-regular sexual partner, or exchange sex for money or have more than one sexual partner or use condoms inconsistently. |
| Rape: is defined as any non-consensual of penile penetration of the vagina or anal by physical violence or by threat of harm, or when the victim is incapable of giving consent due to drug or intoxication of alcohol. |
| Survival sex: offering sex in exchange for food, shelter, drugs. |
| Drug/substance: Any substance that when taken into the living organism may modify one or more of its function. In this study the concept of drug covers substances of alcoholic drinks, tobacco, khat, hashish and benzene. |
| Ethical consideration |
| First the study protocol was approved by the Addis Ababa University, School of Allied Health Science Department of Nursing and Midwifery Research board. The objective of the study was also being discussed with organizations that were working with children and Addis Ababa police crime protection sector (child protection unit-CPU). |
| All participants were be given full information regarding the purpose of the research, what was expected from them and how long the interview expected to last .In addition the research was not expose children to any physical and emotional stress. |
| Results |
| Characteristics of participants |
| Forty-five respondents participated in the ten focus group discussions while fifteen respondents participated in the in-depth interviews. The participants in the study were teenage mothers aged 13–19 years. Majority were not engaged in any employment. Eighteen street teenagers identified themselves as Amara. Twelve women identified themselves as Hadiya and ten women as Oromo and the rest five were Gurages. On average, the participants had less educational background only one participant joined grade ten among the Fortyfive participants.All of the participants described troubled relationships with parents, including histories of neglect, physical abuse, and parental drug problems (Table 1). |
| Pregnancy situation |
| Eight of the Forty-five women were pregnant at the time of the interview (between eight and 30 weeks gestation) but the rest were those who have previous pregnancy history in the past. Five of the thirty seven women whowere interviewed about the previous pregnancy had experienced multiple pregnancies. Two women reported two pregnancies; one woman reported three pregnancies, and two women reported four pregnancies. |
| Eighteen of the pregnancies were voluntarily terminated; three ended in miscarriage; and sixty were carried to term. Of these sixty newborns, only nine remained in their parents’ custody. The remaining seven newborns were removed from their birth mothers by death before celebrating their first birth day due to different unknown cases (Table 2). |
| The main themes of the result |
| We read all participants filled questionnaires and transcribed the data collected from thein-depth interviews to get a general sense of the whole ideas presented. Next, significant statements and phrases pertaining to the phenomenon being studies were extracted from each transcript. Meanings were then formulated from the significant statements. Then the meanings were organized into the following 9 themes. The key challenges participants describe for decision making on the pregnancy process are as follow:- |
| Incompatibility of their current lifestyle with the responsibility of raising a child: The street pregnant teens emphasize as they are particularly faced untold hardship and danger on the streets. They lacked food, clean water and adequate health care, although these are very essential for pregnant women. Living and ‘working’ on the street was a terrible toll on them. They were repeatedly rising as they were often prey to every physical and moral danger than other group of street. So, they cite as thinking such precarious childhoodis the biggest challenge to them to deciding to have child. The participants also noted as life style of pregnant street girl members is an environment that may be harmful for raising a healthy child and conducive for the generational transmission of delinquency. “I’m not going to give birth being in this dark life because there is nothing good on street that was what I was thinking dawn and dusk that was why I decide on my life and I have taken 12 amoxicillin with coca cola to abort”( 16 year-old girl) |
| Worrying about further complication of their life trajectories by early parenthood: The participant also noted that street teenswho become pregnant do so at a time in their developmentwhen they are least prepared economically, and emotionally to care for an infant. They typically lack gainfulemployment, and many raised as unstable conditions in which economic hardship is their common life.Thinking about worsening of this economic hardship by early parenthood is among the issues that challenge them to decide. |
| Memorizing traumatic child hood experience: They describe as neglect, violence, abuse and exploitation by their biological or stepfamilies lead them on our streets, and others were the offspring of prostitutes, handicapped street children.And articulate there is nothing that inspires them to stay till term and give birth. This is another thing that challenges them for decision.They often relate pregnancy tensions to legacies of conflict from their family-of-origin. A 16 years old girl with 6 months old son stated that; she was sexually abused by her stepfather. Her partner was brutally abused and neglected by both his foster families and he doesn’t know his birth families. She also explained: The kind of childhood we had, is what we ever thought about and we have no role models for parenting because our background was not stable. So it’s obvious that neither of us was going to feel good about the pregnancy. |
| Couple’s reaction: Despite having “husband” without their will due to fear of being raped by many street, over half of the them [33] were in long-term relationships and considered themselves to be “street married” referring to their partners as “my husband.”They presented their pregnancy decision-making as a collaborative effort within the couple. All reported confronting profound relationship difficulties however, triggered by the pregnancy decision-making process. For example A 17 year’s old girl stated that: “When we were making the decision about whether to abort or to continue the pregnancy that was the time that violence between us was involved.”Arguments, physical violence and not accepting the pregnancy, occurred most frequently between partners who disagreed about whether or not to terminate the pregnancy. This was particularly true for those couples who separated as soon pregnancy is known or during the pregnancy decision-making process. Nevertheless, despite the dissolution of several of the relationships, some of the participants who were initially partnered continued to discuss the outcome of the pregnancy with their partners. Although couples negotiated or argued over the outcome of the pregnancy, the majority of Participants agreed that the woman is the one to make the final decision about the pregnancy.Participants expressed not to replicate the troubled childhoods they had survived, but they were enforced to give birth due to fear of the complication of unsafe abortion they saw on their peer though they actually need to abort. They also cited religion as one big factor that put them in dilemma and prevents them not to abort. Whatever the outcome of the pregnancy almost all participants had cited the difficulties of their situations and listed money, burning of their plastic shelter by police while they were sleeping, losing their job due to pregnancy, getting pregnant from very close family, and psychopathology of the way they get pregnancy as the primary reason enforcing them to perform un safe abortion though they know as it is life threatening. |
| The decision to terminate—as participants discussed past, present, and future routes, we were able to identify a crucial point in their decision-making. For eighteen pregnancies that were voluntarily terminated, the common theme was the incompatibility of their current lifestyle with the responsibility of raising a child. These women cited their painful origin; darken current life, and unknown destination to be cruel on their life and their fetus life. |
| A 18 year-old woman who had just recently arrived in Addis Ababa from Jimma, explain her decision to terminate her pregnancy as follow;- “I was very sad I was weeping for three months I don’t know what to do my “husband” had left me on the day he knew my pregnancy, I don’t want to tell my family because I don’t want to make them happy because what they expect is my failure. I don’t want to give up my lifestyle. I feel like I wouldn’t be a pregnant I just ignored it and it go away itself.” Another 19 years old girl also explained that during her pregnancies, she was taking much local drink (‘teji’ and ‘tella’) hopefully she would precipitate a miscarriage. This indicates when pregnancy happens to a lot of street girls they don’t know what to do so, and the situation appeared beyond these teenagers ability to cope. |
| Financial constraints to access an abortion: The five women among who chose to stay till term of their pregnancies reported that they were unable to access an abortion because of financial constraints. This enforced them to use other remedies for pregnancy termination, but unsuccessful. For Example, a 28 week pregnant woman who had confronted unwanted pregnancy used large doses of amoxicillin that torture her a lot with gross vomiting , due to lack of help from anybody to get money to abort. |
| Worrying about uprising their unborn baby: Among the participants of this study, only sixteen who were pregnant previously and three who are pregnant during study decided to be parent. In each of these cases, all of them was unable or dislike reuniting with their family because of histories of abuse and/or neglect. From the early beginning they think whether their heart forgive for the past and reconcile for the uprising of the baby they were/are going to born. “The relationship with my mother has been the one between enemies. I feel much safer when I’m not around her. . . . So having had all that experience with my mother just may cause me to do the same thing to my baby because I’d been the kid who was put in the fire at home . . .so I was completely worrying about what difference the time would bring, but thanks to God know I love my babies just like my soul.”(a 17 year-old woman with two sons). The other reason why they raised worrying about how to grow their unborn baby as a challenge for decision making werelack of finance, not knowing the father of their baby, the environment they are living like smoking, chat chewing, and working commercial sex “(business)” in front of their child just like their peers who are actually doing such kind of action, because they had no access to support from parents or other kin. Most of them were unwilling to give birth at such an abusive environment where there is mass rape, urine of intoxicated passengers, but they wish they give birth. For example, a 13 years old girl said: “there were long-term goals for me , I came from Butagra to be employed as maid and help my aged, and very ill mother at 12 year but the birr that I got was to little even to change cloth for me so after working for 5 months one day I consulted one of my elder girl who stayed for five years in Addis working” business” for three years and she advised me to begin that shameful work, then after I have decided and begun to be with her to work a “business”(prostitution) but I haven’t figure out what will happen next to it sometimes I use condom sometimes not, and sometimes condom slips .lastly I have got pregnant ,but I don’t know from whom I have got the pregnancy, within a year but I had nothing on my hand because I was sending what I got for my mother every month, think how much it is difficult to born father less child with no relative to help me I have cursed my mother and my friend, feel sad just like losing my beloved lonely mother, but no change things had already happened, being in grieve I have continued similar work to be alive, my friend enforced my to abort but most of my peers other than her discourage me not to do so, and I myself fear death decide to give birth and lie him/her saying your father had died but still now am very disturbed when I think about this just like when I was pregnant this was what make me worried much when I was pregnant next to my mother’s health (A 15 year-old woman with 6months old daughter.) All of them deeply feel bitter about the finance and the harsh street environment where they were going to raise their baby. |
| Problem of shelter and food: All of the participants cited house as the most crucial resource needed during pregnancy more than ever to have a rest after very tiresome on street walking for begging and throughout the night “business work”. Nonetheless, none of them had house during their pregnancy. The rarely available housing options from NGOS like GOAL Ethiopia were for delivered womenonly. All the participants in this research stayed on the street. None of them stayed in permanent structured house. One 18 years old girl reported: “under the plastic near Saint George church”, while the other participant remarked: “I am sleeping on the street throughout my pregnancy periods, because I don’t have any option.” You should not necessarily have to have a house having a roof and walls to be able to have a child. . I think I can rear my kids outside in “plastic house”. (A 13 year-old woman and 7 weeks pregnant). I was impressed through my observation, that they were obviously malnourished, and that they didn’t get adequate food while on the street. One participant said: -if we have money we buy food, or ‘bulle’ because there is no one who give us even ‘bulle’ free of charge.” Another participant stated: -I ask people money, and then I buy food but sometimes I ate only my lunch only”. 18 years old participant also stated that -I am begging for food from the people at hotel sometimes they give me but sometimes they refused me”. Other participant remarked:” I ask passengers for money sometimes I just ask them to buy me food and they buy me only dry bread.” few of them rummaged through rubbish bins for food. All of the participant feel bitter about the problem of food during pregnancy, and they explained as their choice and wish of having different types of food increase during pregnancy but they don’t have enough money to do so. During the interview it was clear that the participants did look starved, and they explained as they went to sleep hungry most of the times. One participant stated: “the bad thing on the street is that I do not eat enough or regularly.” Another participant also said: “ sometimes we get enough but other times not. Sometimes I go to sleep with an empty stomach.” |
| The dangers, violence and abuse encountered during pregnancy: All of them persisted as violence and abuse are part of their daily lives and as these challenge them for decision making. A16 years old girls : when we sleep on the street people come and nag us to perform sex with us though we don’t want to have sex even they try to do it forcefully, especially when we are alone when our ‘husbands’ go somewhere.” One Participant stated: “it is dangerous because I was sleeping one night after getting very tired because I was exchanging cents for birr for taxi drivers throughout the day I think it is around mid-night three of the street boys come and ask me for sex, but I refused them because I was 6 months pregnant during that time. They have frightened me with knife and raped me turn by turn. Beginning from that day always I sleep at 4:00am and wake up at 7:00am and move with those who do business throughout the night though I don’t do like them and also when we have money the boys take it from us.” Another 14 years old girl stated; “the biggest danger is, from polices who comes and burn our plastic shelter while we are sleeping.”Majority of them had bitter experiences of physical exposure to cold and damp due to lack of shelter and insufficient protective clothing, and exposure to violence and physical and Sexual abuse by other adult street dwellers, and the police themselves, are all common physical risks they face. |
| Problem of water for personal hygiene: Personal hygiene was among things they list as a problem to decide to continue pregnancy. One participant said: “you know how much water is important for pregnant mothers than others but let alone my clothes I cannot wash my face regularly because there is scarcity of water especially during winter season.” Another 15 year old participant said: “sometimes I am very ashamed to go on the street because I do not wash my face and clothes when I am very tired to go to river.” I also noted during the interviews, that the participants ‘bodies and clothes were not clean. |
| Results of Focus Group Discussion |
| The eight currently pregnant teenagers and another second group of 6 street teenagers were recruited on volunteer base for FGD. The discussion was mainly focused on the reasons of coming to the street, where they spent most of their day times and the most common problems that street teenage pregnant face today. |
| The discussion was started by asking the general question “why they joined the street life.” almost all discussant mentioned similar reasons like searching jobs, conflict with family, poor family, death of family, pregnancy, and dispute with their partners etc. most of the participants mainly mentioned sexual related reasons like rape attempt, voluntary and involuntary unsafe sex resulted unwanted pregnancy. In connection to this, one participant stated the following: |
| “My aunt brought me from rural to Addis Ababa by convincing to attend school. I started life in Addis serving my aunts family and attending the class. But my aunt’s husband asked me many times for sex .I became feel bad when he come to home from work. One day when my aunt went to market, he came and tried to rape me. I escape from him and run away and never go back, start street life ( 17 years old girl with 1year old daughter).” |
| Next to the general question about the reasons for streetism, discussants were invited to discuss about commonly faced problems during their pregnancy. All participants were agreed that being street girl and getting pregnancy is a problem more than problem. |
| 18 years old participant had the following to say in this regard; “we have plenty of problems like risk of contracting HIV/AIDS and sometimes sexually abused and psychological problems, but getting pregnancy is the worst of all these problems we remember as we got pregnant when our abdomen gets larger or our menstruation stopped during that time, we don’t know what to do some of us try suicide, some of us feel in grieve and cry for months.” |
| One participant explained: “No one of us want to give birth being in this dark life because there is nothing good on street that was what we were thinking dawn and dusk that was why we decide on our life, and the bad reaction from our partners when we told them about our getting pregnancy are the major problems street mothers face during their pregnancies.” |
| As most of the participants mentioned, sometimes they didn’t know when and from whom they had got pregnant. |
| 16 years old street girl had the following to say: In the mid night there would be alcoholic boys and if they get female sleeping on the road, they will have group and unusual sex so some of our friends got pregnant in such away, but they don’t know from whom they have got the pregnancy, but they had nothing to grow that baby… think how much it is difficult to born father less child so they worry about it throughout the pregnancy period. |
| Sexual abuse and exploitation while in pregnancy is also one of the problems affecting the physical, social and psychological wellbeing of street teenagers during their pregnancy. For example a 17 years old girl have said this: sexual abusing is common in Addis Ababa, no one respect or undermines you because of your pregnancy but especially think how much it is boring thinking about the unwanted pregnancy we have currently, and what is happening to us. She was 8 months pregnant, was gone to river to wash her cloth .In the mean time someone who was HIV carrier had taken her to hidden place and had sex with her, she had no power to punish him the only option for her was crying and crying. |
| Another question was about how street teenage girls negotiate traumatic childhoods characterized by neglect, physical violence, and emotional and/or sexual abuse by their family or institutional caregivers with becoming mother, and diverse responses were given like:- |
| 15 years old girl said: I don’t know what to do when I think what my stepparent did on me and when I think what type of mother I will be it is better to kill myself rather than being such a parent. |
| The next issue that was raised for discussion was about their general recommendation regarding improvement services to street teenage pregnant girls start the discussion by blaming the existing services. They agree that they are totally disconnected from the existing service stream. |
| A 17 years old girl forward the following idea concerned this issue. Governmental and nongovernmental organizations declared more as they did a lot on street children, but we street teenage pregnant particularly face the worst hardship and danger on the streets we lack at least basic needs like food, clean water and adequate health care, although these are very essential for us. |
| Other 19 years old girl with three years old son, and 5 months old daughter: I can say that not enough is being done to address our problem and we are is remains ignored by government it is only NGOs like Goal Ethiopia who are helping us little, I recommend if the government and the concerned bodies and even community urgently address our problems. |
| Participants tried to mention some effective strategies to address their dominant problems like cloth, food and shelter through at least providing the house and food in group during their pregnancy and post natal period and education to aware them how to prevent pregnancy. |
| Discussion |
| Among the participants of this study, only sixteen who were pregnant previously and three who are pregnant during study decided to be parent. In each of these cases, all of them described different factors that made themchallenged. Among the factors financial problems, not knowing the father of their baby, the environment they are living like smoking, chat chewing, and working commercial sex “(business)” in front of their child, mass rape, and urine of intoxicated passengers etc were commonly raised. This was confirmed in another study conductedin Kampalawhich found that pregnancy is a major destabilizing event in the lives of all homeless pregnant teenagers and sadness on the street was a recurring emotion felt by them all due to worrying about how to grow their baby [30]. |
| Teenagers who chose to continue the Pregnancy experienced significant barriers to accessing prenatal services. The most notable obstacle they reported explicitly was distrust of institutions and fear that clinical and social service providers would snatch their baby. Although eventually some of the women who chose to attended prenatal care, they stated that they delayed seeking clinical services because of the negative experiences they share from other homeless youth who think loss of custody of their newborns but they have no other tangible reason. The findings of this research is confirmed bythe study that was done on street girls of Tanzania which found that in a higher rate of participants the most notable obstacle they reported explicitly not to have antenatal follow up was distrust of institutions and fear that clinical and social service providers would immediately report them to Child Protective Services [34,5]. |
| Some of the participants claimed to recognize that they would have to leave homelessness to be good parents, but they think about traumatic childhood experiences and resisted incorporation into mainstream housed lifestyles. This finding is in contrast to the study that was done in Berkley that stated in majority, Pregnancy bring into the focus hope for change, present poverty, and past traumas and those who chose to attempt to become parents were convinced they had the personal ability to transform their lives despite their lack of access to material resources, and join their family of origin [35]. |
| All participants except those who don’t know from whom they got pregnant described their partners as the most important person in their pregnancy decision-making process. Furthermore, in most cases, the relationship within which decision-making was taking place was characterized by emotional, verbal, or physical abuse. This finding was associated with the study that was done in Dese town and that stated the husband of street girl play the major role on deciding what the outcome of the pregnancy and as pregnancy causes separation of couples [28]. |
| Among study participants Very few (3 of currently pregnant teenagers) decide to continue their pregnancies and hoped they would become stable parents. These participants viewed the pregnancy as a promoter for transforming their lives and overcoming past traumas. This indicate very few participants adhering to an optimistic belief that despite their current unstable living conditions, the future would offer new opportunities by providing a better childhood for their future children than those they had experienced, and recognized that they needed to drastically change their living situations by promising for their child. This is consistent with the study that was done on street girls in Berkley and that stated the majority of participants chose to continue their pregnancies and hoped they would become stable parents. Many viewed the pregnancy as a catalyst for transforming their lives and overcoming past traumas [35]. |
| All of the participants described homelessness and survival on the street, and often mentioned poverty, their pathetic background and all harsh life they face on the street as being incompatible with pregnancy. In some cases, participants found their situation so devastating, and they decide to ignore the pregnancy by increasing their use of drugs like amoxicillin and local alcohol like” teji and tella.” The study done on the situation of street girls in Kampala also confirmed this by stating that the problems street girl face during pregnancy is beyond what they withstand and that is why they tried many life threatening way of abortion [30]. |
| Among the eighteen women who chose to terminate their pregnancies via abortion and the three who miscarry, all reported that none of them found legal abortion services. Similarly a study done on the victimization of street children in Addis Ababa, described as pregnancy represents a liminal life crisis in which many of street teenage pregnant unrealistically seek to overcome challenges that have plagued most of their lives through absolute individual will power and everything beyond what they withstand because they have less awareness about legal abortion and they are far from the community infrastructures including clinics [12]. |
| Almost all participants who choose to terminate their pregnancies, took their own remedies of un safe abortion and they encountered gross problems and many of the participants described as they use potentially life-threatening methods to induce abortions due to lack of money and awareness to access abortion service. Similarly the study done on the situation of street girls in Kampala also confirmed this by stating that the problems street girl face during pregnancy is beyond what they withstand and that is why they tried many life threatening way of abortion [30]. |
| From this study it is obvious that the participants didn’t have a reliable shelter in which to stay while on the street. This is among the challenges they raised to continue or terminate their pregnancy. These findings are in accordance with what was found by other researcher in Dareselam that says, children living and working on the streets do not have permanent shelter and live a nomadic lifestyle. They often use drainpipes, alleyways, vacant lots, parks, abandoned cars, shop entrances, stairways, for shelter and places to sleep or will erect makeshift shelters or sleep under cardboard boxes and newspaper covers. Sometimes they go to a place of safety at night during the winter months to sleep and eat while they work and beg on the streets during the day. Another study that was conducted in Londonalso said that one of the main characteristics of children of the street is that they live alone in streets, without proper or reliable shelter [36,31]. |
| Strengths and Limitations of The Study |
| Strength |
| • This research considers marginalized and neglected group of people about whom the information on the challenge they face during pregnancy is lacking. |
| • The reliability of the data was maintained by using pre-tested questionnaire, anddaily clearance and analysis of the data by the principal investigator. |
| • Combining semi structured questioner, in-depth interviewee and focused group discussion to triangulate the findings arethe strength of this study |
| Limitations |
| • Un generalizability of the results to other homeless populations. |
| • Limited number of participants |
| • Recall bias introduced in discussing of past pregnancies |
| Implication |
| • Such research could lead to the design of wrap-around services that meet the needs of this marginalized and neglected group of people at their vulnerable time. |
| • Create a deeper understanding of the complex process of pregnancy decision-making. |
| • FGD may help teens cope with the aftermath, and heal them from their traumatic experiences |
| Conclusion and Recommendation |
| Conclusion |
| • The same factors that lead to homelessness and to pregnancy also lead to challenges in decision-making, and in becoming a parent. |
| • All most all of them reported histories of childhood sexual abuse. |
| • The majority of participants had no attempt to leave homelessness. |
| • Most of street teenage pregnant mothers source of income is begging |
| • Although homeless teenagers have experienced a great deal of stress at a very early age, they are often encountering the worst challenge to survive on the street during pregnancy. |
| • the pregnancy decision-making process is a life-altering moment for many teenage girls |
| • Little is known regarding how marginalized homeless teenagers are affected by pregnancy. |
| • pregnancy can be a powerful motivator for change and selfevaluation |
| • Regardless of the outcomes, all the decisions made by the participants were framed by structural constraints. |
| Recommendation |
| • Safe, free abortion services must be guaranteed to prevent lifethreatening self-induced abortions decisions. |
| • When delivering non-judgmental, honest, and supportive counseling on termination options. |
| • service provider must address the fact that a pregnant woman’s decision-making process at this stage often occurs in the context of an unstable, violence-prone, homeless male partner, even if that partner is not visible to the service provider. |
| • Additionally, the same panel of services that are offered to women who choose to become parents must be made available to women who choose to terminate their pregnancies |
| • More research is needed to understand better the window of opportunity that pregnancy presents, regardless of outcome, to engage youth at a time when they strongly desire support. |
| • Providers should inquire about the youth’s relationship with her partner, explore issues of safety, provide support for decisionmaking and, when appropriate, include the male partner in discussions and medical and/or social services appointments. |
| • Providers working with, pregnant homeless women may want to inquire regarding the woman’s relationship with the father of her child and how this relationship may be positively and negatively affecting her decision-making. |
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| Table 1 | Table 2 |
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