Contraceptives are procedures, medications, behaviours or devices that prevent pregnancy among women (Bansode, Sarao & Cooper 2023). The use of contraceptives enables women to prevent unintended pregnancies, giving them control of reproductive choices. It is estimated that at least two of three women aged 15–49 years use contraceptives globally; however, rates of usage vary with the lowest rate of 15% being among adolescent girls aged 15–19 years in sub-Saharan Africa including South Africa (Chola, Hlongwana & Ginindza 2023). The low usage of contraceptives among adolescent girls in sub-Saharan Africa is because of several reasons such as a lack of knowledge and access (World Health Organization [WHO] 2023). In South Africa, 31% of adolescent girls had an unmet contraceptive need by the end of 2016 (Govathson et al. 2023). As a result of the low usage of contraceptives among adolescent girls, there is a high level of unintended pregnancies, with at least 25% of adolescent girls having unintended pregnancies in South Africa (Govathson et al. 2023). Unintended pregnancies are associated with several challenges among adolescent girls. These include unsafe abortion, mental illness, school dropouts, pregnancy and childbirth-related complications and death (Olika et al. 2021). Among adolescents, complications related to pregnancy and childbirth are the leading cause of death (Olika et al. 2021).

Persons from the ages of 10 to 19 years are classified as adolescents (United Nations International Children’s Emergency Fund [UNICEF] 2018). Adolescence is a transition phase from childhood to adulthood characterised by physical and emotional growth, which also includes sexual maturation (Bukenya et al. 2020). As adolescents mature sexually, there is a tendency to engage in risky sexual practices such as unprotected sex resulting in unintended pregnancies, which could be prevented by contraceptive use (Bukenya et al. 2020). In South Africa, from the age of 12 years, adolescent girls can access reproductive health services including contraceptives without parental and/or guardian consent (Children’s Act of 2005). In public health facilities, contraceptives are also provided free of charge to enable access for everyone including adolescents (Kriel et al. 2023).

Several types of contraceptives are available for use by adolescents, and these include long-acting reversible contraceptives (LARC), emergency contraceptives, female and male sterilisation, natural methods and barrier methods (Chimurkar et al. 2021). Long-acting reversible contraceptives provide long-term pregnancy prevention and are highly effective and include implants, intrauterine devices (IUDs) and injectables (Chimurkar et al. 2021). The etonogestrel implant is regarded as the most effective contraceptive (Bansode et al. 2021). Despite the effectiveness of LARC, among adolescents in sub-Saharan Africa using contraceptives, only 29.8% of them use LARC, with most preferring injectables (McCurdy, Jiang & Schnatz 2018). Some of the LARCs form part of hormonal contraceptives such as the Levonorgestrel intrauterine system, injectables and patches. In South Africa, a survey in Cape Town found that 63.7% of adolescents use hormonal contraceptives (Toska et al. 2020).

Another common contraceptive choice used by adolescent girls are the barrier methods, which include male and female condoms, cervical caps and diaphragms used with spermicides (Hassoun 2018). One important advantage of the barrier methods is that they offer protection from sexually transmitted infections (STIs) including HIV. A 2017 South African survey found that the highest condom use was among young people aged 15–24 years (Duby et al. 2021). This rate of condom use among young people in South Africa is below optimum levels in comparison to the USA where at least 81% of young people use condoms (Barrett et al. 2021; Duby et al. 2021). In addition, since 2017, the number of young people using condoms in South Africa has been declining annually (Duby et al. 2021). Among adolescent girls aged 15–19 years, at least 55% use condoms in South Africa (Davids et al. 2021). This sub-optimal level of condom utilisation among adolescent girls increases their risk of unwanted pregnancies and contracting STIs including HIV (Beksinska, Wong & Smit 2020). Although the use of condoms is higher among adolescent girls relative to other contraceptive methods, the failure rate of condoms is also high because of incorrect and inconsistent use (Ayalew et al. 2022; Sharma & Singh 2022).

Considering the availability of several contraceptive choices and their right to access contraceptives, adolescent girls are less likely to use a contraceptive at sexual debut and only use it after they have fallen pregnant (Sharma & Singh 2022). Among 17 African countries assessed, South Africa had the highest (70%) rate of contraceptive use among adolescents who had previously fallen pregnant (Ahinkorah et al. 2021). There is consensus that adolescent girls are aware of contraceptives although knowledge of specific methods of contraceptives is inadequate, which affects how they use contraceptives (Sharma & Singh 2022; Gyan & Marhefka-Day 2021; Jonas et al. 2020). In the South African study, adolescent girls reported that they needed more information on contraceptives and the majority knew of injectables, a few mentioned implants and no other contraceptive was mentioned (Jonas et al. 2020). Associated with the lack of knowledge are misconceptions and myths about contraceptives. In a systematic review of studies conducted among adolescents from low to medium-income countries, it was concluded that myths about contraceptives contributed to the low usage of contraceptives (Munakampe, Zulu & Michelo 2018). A South African country-wide study also concluded that misconceptions about contraceptives determine use, and these misconceptions were based on choices of contraceptives (Pleaner et al. 2022). For example, adolescents perceived that pills and injectables are associated with future infertility and weight gain, implants were misconceived to rust in the body, and IUDs were placed in the vagina and fill it up (Pleaner et al. 2022).

Interpersonal relationships including intimate partners and parents also influence adolescent girls’ use of contraceptives (Kriel et al. 2019). A study in Ghana found that the nature of sexual relationships and cultural norms affect the use of contraceptives among adolescent girls (Gyan & Marhefka-Day 2021). A South African study explained the issue of power in influencing the use of contraceptives in sexual relationships between men and adolescent girls (Duby et al. 2023). Findings from the study highlight that although there is a shift from traditional gender role expectations, there is still power inequity in sexual relations with men determining the use of contraceptives, especially condoms (Duby et al. 2023). Although men exert power over the use of contraceptives, their power does not deny adolescent girls from negotiating the use of contraceptives including condoms (Duby et al. 2023). Notably, male partner influence is regarded as the most significant interpersonal factor affecting the use of contraceptives among adolescent girls (Kriel et al. 2019). Parents also influence adolescent girls’ use of contraceptives (Chola et al. 2023). Parents can either encourage or discourage adolescent contraceptive use (Chola et al. 2023). On one hand, parents often discourage adolescent girls from using contraceptives assuming their children are engaging in sexual intercourse when they are still too young (Jonas et al. 2020). On the other hand, parents encourage the use of contraceptives for adolescent girls who would have previously had an unintended pregnancy (Jonas et al. 2020).

Healthcare workers are also influential in the use of contraceptives among adolescent girls. Negative attitudes from healthcare workers discourage the use of contraceptives among adolescent girls (Jonas et al. 2020). Such negative attitudes are described in various contexts such as Zambia and South Africa and include rudeness, unfriendly facial expressions and asking unsettling questions like ‘Are you not too young for contraceptives?’ (Chola et al. 2023; Jonas et al. 2020). In addition, adolescents perceive that there is a lack of privacy when seeking contraceptives; for example, nurses will loudly ask if they are seeking contraceptives, which is a hindrance to contraceptive use (Jonas et al. 2020).

In low- and middle-income countries, which include South Africa, contraceptive use among adolescent girls is also affected by financial issues pertaining to the cost of travel for services and the cost of contraceptives (Li et al. 2020). In addition to the inability to afford transport costs associated with accessing contraceptives, adolescent girls in low- to middle-income countries do not always have the freedom to travel to healthcare centres as they please (Chandra-Mouli & Akwara 2020). In South Africa, the issue of distance to clinics is also highlighted particularly in rural areas where adolescents must travel long distances, and parents do not always have money to pay for the travel (Jonas et al. 2020).

The study used the social ecological model (SEM). The SEM assumes there is an interaction of four levels that are related that affect the use of contraceptives. These levels include the intrapersonal, interpersonal, community and societal levels (Bronfenbrenner 2005). At the centre are the intrapersonal factors such as knowledge, myths and misconceptions about contraceptive use. The next level is the interpersonal level that includes relationships with partners, peers and parents. The third level is the community level that includes interactions with community members and services in the community like clinics and religious organisations. The last level is the society level that comprises the policies in the broader society affecting the use of contraceptives such as allowing adolescents to access contraceptives without parental consent.

The study was conducted in the Ekurhuleni district in Gauteng Province. Ekurhuleni district is one of the three metropolitan municipalities in Gauteng Province. In South Africa, Gauteng province has the highest number of teenage pregnancies, and within the Ekurhuleni district, at least 30% of adolescent girls have had an unintended pregnancy (Nkosi & Pretorius 2019). The higher prevalence of adolescent pregnancies in the Ekurhuleni district compared to the national prevalence of 25% is concerning; therefore, there is a need to understand the use of contraceptives among adolescent girls. Previous studies on contraceptive use among adolescent girls have been conducted in contexts outside Ekurhuleni; for example, Jonas et al. (2020) conducted their study in Tshwane and provinces outside Gauteng; Hlongwa, Tlou and Hlongwana (2020) also conducted their study in Umlazi Township in KwaZulu-Natal. The study conducted in Ekurhuleni by Pleaner et al. (2020) focussed on adolescents enrolled in a reproductive health intervention. This study complements these previous studies by providing adolescent girls’ perceptions in Ekurhuleni on contraceptive use where unintended teenage pregnancies are higher than the national prevalence. Understanding the perceptions of adolescents in this context would facilitate the development of reproductive health programmes to address the problem of inadequate contraceptive usage at intrapersonal, interpersonal, community and societal levels. Therefore, the purpose of the study was to describe perceptions of adolescent girls regarding the use of contraceptives in Ekurhuleni District, Gauteng.

The qualitative approach with a descriptive study design was used. Likewise, this study seeks to expand existing knowledge on adolescent girls’ use of contraceptives from previous studies conducted in South Africa.

The study was conducted in Tembisa, which is the second-largest township in South Africa and is in the City of Ekurhuleni (Department of Cooperative Government and Traditional Affairs [COGTA] 2021). The study was conducted at two high schools in Tembisa. Within the Ekurhuleni district, the population of adolescents is approximately 490 702 (13% of the total population) (COGTA, 2021). The inclusion criteria were all adolescent girls aged between 13 and 19 years who had reached menarche and gave consent or whose parents consented on their behalf to participate in the study for participants younger than 16 years. For these participants younger than 16 years, in addition to their parents consenting on their behalf, they individually consented by signing an assent consent form. The researcher determined the inclusion of adolescent girls who had reached menarche, by first asking the prospective participants. A total of 35 prospective participants were identified. The exclusion criteria were adolescent girls aged 13–19 years who had not reached menarche and/or who did not consent to participate in the study. The researcher P.T.M. recruited the study sample in April 2023 in Tembisa.

Convenience sampling was used to select the two high schools. Convenience sampling refers to a non-probability sampling technique that entails the selection of elements readily available to the researcher (Polit & Beck 2020). Purposive sampling was done to select the sample of adolescent girls who participated in the study. Purposive sampling makes use of the researchers’ judgement to select participants (Polit & Beck 2020). In this case, the judgement was based on the age of the adolescent girls. The sample size was determined by data saturation, which occurs when additional sampling does not provide new information (Grove & Gray 2019).

Data were collected using written narratives and interviews by the researcher P.T.M. Narratives entail the writing of words to explain a situation in the way the writer visualises it (Habibi et al. 2020). Participants were given small notebooks that were labelled with codes and wrote responses to questions on contraceptive use. The questions included: What are your thoughts regarding contraceptive use? What are your experiences regarding contraceptive use? What factors do you think promote contraceptive use? What challenges do you experience when you want to use contraceptives? What factors prevent you from using contraceptives? What do you think can be done to promote contraceptive use? The notebooks were collected after 1 week. Data collection through written narratives was done for younger participants (˂ 13 years) who were shy to express their perceptions through interviews. Participants wrote their narratives in English or IsiZulu. Notably, the researcher P.T.M. who collected data is fluent in both English and IsiZulu.

Interviews were conducted for older adolescents aged more than 16 years. Interview questions were exactly like questions in the written narratives. The interviews were conducted at the two high schools in Tembisa in a classroom not in use, which afforded privacy during the interviews. A semi-structured interview guide was used during the interviews. The interview guide was pretested with three adolescent girls, and the results were not used in the final analysis. The purpose of pretesting the interview guide was to check its effectiveness. Interviews lasted 30 min – 60 min and were audio recorded. Interviews were conducted in English or isiZulu. Data collection was conducted for 3 months from April to June 2023.

Data analysis was done using Braun and Clark’s six steps of thematic analysis (Clarke & Braun 2017). The first step was data familiarisation, whereby the researchers read the narratives and transcribed and translated the data from the interviews. Back translation was also done to ensure the accuracy of translated data. The second step was generating the initial codes. Open coding was used, which meant there were no preconceived codes, but codes were generated as the analysis was conducted. Interesting pieces from the data aligned to the research objective were grouped and assigned a code; an example of interesting data assigned a code was ‘fear of parents’. The third step was to generate themes by assembling all the collected information, placing it into categories, themes and subthemes. The fourth step was to review the themes, by reading the initial themes generated and aligning all remaining data to the new themes. This ensured that all data supported the themes generated. The fifth step was defining the generated themes, and the sixth was presenting the findings.

Throughout the data collection and data analysis, the researchers reflected on the distinction of their roles as researchers and previous experience to ensure data collected and analysed remains objective. This reflection considered the role of P.T.M. as a healthcare worker in a public healthcare facility and R.G.M. as an academic.

Trustworthiness was ensured by using the framework developed by Kyngäs, Kääriäinen and Elo (2020); (Lincoln & Guba 1985). Credibility was ensured by prolonged engagement with the participants, and integration of the data was made into the research findings. Dependability was ensured using a co-coder. Confirmability was ensured by checking and rechecking the developed themes, which would enable other researchers to draw similar conclusions should the research be repeated. In addition, to ensure confirmability, a description of the research design and methods was provided. To ensure transferability, the research setting and participants have been described in detail.

The study found that adolescent girls had positive and negative perceptions regarding the use of contraceptives. The positive perceptions were that contraceptives were good in cases where condoms could not be used. They were also good for preventing unintended pregnancies in families that cannot afford to support another child. The negative perceptions were founded on myths and misconceptions such as weight gain and future infertility, which impelled them to use contraceptives after having a child. Negative perceptions of the use of contraceptives were also founded on the fear of being caught in possession of such items by parents. The study also found that adolescent girls perceived contraceptive use negatively because of healthcare workers’ and community members’ judgemental attitudes.

The influence of male sexual partners is described in studies across various contexts. The study by Kriel et al. (2019) found that the male partner influence is the strongest influence on contraceptive use among adolescent girls. In South Africa, Duby et al. (2023) also describe the power men exert over contraceptive use among adolescents. In this current study, the influence of the male partner confirms the findings by Duby et al. (2023) and Kriel et al. (2019); male dominance is described by Participant 15 who notes: ‘Boys don’t want to have kids, so they send their girlfriends or their sexual partners to have these contraceptives’. Despite the dominance, illustrated by girls being told to use contraceptives by male partners, participants in this study highlighted that they perceived this positively as it prevented pregnancy among adolescent girls through enabling contraceptive use. Given these findings, it is critical to acknowledge the role of the male partner in increasing contraceptive use among adolescent girls.

Adolescent girls in the study also demonstrated that they were not oblivious to the financial constraints that their families endure. In this regard, they held positive perceptions of contraceptives as a means of preventing unintended pregnancies to prevent additional financial burden to their families. Studies previously conducted discuss the issue of financial constraints in families as a hindrance for adolescent girls to access contraceptives as they cannot afford costs associated with accessing contraceptives such as transport costs (Li et al. 2020). Notably, the study conducted by Li et al. (2021) draws these conclusions from 103 low- to middle-income countries using data from demographic health surveys. In South Africa, the study conducted by Kriel et al. (2023) acknowledges that contraceptives are provided free of charge in public health facilities; however, financial challenges are related to transport costs associated with accessing the contraceptives. The difference in conclusion between our study and the studies conducted by Kriel et al. (2023) and Li et al. (2021) could warrant further studies to ascertain how financial constraints in families influence the use of contraceptives.

Several negative perceptions of the use of contraceptives were also discussed by the adolescent girls. The study confirmed previous findings by Pleaner et al. (2022) regarding the presence of myths and misconceptions surrounding contraceptive use, which contributed to a negative perception of contraceptives. Participants described how contraceptive use resulted in future infertility:

This assertion by Participant 15 shows the strong influence of misconceptions on contraceptive use. In addition, the use of contraceptives only after having a child also reflects on findings of the study conducted in India by Sharma and Singh (2022) who found that adolescent girls only made use of contraceptives after having a child. Furthermore, Ahinkorah et al. (2021) found that South Africa has a high number of adolescent girls who use contraceptives only after having a first child among 17 countries assessed. The misconceptions and consequent negative perceptions on contraceptive use also illustrate the lack of knowledge on contraceptive use described by Sharma and Singh (2022).

The attitudes of healthcare workers and community members also influenced negative perceptions of contraceptive use. The issue of negative judgemental attitudes from community members and healthcare workers confirms findings by Jonas et al. (2020) in South Africa and Chola et al. (2023) in Zambia. The issue of ‘you are too young to seek contraceptives’ described in the South African study and confirmed in this study is concerning, given the provision for access to contraceptives for adolescents above the age of 12 years without parental consent (Children’s Act of 2005). This negative attitude from healthcare workers and community members could imply a need for awareness of adolescent girls’ right to access contraceptives. In addition, the negative attitudes could mean that there is a need for health workers to understand how these negative attitudes hinder adolescents’ use of contraceptives. Similarly, the negative perceptions of contraceptive use were attributed to the influence of parents whom the adolescents ‘feared’. This fear is explained by Participant 12 who said: ‘fear of parents finding out, that they might be intimate’. The study by Chola et al. (2023) in Zambia also draws similar conclusions that adolescents fear parents, thus discouraging contraceptive use.

The study sought to describe the perceptions of adolescent girls regarding the use of contraceptives in Ekurhuleni. The study found that adolescent girls have positive and negative perceptions regarding the use of contraceptives. The findings from the study are important in addressing the low number of adolescent girls who use contraceptives leading to unintended pregnancies in Ekurhuleni. The study described the critical issue of negative attitudes of healthcare workers and community members, which have effects on the use of contraceptives and recommends the need to address such issues through programmes targeting adolescents. Moreover, a different insight on how financial constraints in families elicited positive perceptions of contraceptives is described, which could be explored further in other contexts to understand its effect on contraceptive use.