Family planning (FP) is a key component of primary health care (PHC). Nurses are the first source of FP information to women outside their social context. There is a paucity of research regarding clients’ lived experiences of FP, particularly understanding both the client’s and the healthcare worker’s experiences in the same clinical context and community.
This study aims to explore the lived experiences of nurses and female clients regarding FP services at PHC clinics.
Two PHC clinics in a rural sub-district in South Africa.
A descriptive qualitative study using semi-structured interviews was conducted. Clients and nurses were selected using criterion-based purposive sampling and interviewed by female research assistants in a home language in a private setting. Transcription and translation of audio recordings were done. Data were analysed inductively using the framework method.
Ten clients and eight nurses were interviewed, with an equal number from each clinic. The median age of clients was 28.5 years and of nurses was 47.5 years. Four themes emerged: (1) Stigma, culture and the teenage girl; (2) Bad effects – the Big Five, clustered around weight changes, blood blockages and abnormal bleeding, pain, fertility and cancer; (3) FP social dynamics; and (4) FP and the health system.
Family planning is highly moralised and stigmatised. Negative effects of FP were not adequately recognised by the health system. Family planning outreach into the community and dedicated FP resources at clinics were suggestions to improve the service.
This work helps to better understand patients’ experiences of family planning services.
Family planning (FP) forms a key component of primary health care (PHC) and contributes significantly to reducing maternal and child mortality.
A South African (SA) survey in 2016 showed that the overall use of modern contraceptives (female and male sterilisation, intrauterine contraceptive devices [IUDs], implants, injectables, pills, male and female condoms, and emergency contraception) by women aged 15–49 years was 58%, but 18% of women still had unmet contraception needs.
The couple-year protection rate (CYPR) measures the proportion of women aged 15–49 years who are protected against unplanned pregnancies for a year using modern contraception, including sterilisation.
Studies aiming to improve the uptake of LARCs have identified the need to understand women’s perspectives on a particular method. Interventions that improved knowledge of LARCs did not necessarily translate into improved uptake.
When engaging with FP services at a (PHC) clinic, a female client first encounters a nurse, the majority of whom are female and are likely from the same community. This nurse becomes the first source of FP information to the client outside of her social context. She may have herself used FP and may also bring to this consultation her personal experiences, expectations and biases.
For a service that is so dependent on personal decision-making, there is a paucity of research seeking to understand women’s lived experiences of FP.
A descriptive qualitative study using individual semi-structured interviews was conducted at Alma and D’Almeida clinics, two of the largest PHC clinics in Mossel Bay, a rural sub-district in the Garden Route district of the Western Cape, South Africa. Mossel Bay had an estimated population of 95 225 people in 2019, with 53% being female.
D’Almeida clinic, attended by 4000–5000 patients monthly, had three clinical nurse practitioners (CNPs), two of whom could administer all FP methods. There were three professional nurses (PNs), three enrolled nurses (ENs) and two enrolled nursing assistants (ENAs). The ENAs could also administer FP methods under supervision. Alma clinic, attended by 7000–8000 patients monthly, had five CNPs, all of whom could administer all FP methods. There were four PNs, five ENs and one ENA. At both clinics, the PNs and ENs could provide follow-up FP methods once initiated either by a CNP or a doctor. Both clinics offered condoms, oral contraceptives, injectables, implants and IUDs as FP methods, the most used being injectables. All nurses could counsel about FP. Both clinics were supported by a doctor visiting daily.
All nurses involved with FP as well as female clients attending the two clinics were included. For nurses, inclusion criteria were working at the clinic in any category, i.e., CNP, PN, EN or ENA, and having any experience of FP from counselling to administering contraceptives. An exclusion criterion was working at the clinic for less than 1 year. For clients, inclusion criteria were attending the clinic and having some experience of the FP service (from counselling to having used any method). Exclusion criteria were being pregnant, postpartum (defined as within 42 days post-delivery), and younger than 18 or older than 49 years. Pregnant and postpartum women were excluded because their recent experience with carrying a baby may have a biased influence on their choice to receive FP or not. Criterion-based purposive sampling was used to select information-rich participants and to ensure fair selection.
In total, 18 interviews were conducted (10 with clients and 8 with nurses) from July 2020 to April 2021. The interview guides and processes were piloted using two interviews from each clinic in Afrikaans and Xhosa, respectively, as these are the main languages of people living in the community. These interviews showed rich and appropriate data and were therefore included in the data. Following four nurse interviews, data were updated with emerging themes involving specific methods like condoms and sterilisation, perceived ethnic differences in FP use, opinions on whether young clients should not use FP and why, and personal beliefs about FP. Data saturation occurred after eight client interviews and by the eighth nurse interview.
Data were collected by female research assistants using semi-structured individual interviews in a home language. The reason for research assistants was to overcome any language barriers and power differential that could have existed between the nurse or client and the primary researcher as a male doctor. Furthermore, focus group discussions were not chosen for nurses as power dynamics between levels of nursing staff were anticipated. The average length of the nurse interviews was 42 min while that of the client interviews was 20 min. The research assistants translated and back-translated the interview guides, as well as reviewed them for local language appropriateness.
One research assistant was assigned to each clinic but moved between clinics as needed. Both the research assistants were from the local community, in their late twenties, and were both completing a degree in the medical field at an SA university; therefore, they were familiar with the medical environment and were capable of navigating the complexities of medical field research. One was studying for a degree in community and health psychology. The other was studying for a degree in medical laboratory science. Training of research assistants was done by the primary researcher, including feedback and debriefing after the initial interviews, to help refine the quality and depth of the interviews.
Nurse participants were purposively selected by the primary researcher according to the inclusion criteria and were invited to participate. The interviews were done after-hours at Mossel Bay Hospital’s outpatient department so that no other staff member at the clinic was aware of the nurse’s participation. The nurse was not addressed by name throughout the interview to ensure that the primary researcher also did not know who the participant was. For clients, the research assistant stationed at the clinic recruited participants by directly approaching women at the clinic or receiving referrals from health workers. Selected client participants were interviewed at the clinic in a private room. All participants received refreshments and an honorarium. Corornavirus disease 2019 (COVID-19) precautions were followed. A process for referral to the employee wellness programme or the local social worker was established should it be needed following an interview. An orientation session with the clinic staff was done to ensure support for the research assistant and respect for the confidentiality of participants.
Audio recordings were translated and transcribed using an external service. Transcripts were anonymised and quality checked by the research assistant who conducted the interview to ensure quality translation and transcription and retention of meaning. Data were backed up and stored securely on a password-protected online drive, only accessible by the primary researcher. Audio recordings were deleted once the study was completed. The transcripts are kept in a secure repository at the University of Stellenbosch should they be requested by readers or journals. The repository is an online, password-protected database, only accessible by the departmental head.
The primary researcher inductively analysed the data with assistance from the supervisor using ATLAS.ti version 8. The framework method was applied (see
The framework method.
Number | Steps in the data analysis |
---|---|
1. | Familiarisation occurred through reading all transcripts, reviewing field notes and trying to gain a deep sense of the data. |
2. | Codes and categories were formulated, and a thematic index was created. This was reviewed and refined together with the research supervisor. |
3. | All transcripts were coded. |
4. | The codes were charted in order to gather all the data from the same category in one place. |
5. | Each chart was read, and the data were interpreted looking for both the range and strength of themes and their relationships to try and provide an appropriate and coherent explanation of findings. This process was done together with the research supervisor. |
Trustworthiness of the data.
Element | Description |
---|---|
Credibility | Peer debriefing – researcher debriefed with the supervisor and research assistants debriefed with the researcher. Supervisor with experience in qualitative research supervised the process. Triangulation of data between nurses and clients, as well as between clinics, was done to identify themes that are related to each other, which provides an in-depth understanding. |
Transferability | A thick description of the study setting, audit trail and participants is provided. Purposive sampling was done, and data saturation was achieved. |
Dependability | Methods employed are documented in detail. Triangulation between nurse and client groups and between clinics was done. |
Confirmability and reflexivity | Findings between research assistants at the two respective clinics were triangulated. The primary researcher described his credentials, background and relationship to the objective of the study in a reflexivity statement. Potential bias in the researcher and research assistants was addressed and minimised with reflective discussions between the research assistants and researcher, and the researcher and supervisor. |
The primary researcher is a South African male in his thirties working as a Family Medicine registrar in the local sub-district. He has worked at both clinics, as well as in the maternity ward at the district hospital. He is interested in preventing unplanned and unwanted pregnancies by enabling appropriate FP choices and increasing FP uptake at PHC clinics. He believes that social factors and local beliefs highly influence clients’ use of FP as well as nurses’ provisioning of them. In attempting to minimise bias, the researcher frequently reflected on his own judgements, practices, beliefs and assumptions during the study process with the supervisor, which helped him to be reflexive and aware of potential bias.
Ethics approval was granted by the Health Research Ethics Committee of the University of Stellenbosch (S19/07/129). Permission was granted by the Research Committee of the Department of Health of the Western Cape (WC_202003_024), the district manager and the district hospital management. Informed consent was obtained from all study participants.
Ten clients and eight nurses were individually interviewed. The median age of clients was 28.5 years and of nurses was 47.5 years (see
Demographics of study participants.
Participant | Age | Clinic | Relationship status |
---|---|---|---|
Client_01 | 28 | D’Almeida | Single |
Client_02 | 27 | D’Almeida | In relationship, not living together |
Client_03 | 25 | Alma | Married |
Client_04 | 32 | D’Almeida | Single |
Client_05 | 21 | Alma | Single |
Client_06 | 43 | D’Almeida | In relationship, living together |
Client_07 | 33 | D’Almeida | Divorced, in relationship, not living together |
Client_08 | 29 | Alma | Single |
Client_09 | 19 | Alma | In relationship |
Client_10 | 36 | Alma | Married |
Nurse_01 | 40s | Alma | - |
Nurse_02 | 30s | Alma | - |
Nurse_03 | 40s | Alma | - |
Nurse_04 | 50s | Alma | - |
Nurse_05 | 50s | D’Almeida | - |
Nurse_06 | 30s | D’Almeida | - |
Nurse_07 | 50s | D’Almeida | - |
Nurse_08 | 40s | D’Almeida | - |
Major and minor themes.
Major themes | Minor themes |
---|---|
Stigma, culture and the teenage girl |
Moralising and stigmatising FP. FP leads to sex, babies lead to FP. Culture and FP. Teenagers dominate the conversation. |
Bad effects – the Big Five |
FP makes me fat. FP blocks blood or makes me bleed. FP causes pain. FP messes up my fertility. FP might give me cancer. |
FP social dynamics |
Education and self-determination. Caregiver responsibility. Rape, abuse and a sense of safety. Teen mommies and sugar daddies. |
FP and the health system |
Clients and nurses value efficiency and respect. Dedicated FP resources. FP outreach. Nurses are kind. |
FP, family planning.
There was a pervasive stigma about FP that was deeply associated with moral ideas around sex:
‘I think there is still a huge stigma about the prevention [
This stigma was also shared among peers:
‘… there are a lot of young girls whose peers are discussing them [
If a teenage client is accessing FP, she was deemed sexually active or even promiscuous:
‘
‘… when my child comes for the pill or the injections, people are going to talk about it and say that my child is loose before her time.’ (Nurse 8, D’Almeida clinic, Age 40s)
Some were worried that their parents would assume they are sexually active if they use FP:
‘… they are scared because their mommies must not know that they are coming to the clinic because they are not sexually active … if I tell my mother … then [
The majority of clients were first introduced to FP only after their first baby:
‘I was 15 when I fell pregnant … back then parents didn’t talk about prevention. My mother never spoke a word about prevention, but the moment that I gave birth to my child it was only then that I heard anything about prevention.’ (Client 6, D’Almeida clinic Age 43)
There was a belief in the community that FP being used by teenagers led to early sexual debut and gave them ‘permission’ to have sex, or even encouraged it:
‘… they feel ashamed … sometimes parents … that I chat to everyday say that they can’t put their child on FP because it would give their children reason to be sexually active …’ (Nurse 6, D’Almeida clinic, Age 50s)
‘… [
At the same time, nurses reported that local schools believed that FP leads to sex:
‘… schools don’t actually want us to come and talk about [
Some nurses believed that young teenagers should not be engaging in sex and so FP is not needed if abstinence is followed. However, many clients and nurses felt that barriers to teenage FP should not exist, even advocating this from personal experience:
‘But I as a parent feel that … it’s pointless to try and hide it [
‘I was a teenage mom and I wish I had that courage to go and say that I want to use FP, but I was too afraid to do that because of the attitudes of nurses … you know, when the client has that first point of contact and she gets that attitude, she is not coming back.’ (Nurse 2, Alma clinic, Age 30s)
A solution lies in what one nurse succinctly said:
‘I really feel that FP should not be hidden. They should do a lot more outreaches … make it fun, don’t present it as a moral, ethical dilemma which puts unnecessary strain on the teenagers.’ (Nurse 8, D’Almeida clinic, Age 40s)
Half of the nurses reported that differences in cultures influenced those accessing FP. For the purposes of this research, culture was understood to mean an umbrella term encompassing the social behaviour, norms, beliefs, customs and habits found in a society. Differences in requesting FP seemed to come from community-based ideas regarding opportunity, education and self-determination:
‘I think what happens now is that the [
‘… it is not a cultural thing, it is just a social thing … there is this mindset in [
Stigma seemed to play a large role in different communities:
‘… there are groups in the community who would bring their daughters to the clinic for FP at an earlier age to prevent them from getting pregnant … I would think it will mostly be [
‘When I was growing up my mother never discussed FP with me. I had to learn about that when I started my nursing training. Our people don’t really like to use FP … I suppose it is tradition …’ (Nurse 4, Alma clinic, Age 50s)
Despite the above, some nurses believed that there were no cultural differences regarding accessing FP:
‘All the young ladies are visiting to protect themselves from early or unwanted pregnancies, it is not really race or religion related.’ (Nurse 5, D’Almeida, Age 50s)
Seven of the eight nurses mentioned teenagers at the beginning of their interview, despite the interview guide not mentioning teenagers. The interview guide was set up not to prejudice nurse interviewees towards teenagers but allowing for it to emerge. While this study was limited to adult women of reproductive age and their own experiences, participants were encouraged to express any thoughts that they felt related to FP.
Nurses expressed concern about teenagers under 15 years of age requesting FP. This varied from them believing that such clients are too young to engage in sex, to concerns about the long-term effects of FP on young bodies. Some nurses have turned such clients away without providing FP:
‘Those early ages like twelve, thirteen, I feel like it is still early for them, that’s my opinion. But if they come, you ask her to come with an adult. We are unable to give her at that age.’ (Nurse 1, Alma clinic, Age 40s)
‘… before I administer anything at that age, I always ask why are you on this FP … because you are so young … your womb must grow to become a woman … what are we doing with FP? We’re going now to control this young child’s hormones.’ (Nurse 3, Alma clinic, Age 30s)
Importantly, other clients have noticed this attitude towards young teenagers.
‘… sometimes it is weird when a 14-year-old girl comes in here, the nurses are always worked up about it. But there is a stigma about the whole story.’ (Client 4, D’Almeida clinic, Age 32)
This concern about young teenagers was not universally shared. Other nurses felt that it is good that young people accessed FP, whether they are sexually active or not:
‘… a teenager will come in for [
Five minor themes can be clustered around perceived or real side effects of FP (see
Perceived or real side effects of family planning.
Minor themes | Quotations |
---|---|
2.1 FP makes me fat: |
|
2.2 FP blocks blood or makes me bleed: |
|
Although some women simply preferred to menstruate, for many amenorrhea was a concern that seemed to emanate from ideas of blood being blocked inside and was also associated with the belief that this was ‘dirty’ or ‘dead’ blood. | |
Clients were often concerned about amenorrhea and blocked blood but these were underreported as client concerns by nurses. In contrast, nurses tended to over report abnormal bleeding as a client concern. | |
2.3 FP causes pain: |
|
2.4 FP messes up my fertility: |
|
Regarding male partners’ influence on FP, they were mainly concerned about fertility, with some worrying about weight gain and blood being blocked. | |
2.5 FP might give me cancer: |
|
Two of the eight nurses (one from each clinic) believed that FP in young women led to cancer. One nurse referred to a 50-year-old client who presented with abnormal bleeding and had used FP from her teenage years. |
FP, family planning.
The use of FP by young women seemed motivated by their desire to study and determine their futures. When asked when was the first time she heard about FP, this client responded with ‘while being at school’ and further said:
‘So that I don’t have a child because I am still young. I had to study first.’ (Client 10, Alma clinic, Age 36)
Nurses reflected on this when asked about the age groups that attend the clinic for FP and why:
‘… like from the 20- year age are women that are becoming more emancipated and liberated so they want to go and study, so they get to choose – they get to plan.’ (Nurse 2, Alma clinic. Age 30s)
‘I think one reason is that they thinking about their future. A lot of our younger community members see how our parents suffered, because they got us so early … We really want to be more successful.’ (Nurse 6, D’Almeida, Age 50s)
When asked whether she thought that FP helped the community, one nurse said:
‘… if you have a teenage daughter in your house and … if she is well-informed and she uses her FP then she can complete her schooling and go for her studies without being kept behind by an unplanned baby or family.’ (Nurse 8, D’Almeida clinic, Age 40s)
Many women reported either their caregivers (mothers, aunts, older sisters) having assisted them with FP, or themselves having assisted their daughters, nieces or younger sisters with FP:
‘My aunt saw that I have grown up. She said I must start using contraceptives.’ (Client 9, Alma clinic, Age 19)
‘I said to my little sisters, come to me if you don’t want to go to your mom about it, then I will go with you [
Clients and nurses reported that parents are bringing their young daughters to put them on FP:
‘… I am just waiting until she is 14. Then I will put her on it, not that I don’t trust her … you know how life is out there … every parent must do that.’ (Client 6, D’Almeida clinic, Age 43)
‘… parents normally bring their children from the age of 12 years and then they want to let their children use FP to prevent teenage pregnancies.’ (Nurse 4, Alma clinics, Age 50s)
Family planning played a big role in providing a sense of safety from the effects of rape in the community:
‘Yes, it (implant) is helping me because anything can happen. Maybe you can be raped, and I know if ever that can happen, I know I am safe …’ (Client 5, Alma clinic, Age 32)
‘… we have a lot of clients, young 12- year- old children that are already on [HIV] medication as a result of sex with older men … maybe they were raped. Rape is quite a big thing in this area. The shebeens are the problem.’ (Nurse 4, Alma clinic, Age 40s)
Family planning provides protection for women in abusive relationships:
‘… when you now sit with the woman … it is like no, my husband threw away my tablets. He wants a baby but I am not ready for a baby … [
Nurses reported that some teenagers value fertility and desire pregnancy at a young age:
‘… there was a 15- year- old and she came to check if she was pregnant … she is 15 and the partner is 19 … she actually hoped that she was pregnant … she is in Grade 9 … I actually saw the disappointment in her face … when she found out she is not pregnant … she left without contraceptives.’ (Nurse 7, D’Almeida, Age 50s)
‘There are still a lot of teenage pregnancies and especially in the lower income communities the younger girls think it is an achievement to have a baby …’ (Nurse 5, D’Almeida clinic, Age 50s)
Some nurses reported that teenagers are forced into illegal relationships:
‘… the kids actually do it for the money especially if there is a financially difficult time at home … they go for the older men who might possibly pay them … they come to the clinic as a group who uses the same kind of preventative measures, because the older men pay them for [
Clients understood the dynamics of a clinic; however, because of work and family demands, they could not accommodate long waiting times. This client asked her 9-year-old to take care of her 5-year-old, lock the doors and wait till she quickly returned from FP:
‘… it really took too long and I also have duties that I need to do at home. I have children waiting for me.’ (Client 1, D’Almeida clinic, Age 28)
Clients felt the long wait to be unnecessary for something quick that they came for frequently. The nurses shared this view:
‘Other times you had to sit and wait which was unnecessary. They could have helped us first. It is just your birth control that you are coming for.’ (Client 2, D’Almeida clinic, Age 27)
‘You find people for FP having to wait for a long time yet FP doesn’t take long. So, it is not really okay. I wish we can do better.’ (Nurse 1, Alma clinic, Age 40s)
Some clients chose to spend money on transport to attend a more efficient clinic or pay for FP by attending a private pharmacy instead:
‘I thought about getting my file transferred [to a nearby clinic], because I don’t have to take a taxi. It is 20, 30 meters from my house … But when I saw that service, I said no way … the service is just not good enough for me.’ (Client 6, D’Almeida clinic, Age 43)
‘I am on chronic medication, so I come every two months to collect my tablets … I work so it will take too long to come to the clinic [for FP] and then go to work. So, I get [FP] there at Clicks (a private pharmacy) and then I walk over the road to work.’ (Client 4, D’Almeida clinic, Age 32)
When asked how the service can be improved, every nurse from both clinics felt that FP should have dedicated resources, including a specific nurse, room and consulting times:
‘We do not have a specific room where clients can go for FP when they arrive at the clinic, then they have to sit and wait in the queue – FP should be a fast and efficient method of in and out.’ (Nurse 4, Alma clinic, Age 50s)
When asked whether there is enough time to advise clients adequately, the overwhelming answer was no. Nurses valued efficiency and respected their clients’ time:
‘… every point of contact … FP is provided … the client has a one-stop service. If she is coming with her baby that’s sick, the sister in the baby clinic room will administer her FP … if she is coming for a dressing, she can get it there … [
‘In the past … you only produced your clinic card and your name is entered into the register, you don’t have to wait for your file … [
Many nurses suggested that FP outreach should be considered:
‘[
The majority of clients have had a positive experience with nurses regarding FP:
‘She is good and kind … everything she does, she is kind. She has never been rough or maybe shout at me. If I don’t understand English well, she explains till I understand.’ (Client 3, Alma clinic, Age 25)
‘They are always honest, they always tell me what they are going to do, how they will do it. They don’t do things first and then explain to you … I don’t feel uncomfortable asking them something or shy or anything like that … that is what I like about the clinic.’ (Client 6, D’Almeida clinic, Age 43)
Clients felt that nurses took time to answer their questions and even explained reasons for delays:
‘Like the nurses … explained to us now, there are only two of them … there is a sick child … be a little patient, we have a sick patient, we have to just see the older patient first and there was always an explanation …’ (Client 6, D’Almeida clinic, Age 43)
‘When you come on your appointment, they … will take a few minutes to sit down with you and then ask you questions.’ (Client 5, Alma clinic, Age 21)
‘If they give you an injection … if they give you tablets [
The aim of this study was to explore the lived experiences of both nurses and female clients regarding FP services at PHC clinics in a rural sub-district in South Africa. Four major themes emerged: (1) Stigma, culture and the teenage girl; (2) Bad effects – the Big Five, clustered around weight changes, blood blockages and abnormal bleeding, pain, fertility and cancer; (3) FP social dynamics; and (4) FP and the health system.
In a social milieu where teenage sex, and therefore FP, has been highly stigmatised and regarded as immoral, there was a corresponding belief in the community that FP at a young age gave teenagers the impression that sex is appropriate and can be explored. Many nurses, who were from the same community, also held these beliefs and brought them into their practice. Participants also reported that schools prevented FP services on site, while many parents have reported to the nurses that they were concerned their children will be stigmatised if they receive FP. These are not uncommon, as a study in Cape Town about sexual and reproductive health (SRH) described a nurse being conflicted by providing a currently sexually inactive teenager with condoms, as it could be viewed as permission to have sex.
The majority of clients reported that they first encountered FP after their first child. Paradoxically, nurses believed that FP helped young women to complete their education and determine their futures. Clients in general, and family in particular, supported this idea, many of whom have since assumed responsibility for FP for the younger women in their care. A study on stigma and unmet FP among adolescents in sub-Saharan Africa described internalised stigma, the subjective feeling of being devalued or marginalised, and enacted stigma, the acts that devalue those stigmatised, as culminating in the community idea of the ‘bad girl’.
The cultural differences regarding opportunity, education and stigma that emerged seemed to be restricted to the local context as research has not been found elsewhere to corroborate these findings. However, a 2004 study looking at contraceptive use in late-and post-apartheid South Africa found that among some groups of sexually active women who have never been married, the use of FP before marriage was high, while for other groups of women, this was found to be low. After marriage, for both groups, FP use rose after the birth of the first child.
The majority of bad effects from FP centred around the five minor themes. As reported in other research, bad effects included both true side effects and myths, and clients learnt about these from family and friends, rather than nurses.
Family planning impairing fertility was a common concern among both younger and older women and resulted from ideas of hormonal or anatomical harm from FP. Some nurses also shared this concern. A study exploring sexual risk behaviour perspectives of teenage mothers in rural KwaZulu-Natal also found that many believed FP caused sterility.
This study showed that parents were so concerned about teenage pregnancies that they brought their children for FP irrespective of whether the teenager was sexually active. The nurses, also concerned about teenage pregnancies, were inhibited by concerns about biological harm and perhaps a latent belief that teenagers should not be engaging in sex. These nurse beliefs represent barriers to FP uptake with abstinence being advised instead of FP, resulting in teenagers being left relatively unprotected from pregnancy.
Family planning was regarded as protective from the effects of rape, intimate partner abuse and illegal teenage relationships with older men. Fertility was highly valued at a young age and also among the most vulnerable women, especially those in so-called transactional relationships, where a pregnancy or child was used to secure her future with a partner. Family planning should play a greater role in such social dynamics, but received more stigma as, in the hope of protecting young women, people advocated ideas like abstaining from premarital sex, thus moralising sex and FP. Male partners influence FP, and as found in this study, clients may have to use FP without disclosing to their partner. This was also found in a study focused on male partner influences on FP.
Nurses unanimously suggested that dedicated FP resources could improve the FP service at their clinic. This has been echoed in research where separate space and timeslots were needed to cater for the SRH needs of teenagers.
Family planning is viewed in a disease-focussed mindset and finds itself in a health system that is ‘sick role-centric’, focused on treating disease rather than promoting and maintaining health.
At the Global Conference on PHC, the Declaration of Astana envisioned PHC and health services that are provided with compassion, respect and dignity, as well as enabling empowering and healthy environments that maintain health and well-being.
COVID-19 delayed research approval, data collection and analysis. Data collection for nurses was deferred to after a COVID-19 wave because of staff shortages and staff burnout which prevented concurrent data collection and analysis as initially planned. Given this delay, member checking, respondent validation and negative case analysis were not done which limit the credibility of the data analysis. It was difficult to find older clients who were willing to participate, with only one out of the eight clients interviewed being above 36 years of age. No nurses between the ages of 18 to 29 years agreed to participate despite multiple attempts at setting up interviews with them. This may have provided unique information on the FP experiences of older clients and younger nurses, respectively. Because of scope constraints on the project, women below the age of 18 years were excluded. However, the data showed that nurses in particular were concerned about teenagers when it came to FP, and clients viewed experiences with nurses as positive, which may have not been the case for younger teenagers. This should be explored in future research.
A guideline should be formulated to enable nurses to effectively and appropriately manage teenagers or their parents requesting FP. No client requesting FP should be turned away.
The Big Five bad effects, and not just biological side effects, need to be focused on and actively addressed in FP education and counselling, including appropriate training for all nurses before they provide any form of FP service, even just counselling.
Dedicated FP resources (a combination, in part or all, of nurse, room and time slots) should be encouraged at clinics, especially for clients presenting specifically for FP. Family planning outreach into communities should be provided.
Topics for future research include exploring teenage clients’ and nurses’ experiences regarding FP; exploring the beliefs, ideas and attitudes that teachers and parents of school-going children have about FP; and using community-oriented primary care principles to address FP stigma in the community.
This study explored the lived experiences of nurses and female clients regarding FP services at PHC clinics in a rural sub-district in South Africa. Family planning is highly moralised and stigmatised with a prevailing idea that FP leads to sex among teenagers. In contrast, FP is also used by sexually inactive women and is viewed as beneficial in completing education and enabling self-determination. Family planning outreach into the community and dedicated FP resources at clinics were suggestions to improve the service. These findings may be useful to inform FP services in similar PHC contexts in sub-Saharan Africa and elsewhere.
The authors express their sincere thanks to the study participants who participated in the individual and focus group interviews.
The authors declare that they have no financial or personal relationships that may have inappropriately influenced them in writing this article.
K.N. conceptualised the research, analysed the data and drafted the first manuscript. L.J. supervised the research and supported the analysis. Initially, Prof. Klaus von Pressentin co-supervised, before moving to a new occupation. K.N. and L.J. contributed to subsequent drafts, and all authors approved the final manuscript.
The Discovery Foundation and Harry Crossley Foundation funded this research.
Data are available in the Department of Family and Emergency Medicine, Stellenbosch University,
The views expressed in the submitted article are those of the authors and not an official position of an institution or funder.