Adolescents’ childbearing dynamics in urban Mozambique: a qualitative analysis in Maputo, Quelimane and Lichinga cities

Despite the implementation of some policies and programs aimend at reducing early and unsafe adolescent sexual activity, adolecent pregnancy and childbearing are major concerns in Mozambique. About 40% of adolescents aged 15 to 19 are already mothers or pregnant. In ltight of this high prevalende of ealry motherhood, this paper aims at dicussing social-economic and cultural factors influencing adolescent pregnancy and childbearing in urban Mozambique. The analysis is based on focus group discussions with adolescents, parents and community leaders in the cities of Maputo, Quelimane, and Lichinga. The analysis reveals that instructions transmitted in initiation rituals, living conditions and the exposure to information and communication technology are the main factors influencing early pregnancy and childbearing among adolescents in Mozambique.


Introduction
Adolescent pregnancy and childbearing are common phenomena in rural and urban areas of Mozambique. Adolescence 1 is a transition period from childhood to adulthood, during which biological changes of puberty and ends with full maturity (Dehne and Riedner 2001;Hindin and Fatusi 2009;Fatusi and Hindin 2010). In this period adolescents develop their sexuality and sexual identity and may engage in unprotected sex that may result in unplanned and unwanted pregnancy (Arnaldo et al. 2014;Hindin and Fatusi 2009;Klingberg-Allvin 2007;Blum 2004;DHS data 2011;MacPhail and Campbell 2001). It is estimated that 11% of all births worldwide are born to adolescent girls aged 15 -19 years old; the majority of these births (95%) occur in low-and middleincome countries and 50% of them occur in Sub-Saharan Africa (WHO 2014;Chandra-Mouli et al. 2015).
In Early pregnancy and childbearing have some health and social consequences for adolescent and her newborn child. Among the consequences are the complications during pregnancy and delivery and the high risk of maternal death, higher than average levels of blood pressure, toxaemia, eclampsia, anaemia, bleeding, obstructed and prolonged labour, low birth weight premature delivery, as well as a permanent or temporary drop out from school for the pregnant girls (UNFPA 2013;2014;Arnaldo et al. 2015;Agunbiade et al. 2009;Atuyambe et al. 2005;Oyefara 2009;Pratt and Okigbo 2002;Izugbara 2015;Fatusi nad Blum 2008;Vundle et al. 2001). Several adolescent """""""""""""""""""""""""""""""""""""""" """"""""""""""""""""" 1 For the purpose of this study, adolescents arte those aged 10 to 19 years old. and a reproductive health program called Geração BIZ introduced in 1999 aimed at reducing the prevalence of early childbearing. These programms were designed to promote sexual and reproductive health for adolescents and youth. Although they have been implemented in Mozambique for more than 15 years, the impact is not yet to be seen. Thus, this papers uses qualitative data collected in three cities to discuss sociocultural factors influencing adolescent pregnancy and childbearing in urban Mozambique.

Data and Methodology
The study uses data collected in 5 neighborhoods: George Demitrov, in Maputo city, Mapiazua and Torone in Quelimane, and Mitava and Ceramica, in Lichinga. . The three cities where selected to represent the three major regions in Mozambique with marked sociocultural differences: Maputo in the south, Quelimane in central region and Lichinga in northern regions. The three regions are different in level of sócio ecnomic development and access to resources, infrastructures and services. As can be seen from the selected presented in Table 1.2, the Southern Region have the best socioeconomic indicators and the Northern Region the worst; the Southern and central regions are predominately patrineal while the north in predominantly matrilineal.
The fieldwork was conducted between February and March 2013. In total 17 focus group discussions were conducted in the three study sites, 11 with adolescents and 6 with parents. The participants were identified in total 110 youth and adolescents (57 females and 53 males) and 52 parents (40 mothers and 12 fathers) participated in the focus group discussions. The level of education varied among both adolescents and parents with generally more educated (primary and secondary) than those with no education among both adolescents and parents All focus group discussion were recorded and transcribed and qualitative content analysis (Smith 2000) was performed for

Adolescent pregnancy and childbearing in Sub-Saharan Africa
The Adolescent's childbearing dynamics involve the pregnancy, maternity, and the determinants and the consequences of those processes.  Mumah et al. 2014;Craig and Richter-Strudom 1983;Pratt and Okigbo 2002). Gupta and Mahy (2003) showed that girls with at least secondary education were more likely to delay childbearing than those with primary education. Mumah et al. (2014) and Machungo (2004) also observed that sexual activity often started at a very early age when adolescents have little information about pregnancy prevention.
Adolescent childbearing has also been attributed to poor use of contraception by the adolescents. Pratt and Okigbo's (2002) on Kenya shows that the higher incidence of teenage pregnancy was associated with low rate of contraceptiive use and disease protection. The gap between knowledge and behavior suggest a need for strategies to reduce risky sexual behavior, among youth and adolescents. pregnancy, the inadequate financial provision, poor parental support, marital promise or peer pressure to get married as the major predisposition factor for teenage pregnancy, found that also, ignorance, sexual abuse, lack of religious commitment, and family instability could contribute to teenage pregnancy. The author also highlights that most of adolescent engaged in pre-marital sex for economic reasons, because their parents were subsistent farmers, which places them within the lower social and economic level in the society, and make them vulnerable to infection and pregnancy compared other adolescents from wealthier families (Ochiogu et al. 2011;Obi et al. 2002).
Apart from in a study in Nigeria, Ankomah et al. (2015), shows that exposure to movies (with scenes often around love, sex, and money), television, friends and peer relationship, and myths are set of factors working as adolescent motivators to engage in sexual intercourse. Parents were found not being precise when giving advice to their 7" " children regarding sexual life. Poverty and the inability to abstain from sexual intercourse were driving adolescents to engage in sexual activity that was leading to an early pregnancy and childbearing. On the other the authors found that religion, disease prevention, the fear of pregnancy, dropping out school, and bringing shame to the family restrain adolescents from engaging early in sexual activity (Ankomah et al. 2015).
Some studies emphasize the parent-adolescents communication about sex and parental disapproval of adolescent sexual behavior as important to restrain adolescents from engaging early in sexual activity, or without protection. It is important that the parents are comfortable, and confident, and also that they know how to discuss sexuality with adolescents (Widman et al. 2014;Guilamo et al. 2012;Miller and Whitaker 2001;DiIorio et al. 1999). Parents form a family which is theoretically defined as a group of intimates, whose interaction generate a sense of home and group identity; complete with strong ties of loyalty and emotions, and experience of a history and future (Segrin & Flora 2011).

Factors influencing early pregnancy among adolescent in Mozambique
Drowing from the literature and our data we will move to present and discuss the factors influencing early pregnancy among adolescents in Mozambique. The factors are gruped into three categories: sociocultural, socioeconomic, and peers communication and information technology.

a) Sociocultural factors
In this section we present the main categories of sociocultural factors that were mentioned by the participants in focus group discussions. Most sociocultural factors are related to puberty preparation and involve conversation between parents and adolescents, and sexual initiation. Bellow we present some extracts of focus group discussion illustrating the mechanisms trhough which they influence adolescent pregnancy and childbearing.

Dialog between parents and adolescents
The dialog between parents and their children can be integrated into the discussion about family communication, which is a way of interaction and values transmission in the family. In the context of sexuality, parent-adolescent' communication about sex has been seen as a way to reduce sexual risky behavior among adolescents, because adolescent who talk with their parents about sexuality tend to have more conservative sexual attitudes and later onset of sexual initiation (DiIorio et al. 1999 As the adolescent girl referred she has never talked openly about sexuality and sex with her mother. The mother tried to explain what the daughter should not do during the period of menstruation. However, all procedure related to the period in which she was (transition from childhood to adulthood), the challenges related to the construction of her identity, how to protect herself from pregnancy and STIs, is not explained. The lack of 9" " this explanation could contribute to risk behavior that may lead to early pregnancy and childbearing.
It has been mentioned that mothers were afraid of being misunderstood by their daughters. Some fears can be observed in the following extract where a mother considers informing her daughter at the age 15 or 16 years because she thinks that it is too early to talk about sexuality, despite the mother recognizing that the adolescents

Initiation Rites
The social status is important pattern in society with each often passing from one status to another during the lifetime. The transition from one to another status is accompanied by rites of passage (Holm and Bowker 1994) -rituals that make significant life transitions of the individuals in a community (Leeming 2014).
We noticed that it is common in Quelimane and Lichinga (cities located in Center and North of Mozambique) the participants to talk about the specific period in which an adolescent is sent to receive preparation for adulthood. Whereas, in Maputo city, South 10" " of Mozambique, the participants did not mention this. However, despite rituals being considered important for the preparation of individuals for a new status (of the life), some participants showed their disappointment regarding the way this process is being performed. The following exsert illustrates this issue: The nhaco 2 I did in my community is different from the one I saw now. They say to the girls that no man is big, and should not worry about his body. When I took my daughter there, I asked, after all, is it was about to teach children to have sex? (Mother of focus group, Lichinga).
This idea that there is no big man for the teen girls can create on the adolescent the idea that is not a problem to date, and consequently have sexual intercourse with an old man. This may contribute to the actual phenomena called catorzinhas, which refer to the relationship between an adolescent girl and an adult man. However, as we know many of those sexual intercourses are transactional, consequently the adolescent girl is not in a condition to discuss safe sex with the use of a condom, exposing herself to the unwanted pregnancy and childbearing. Although the mother recognizes the importantce of sexual initiation, some mothers are not comfortable with the way their daughters are being initiated. In fact in our observation, the information can be interpreted that adolescents are given permission to engage in the sexual activity without precaution.
When I reached puberty, my mother called some women, and they tought me how to wash the penis, to take care of my husband, and to hold that thing [penis]" (focus group of mothers, Quelimane).
There are rituals where they [namalaka/anamalaka] 3 teach you [adolescent] how to care for yourself during menstruation, how to take care of your husband, including the sexual intercourse (focus group of fathers, Lichinga).
3 ""Name"of"given"in"local"language"(eBmakwa)"to"the"woman/women"in"charge"of"initiation"rituals" 11" " corresponds the process of preparation that informs adolescents to be able to have sexual intercourse. Thus, it is not surprising, after the period of initiation rituals, to see adolescents, by curiosity, engaging in sexual activity because they are stimulated to put in practices what they learned about sexuality and try to get married or to have a partner, which usually results in pregnancy (Osório 2005).
For a long time ago there were initiation rites in which the boys were taken to the woods and stayed there for 2 or 3 weeks up to a month. [There they] were prepared to be a man and were informed to be careful with women [because] they bite. [in that time] to get involved with a woman it was the uncle who was saying, now you grew up (Father focus group discussion, Quelimane).
However, the preparation for sexual intercourse does not occur only for girls, but also boys. Once prepared boys could try to put into practice what they have learned, and the first person whom they probably will try to contact in those intentions could be an adolescent girl, often equally unprepared to have safe intercourse. Consequently, both could experiment the effects of early pregnancy, childbearing, and sexual infections.
The last extracts seems to highlight how the initiation rites were done in the past.
However, despite the long period that adolescents were staying in woods, they were not taught all things openly. The persons who were in charge of the initiation rituals taught them using myths, be careful with women [because] they bite, to show, adolescents the necessity to be prepared to engage in sexual activity. At that time, these kind of myths were powerful because communication and information technology were not developed such as now. In these days, the availability and accessibility of some kind of media (that show them pornographic material, soap opera, and movies) even in remote areas; the grown facility of mobility, that allows adolescent to be in contact with other cultures, reduces the power of local myths and encourages adolescents to engage early in sexual activity often with risky sexual behavior.
According to Holm and Bowker (1994), self-identity emerges and grows as we come to grasp our various social statuses and live them out. Rites of passage often help prepare people for that sense of identity that needs to run alongside the social status . During the process of passage, the society took individuals by the hand and led them from one social status to other, conducting them to transit the thresholds and holding them for a 12" " moment in a position when they were neither in one status or another (Holm and Bowker 1994). There is different kind of rites, and one of them is a period of transition called puberty when boys become men and girls become women (Leeming 2014).
According to Osório and Macuácua (2013) currently in many regions, the ritual appear to be differently performed as they were performed before. The extracts of the focus group discussion show that adolescents in different parts of Mozambique transit this period differently since in there is various traditions.

b) Socio-economic factors
Socio-economic conditions are factors that have been explored in many studies, through analysis of the association between ages, residential areas, educational level and income with knowledge, attitudes, and practices related to pregnancy. The common conclusion refers that there is a relationship between early sexual activity and poor and low education level with early pregnancy, and living in rural areas increases this probability. Although this paper presents only qualitative results, there are some extracts that can illustrate the previous explanation, especially the lack of financial resource. For this factor we had these participants words: Women [girls] often say, today I do not have soup, and I want to have it. We want to help them [adolescent girls], and they also help us. (adolescents boys focus group discussion, Lichinga).
Girls start dating with 9, 10 years, long before menstruation. This occurs because girls want to have money to buy snacks and clothes. (Mothers focus group, Quelimane) [girl] Wants money, telephone, ride. The young boys do not have taco [money]. The father has no conditions." (adolescent girls focus group discussion, Maputo City) To want to have soup, is a basic need that exposes adolescents to practice transactional sex. As is known, the main activity for adolescents is to prepare themselves for the future using the resources offered by parents. In developing countries, like Mozambique, the poverty does not allow parents to supply their children adequately. As alternative, adolescents prefer to ask for help from others because they want to buy not only "unnecessary" things but also obtain the resources needed for their schooling and families' necessities (Weiner and Kulczycki 2014) 13" " One of the differentiating factors for the occurrence of pregnancy here in Lichinga is the economic power of families. If a family is economically sustainable, the probability of their children to have early pregnancy is less. Most of the population here is involved in subsistent agriculture. This activity is performed during six months. During this period, they leave their children alone, one with 14 and another with 12, caring of the youngest, for those who think they should leave, and when products end up they enter to prostitution unconsciously without knowing what would happen and end up becoming pregnant. (Key informant, Lichinga) Also, the low economic conditions of the girls and their families could motivate them to involve with an old man with economic conditions to supply what the teens daily want to do and have.

c) Information and communication technology, and peers relations
As human beings, adolescents are influenced by the environment surrounding them.
The influence can be positive or negative depending on the environment and the capacity to select things that lead to behave as is acceptable in the society. It is recognized that information and communication technology (ICT) is a dominant factor that influences the development worldwide, because it links people, and promotes the communication between people located in different continents at the same time. It is also important because ICT facilitates the dissemination of various services worldwide.
However, ICT also can have negative influence depending on the kind of information disseminated, for example, pornography, and some passages of soap opera. The same role can be performed by peers relations or friends when someone engages in certain behavior to fit into the group or change their beliefs or opinion to agree with the opinion of a group. The following extracts of our materials are some examples of this kind of influence: Sometimes we saw a lady with the whole body exposed by copying what she sees on TV.
I have my grandchild with two years old, but he already knows what the romantic kiss is. It is hard to raise a child, when the television is there, showing everything that should not be shown. (father focuses group discussion Maputo City) In school the children study with people who already know what dating is, and you think that the child went to school while she served and went to places that only she knows. How will mother know what is going on? (Mothers focus group discussion, Maputo City).
When girls start to have menstruation, some do not follow the mothers' advice because they follow what they see on television. They watch everything there, birth, menstruation, the world changed. The children are still younger, but they talk about what happens in the soap opera. For

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" example, my grandson says: 'see, there [in the soap opera] they are having sex (Mothers focus group discussion, Lichinga).
We advise our children [about what they see on soap opera], but when they watch soap opera, they follow what they saw there. Currently, what the father says is nothing. The Government does not produce soap opera according to our tradition. (Mothers Focus group discussion, Maputo City).
According to these extracts, communication and information technologies are one of the factors that influence behavior of teens on sexual activity and be exposed to the risk of early pregnancy and childbearing.
The peer relationships also influence adolescents to experiment sexual activity because they hear from friends about the experience and could want to do the same. These situations show up the power of influence that peer relationship plays on adolescent's behavior. This power may contribute to early pregnancy and childbearing particularly if the adolescents lack of dialogue about sexuality and reproductive health with their parents.
Thus, the data shows that both, information and communication technologies and peer relationships, are replacing parents on the process of adolescent's socialization and initiation rites, on sexuality and reproductive health.

Discussion and conclusions:
The paper proposed brings up some factors that influence adolescents' well-being and health in families. This study supports earlier results that found socio-cultural, economical, information and communication technology, media, and peers relationships as a set of factors that determine or contribute among adolescents to the early pregnancy and childbearing. In fact, the lack of dialogue between parents and adolescents about sexuality and initiation rites; the lack of the resource to satisfy the basic needs; the access to internet and television, and friends/peers relationships were mentioned during the interviews as influencing early pregnancy among adolescents.

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Regarding to ICTs some parents have fear on ICTs because it is new for them, but maybe teenagers use those media also to find valid information.
In Mozambique, it is not common that a mother or father discusses sexual issues with her or his children. This activity is reserved for another person such as grandmother and aunt or to initiation rites. This is the reason adolescents said they have never talked about sexuality with their parents. This result supports with Holmam (2014) who found that adolescents never had a direct conversation with their parents or stated that they talked to someone other than their parent about sex-related topics. As many studies emphasized, the absence of communication influences the adolescent to be influenced by friends, peers relationships, and medias, sometimes negatively. The similar thinking can be perceived on Craig and Richter-Strudom (1983) when they verified, that adolescents were seemed to be forced to drive an "individual bargainˮ often from a standpoint of ignorance. From our perception, Craig and Richter-Strudom (1983) found that there is necessity of the closeness and interaction between adults and adolescents to transmit the necessary information that can protect the young people from early sexual activity and its consequences. Sometimes, this occurs because, most of the time, communication about sexual health among parents and children is indirect, especially with fathers, parents may feel that they had had a discussion about a certain topic when the child did not understand, listen to, or receive the message transmitted (Saskatchewan Prevention Institute, 2011). The lack of communication could also occur because mothers are uncomfortable to discuss the topics such as dating, menstruation, sex, and birth control with daughters because of the fear of encouraging adolescents towards sexual behavior (Meschke et al. 2000). Undoubtedly, in this study, early pregnancy does not result only in the absence of communication, but also from other factors such as economic factors, which exert significant influence on adolescents, since this group of the population wants to satisfy their basic needs. As we indicated previously, some adolescent girls resort to transactional sex as a way to have money or things that their want, because the parents do not have enough financial resources to supply them. This practice was also reported by other authors, such as Ochiogu et al. Culture is recognized to be a factor of cohesion among community members, since they share the same patterns of thinking, feeling and acting (Franco 2002;Hofstede 1980).
In this study, the findings refer the existence of cultural practices -initiation rites-that prepare an individual to transition from one step of life to another. Despite their role in building cohesion, there were the same aspects (sexual activity preparation) that the participants, mothers, claimed to contribute to early sexual activity and its consequence.
In fact, this issue was described by Anfred (2011) when she explains that the young people initiate are not only told and shown how to behave as adult women, and or how to show respect to the elderly, but are also, instructed about how to conduct sex in marriage, how to move during intercourse with the husband, how to wipe and clean his penis after sex, and what to expect from the husband afterwards.
However, according to the key informant of Lichinga city, currently, the process of preparation is made once due to the lack of financial resource. She (the key informant) mentioned that a long time ago, there were three phases of this process of preparation.
The first was reserved for teaching the child how to behave and show respect to the elder. The second was reserved for the child who reaches the puberty. In this phase, he/she thought everything related sexuality and married. The third was occurring when the girl becomes pregnant, to teach her how to care pregnancy and baby. Nowadays, these phases are not observed. All things are thought at once, without separation according to ages. It is important to refer that the initiation rites were mentioned only in Quelimane and Lichinga. Participants of Maputo City did not mention these practices, but this does not mean that the initiation rites do not exist in this region of Mozambique.

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At the same context, information and communication technology, media, and peer relationships in how to deal with sexual activity influence adolescents.
As in other parts of world, Mozambican adolescents are more likely to follow what they see from others with whom they interact directly or by television as well as what they see on the internet, which can be positive or negative. The mothers and fathers referred that adolescents get pregnant because they wear tight and short clothes which expose the body because they see it on television or in the shops. They also explained that the children saw people kissing on television and they comment about it. In our perception, this is part of the natural process resulting from the influence of the environment in which they are exposed. First, they have curiosity as people who are in the period of transition to exercise their sexuality. Second, during this period, the adolescents are more vulnerable and probability to engage in conformist behavior to feel belonging to a group is grown. Especially, this true for the adolescents living in a family without clear set of guidelines or belief structure, and consequently this leads adolescents to seek help in other social groups.
Looking at all these factors, we can conclude that, the necessities to reduce early pregnancy and childbearing require the adolescents empowerment in knowledge about sexuality, showing them disadvantages of early pregnant and how to avoid it. It is also important to make adolescents able to select what is useful and healthy in all things that they saw on the television and Internet. Sometimes, the parents have to be empowered economically and encouraged to talk truth about sexuality with their children. Otherwise, they will learn from friends and peers.
The adolescents, mainly the girls, must be empowered about how to delay sexual relations, to know that they are the owner of their bodies, to know how negative it is to be exposed to transactional sexual relations, and claim to the use condom in sexual intercourse. The adolescent boys must know the cost to have baby at early age, without any formal or informal income, and they must also be prepared to be first on dating situation, to propose the use of condom as the way to prevent early pregnancy, childbearing, and protect from STIs.