Research Article|Articles in Press, 110006

“I was waiting for my period”: understanding pregnancy recognition among adolescents seeking abortions in Ethiopia, Malawi, and Zambia



      For a person seeking an abortion, the ability to recognise a pregnancy is a critical first step. Pregnancy recognition is complex and shaped by numerous factors. This paper explores the experiences of pregnancy recognition among adolescents in Ethiopia, Malawi, and Zambia.

      Study Design

      The final sample included three hundred and thirteen adolescents aged 10-19 who had sought abortion-related care at urban public facilities in Ethiopia (N=99), Malawi (N=104), and Zambia (N=110). Researchers collected mixed-method data on how adolescents came to recognise that they were pregnant and thematically analysed qualitative data alongside descriptive statistics from quantitative data.


      Most adolescents reported that their main mode of recognising a pregnancy was medical pregnancy tests or late menstruation. Reasons for not recognising a pregnancy included irregular menses or recent menarche and attribution of signs and symptoms to other medical conditions. Psychological barriers to pregnancy recognition were important, including the refusal to accept a pregnancy and denial of a pregnancy. Timing of recognition shaped the abortion care available for adolescents and the affordability of care. For some adolescents, their capacity to recognise their pregnancy led to involuntary or voluntary disclosure, which decreased their reproductive autonomy.


      Adolescent experiences of pregnancy recognition complement existing evidence, illustrating critical barriers across age and context. Interrogating pregnancy recognition among adolescents exposed the critical implications for the availability, accessibility, affordability, and autonomy of their abortion trajectory.


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        • Somefun O.D.
        • Harries J.
        • Constant D.
        Reproductive awareness and recognition of unintended pregnancy: young women, key informants and health care providers perspectives in South Africa.
        Reprod Health. 2021; 18: 211
        • Strong J.
        • Coast E.
        • Freeman E.
        • Moore A.M.
        • Norris A.H.
        • Owolabi O.
        • et al.
        Pregnancy recognition trajectories: a needed framework.
        Sex Reprod Health Matters. 2023; 31: 2167552
        • Coast E.
        • Norris A.H.
        • Moore A.M.
        • Freeman E.
        Trajectories of women's abortion-related care: A conceptual framework.
        Soc Sci Med. 2018; 200: 199-210
        • Olukoya A.A.
        • Kaya A.
        • Ferguson B.J.
        • AbouZahr C.
        Unsafe abortion in adolescents.
        Int J Gynecol Obstet. 2001; 75: 137-147
        • Foster D.G.
        • Gould H.
        • Biggs M.A.
        Timing of pregnancy discovery among women seeking abortion.
        Contraception. 2021; 104: 642-647
        • Foster D.G.
        • Kimport K.
        Who Seeks Abortions at or After 20 Weeks?.
        Perspect Sex Reprod Health. 2013; 45: 210-218
        • Baum S.
        • DePiñeres T.
        • Grossman D.
        Delays and barriers to care in Colombia among women obtaining legal first- and second-trimester abortion.
        Int, J Gynaecol Obstet. 2015; : 1879-3479
        • Gallo M.F.
        • Nghia N.C.
        Real life is different: a qualitative study of why women delay abortion until the second trimester in Vietnam.
        Soc Sci Med. 2007; 64: 1812-1822
        • Laing S.P.
        • Sinmyee S.V.
        • Rafique K.
        • Smith H.E.
        • Cooper M.J.
        Barriers to Antenatal Care in an Urban Community in the Gambia: An In-depth Qualitative Interview Study.
        Afr J Reprod Health. 2017; 21: 62-69
        • Harries J.
        • Orner P.
        • Gabriel M.
        • Mitchell E.
        Delays in seeking an abortion until the second trimester: a qualitative study in South Africa.
        Reprod Health. 2007; 4: 7
        • Ingham R.
        • Lee E.
        • Clements S.J.
        • Stone N.
        Reasons for Second Trimester Abortions in England and Wales.
        Reprod Health Matters. 2008; 16: 18-29
        • Kjelsvik M.
        • Sekse R.J.T.
        • Moi A.L.
        • Aasen E.M.
        • Chesla C.A.
        • Gjengedal E.
        Women's experiences when unsure about whether or not to have an abortion in the first trimester.
        Health Care Women Int. 2018; 39: 784-807
        • Swanson M.
        • Karasek D.
        • Drey E.
        • Foster D.G.
        Delayed pregnancy testing and second-trimester abortion: can public health interventions assist with earlier detection of unintended pregnancy?.
        Contraception. 2014; 89: 400-406
        • Lince-Deroche N.
        • Fetters T.
        • Sinanovic E.
        • Blanchard K.
        Accessing medical and surgical first-trimester abortion services: women's experiences and costs from an operations research study in KwaZulu-Natal Province, South Africa.
        Contraception. 2017; 96: 72-80
        • Ralph L.J.
        • Foster D.G.
        • Barar R.
        • Rocca C.H.
        Home pregnancy test use and timing of pregnancy confirmation among people seeking health care.
        Contraception. 2022; 107: 10-16
        • Kiley J.W.
        • Yee L.M.
        • Niemi C.M.
        • Feinglass J.M.
        • Simon M.A.
        Delays in request for pregnancy termination: comparison of patients in the first and second trimesters.
        Contraception. 2010; 81: 446-451
        • Branum A.M.
        • Ahrens K.A.
        Trends in Timing of Pregnancy Awareness Among US Women.
        Matern Child Health J. 2017; 21: 715-726
        • Munakampe M.N.
        • Zulu J.M.
        • Michelo C.
        Contraception and abortion knowledge, attitudes and practices among adolescents from low and middle-income countries: a systematic review.
        BMC Health Serv Res. 2018; 18: 909
      1. World Health Organization. Adolescents: health risks and solutions. 2018 .

        • World Health Organization
        Safe abortion: technical and policy guidance for health systems. Second edition. WHO, Geneva2012
      2. Nandagiri R. Sexual and Reproductive Health Matters2022. [cited 2022 ]. Available from: 〈〉.

        • Foster D.G.
        • Dobkin L.M.
        • Upadhyay U.D.
        Denial of abortion care due to gestational age limits.
        Contraception. 2013; 87: 3-5
        • Darney B.G.
        • Saavedra-Avendano B.
        • Sanhueza P.
        • Schiavon R.
        Disparities in access to first-trimester legal abortion in the public sector in Mexico City: who presents past the gestational age limit?.
        Contraception. 2016; 94: 400-401
        • Kangaude G.
        • Coast E.
        • Fetters T.
        Adolescent sexual and reproductive health and universal health coverage: a comparative policy and legal analysis of Ethiopia, Malawi and Zambia.
        Sex Reprod Health Matters. 2020; 28: 1832291
        • Sully E.
        • Dibaba Y.
        • Fetters T.
        • Blades N.
        • Bankole A.
        Playing it Safe: Legal and Clandestine Abortions Among Adolescents in Ethiopia.
        J Adolesc Health. 2018; 62: 729-736
        • Munthali A.
        • Zulu E.M.
        • Madise N.
        • Moore A.M.
        • Konyani S.
        • Kaphuka J.
        • et al.
        Adolescent sexual and reproductive health in Malawi: results from the 2004 National Survey of Adolescents.
        Occasional Report. 2006; 24
        • Coast E.
        • Murray S.F.
        "These things are dangerous": understanding induced abortion trajectories in urban Zambia.
        Soc Sci Med. 2016; 153: 201-209
        • Mulat A.
        • Bayu H.
        • Mellie H.
        • Alemu A.
        Induced second trimester abortion and associated factors in Amhara region referral hospitals.
        Biomed Res Int. 2015; 2015256534
        • Kebede K.
        • Gashawbeza B.
        • Gebremedhin S.
        • Tolu L.B.
        Magnitude and Determinants of the Late Request for Safe Abortion Care Among Women Seeking Abortion Care at a Tertiary Referral Hospital in Ethiopia: A Cross-Sectional Study.
        Int J Womens Health. 2021; 12: 1223-1231
        • Odland M.L.
        • Membe-Gadama G.
        • Kafulafula U.
        • Jacobsen G.W.
        • Kumwenda J.
        • Darj E.
        The Use of Manual Vacuum Aspiration in the Treatment of Incomplete Abortions: A Descriptive Study from Three Public Hospitals in Malawi.
        Int J Environ Res Public Health. 2018; 15: 370
        • Dahlback E.
        • Maimbolwa M.
        • Yamba C.B.
        • Kasonka L.
        • Bergstrom S.
        • Ransjo-Arvidson A.-B.
        Pregnancy loss: spontaneous and induced abortions among young women in Lusaka, Zambia.
        Cult Health Sex. 2010; 12: 247-262
        • Ganatra B.
        • Gerdts C.
        • Rossier C.
        • Johnson Jr., B.R.
        • Tunçalp Ö.
        • Assifi A.
        • et al.
        Global, regional, and subregional classification of abortions by safety, 2010-14: estimates from a Bayesian hierarchical model.
        The Lancet. 2017; 390: 2372-2381
        • Espinoza C.
        • Samandari G.
        • Andersen K.
        Abortion knowledge, attitudes and experiences among adolescent girls: a review of the literature.
        Sex Reprod Health Matters. 2020; 28: 1744225
        • Melesse D.Y.
        • Mutua M.K.
        • Choudhury A.
        • Wado Y.D.
        • Faye C.M.
        • Neal S.
        • et al.
        Adolescent sexual and reproductive health in sub-Saharan Africa: who is left behind?.
        BMJ Glob Health. 2020; 5e002231
      3. Centre shares its success in family planning work with the NGOs in the SAARC region. GLIMPSE. 1995 ;17(2):3.

        • Foster D.G.
        • Jackson R.A.
        • Cosby K.
        • Weitz T.A.
        • Darney P.D.
        • Drey E.A.
        Predictors of delay in each step leading to an abortion.
        Contraception. 2008; 77: 289-293
        • Ricker C.L.
        • Ashmore R.
        The importance of power and agency in a universal health coverage agenda for adolescent girls.
        Sex Reprod Health Matters. 2020; 28: 1787312
        • Berro Pizzarossa L.
        • Nandagiri R.
        Self-managed abortion: a constellation of actors, a cacophony of laws?.
        Sex Reprod Health Matters. 2021; 29: 1899764
        • Cornish F.
        Communicative generalisation: Dialogical means of advancing knowledge through a case study of an ‘unprecedented’ disaster.
        Cult Psychol. 2020; 26: 78-95
        • Lavelanet A.F.
        • Johnson B.R.
        • Ganatra B.
        Global Abortion Policies Database: A descriptive analysis of the regulatory and policy environment related to abortion.
        Best Pract Res Clin Obstet Gynaecol. 2020; 62: 25-35