Adolescent years are the most important and difficult time of life. During this time different individuals become independent, build new relationships, develop social skills and learn behaviours that might last the rest of their lives. It is the time when adolescents face sexual health issues such as sexually transmitted diseases, teenage pregnancy or human immunodeficiency virus (HIV) (World Health Organization [1]. In developing countries, total 21 million girls are aged between 15 and 19 years and 2 million girls become pregnant annually, which exposes them to the risk of sexual and reproductive health problems. Teenagers between the ages of 15 and 19 years give birth every year, while they don’t want to have the children. They have different experiences, which lead them either to keep their babies or opt for Termination of Pregnancy (TOP) [2]. Globally between 2010 and 2014, it has been estimated that 56 million (safe and unsafe) abortions were performed each year [3].

In South Africa (SA), the Termination of Pregnancy (TOP) was legalised in 1996 based on the constitutional charter of Human Rights, which allows everyone freedom of choice, including, the right over procreation. The Termination of Pregnancy Act, no.92 of 1996 states, women can exercise their constitutional rights to reproductive choice and can request and give consent to abortion [4]. Since the passing of the Termination of Pregnancy Act, which legalised voluntary abortion, the ethical question around this issue has been the topic of much public and private debate [5]. Cultural beliefs were some of the reasons nurses chose not to provide these services to teenagers who requested CTOP, but they do refer them to other health care professionals [4, 6]. In the study conducted by Govender, the majority of nurses were not in favour of the legislation and provision of the abortion services to teenagers, yet their profession is built on the principles of care and empathy towards their patients [7]

It is essential to note that the decision to have children is fundamental to women’s physical, psychological and social health and what the person who is pregnant is experiencing [8]. The Democratic Nurses Organisation in South Africa (Denosa) has published a position paper on this issue, in which it affirms that every woman has the right to freedom of choice, appropriate referral systems, respect to the individuals' dignity as well as provision of supportive and neutral counselling before and after the termination of pregnancy [9].

In South Africa, Stampler and Flemmit (2017) reported that though there was a decline of 90% after the legalisation of the Choice of Termination of Pregnancy (CTOP) Act, there was still over 90 000 illegal TOP which were performed in this country by 2017 [10]. Although TOP was legalised in SA, there are still gaps observed for proper implementation of the activities such as lack of registered TOP clinics in certain areas. The stigma still associated with TOP could be the reason behind the high number of illegal termination of pregnancies in SA.

The decision about the termination of a pregnancy is considered to be urgent and might be made without any emotional conflict because once the teenager has become pregnant her unintended pregnancy develops rapidly whilst she has to come to terms with the situation and how to resolve it [11, 12]. Several issues could convince teenage girls and women to instead opt for illegal abortions. An illegal abortion could cause haemorrhaging, toxic shock, sepsis, scarring of the cervix and death. The danger to a woman's health due to an illegal abortion was one of the reasons that prompted a change in South African legislation concerning TOP [13].

Unwanted pregnancy has an impact on a teenager's life, which increases practices such as dumping of foetuses for example. Legislation permits TOP to protect the teenager's mental and physical health [14]. The psychological distress suffered by teenagers caused by social and or economic circumstances related to pregnancy demands might be worsened by keeping an unwanted pregnancy. Therefore, TOP might be an option [15]. The woman’s life may be threatened with serious or permanent injury due to illegal termination of her pregnancy. Socio-economic factors such as economic resources, the teenager’s age and marital status are all contributory factors towards deciding to terminate the pregnancy [16]. Termination of pregnancy in some countries is generally interpreted as being liberal. Numerous countries, including South Africa (SA), explicitly allows TOP on grounds such as rape, incest, and foetal impairment. In SA, the TOP Act No 1 of 1998 stipulates that a pregnant teenager is entitled to termination of pregnancy on request within the first 12 weeks of pregnancy [4].

Additionally, factors that influence TOP decision-making include cultural, psychosocial and economic situations [17]. A pregnant teenager is confronted with countless experiences of unplanned pregnancies from incest or sexual abuse that might influence her decision of either keeping or terminating the pregnancy. Educating the teenager first is an option so that an informed decision could be taken [12]. For many of the adolescents, teenage pregnancy and early childbirth means an end to their education, increased poverty and lack of options (Foundation for Women’s Health, Research, and Development & International Planned Parenthood Federation (IPPF) International Planned Parenthood Federation [18].

The primary researcher discovered that the teenagers seem to be having negative experiences such as stigmatization and name calling (outcast) by parents, peers and community members, this led them to request CTOP in the Mpumalanga hospital. The teenagers indicated during history taking that their pregnancies were unplanned. As such, they experience challenges and are embarrassed by the pregnancy. These are some of the reasons that contributed to the decision to opt to terminate their pregnancies. It was against this background that the researchers identified the need to conduct the study, aiming to achieve the following objectives:

• Determine the occurrences leading to the choice of termination of pregnancy amongst teenagers at Mpumalanga hospital.
• Explore the experiences to the choice of termination of pregnancy amongst teenagers at Mpumalanga hospital.

Themes and sub-themes reflecting experiences leading to the Termination of Pregnancy (TOP) amongst teenagers emerged from the 15 interviews which were conducted. Four themes and sub-themes are summarised in Table 1.

The findings of the study revealed that teenagers had different experiences which led them to opt for CTOP, this emerged in the three sub-themes of this study namely: The feeling of fear and anxiety, the despair related to ending the life of the unborn baby and disclosure of the pregnancy to family members.

The choice of TOP remains a controversial issue worldwide. In South Africa, the TOP Amendment Act 5(3) Act NO 92 of 1996 states that a minor as young as 12 years old do not need to have the consent of her parents to obtain an abortion. The current study aimed to determine the incidences leading to the choice of termination of pregnancy and to explore the experiences leading to the choice of termination of pregnancy amongst teenagers at Mpumalanga hospital.

The qualitative study findings revealed that several circumstances led to teenagers' decision to opt for TOP. The participants experienced mixed feelings such as the feeling of shame and embarrassment amongst their peers, within the community and also at school. Furthermore, some teenagers had a fear of being disowned by their parents and their peers, which resulted in them feeling isolated. Consistent with this finding the study conducted by Bhana, Morrell, Ngabaza, and Shefer on South African teachers' responses to teenage pregnancy and teenage mothers in schools, the study revealed that some pregnant teenagers displayed feelings of shame, embarrassment, humiliation, and fear of losing the respect of their parents [23]. In agreement with Bhana et al., Morake’s study in SA’s Limpopo Province outlined a variety of factors which led teenagers to consider a termination of pregnancy. These included poverty, the social stigma surrounding pregnancy in teenagers, or fear of their parents' reaction to premarital pregnancy, educational difficulties, fear of a broken engagement or abandonment, or a boyfriend’s denial of paternity [11]. It was further specified that the thought of termination of pregnancy amongst teenagers can be influenced by several factors such as religious beliefs, the living environment, how the teenager relates with her parents, peer group behaviour and accessibility of family planning services [24]. More importantly, the study conducted by Frederico, Michielsen, Arnaldo, and Decat indicated that in most instances the family members of the teenagers are the ones who usually influence the teenager's decision to opt for a termination of pregnancy either directly or indirectly, for instance, most parents threaten to chase them away from home [25].

The study’s findings show that the decision to terminate the pregnancy amongst teenagers was not easy, during the process, they experienced feelings of despair. The thought of wrongdoing by ending the life of a living being led to depression of some of the other participants. In a study done by Loke and Lam, it was revealed that the personal views on life influenced their decision on what to do about their pregnancy [26]. It was reported that the teenagers who opted to retain the pregnancy perceived the fetus as a living being and respected its right to live.

The study also revealed that some teenagers experienced feelings of despair and self-blame because emotionally, they felt that ending the life of a human being is wrong and they blamed themselves. On the contrary, post TOP other teenagers had a feeling of relief; they also reveal that they were coping well and they were free from the burden of an unwanted pregnancy. MacGill and Legg outlined that despite the reason behind TOP, the emotional response might differ from feelings of being happy and relieved to feelings of sadness, grieving, and regret. Different emotions might also be engendered in the situation faced by the teenager [27]. The American Pregnancy Association outlined that it is essential that different emotions experienced by women pre and post-abortion such as anger, shame, remorse or regret, loss of self-esteem, feelings of isolation and loneliness and relationship problems, be understood and recognized [28]. Additionally, from the psychologist's perspective self-blame is an ethical and socially acceptable behaviour that displays that the teenager accepts and understands the responsibility of wrongdoing. More importantly, moving forward, it helps the teenager to maintain self-integrity and honesty [27].

The health care professionals were receptive to teenagers regarding TOP and their services were applauded and recommended by the teenagers who opted for TOP, the services included pre-and post-counselling. Furthermore, the teenagers stated that the care and support they received from the health care professionals both from the referral clinic and the hospital, made them feel at ease during the abortion process. Some teenagers relayed how they were supported by the health care professionals who were not judgemental to their decision to terminate their pregnancy. In a contrary literature review study, which was done amongst health care providers in Sub-Saharan Africa and Southeast Asia, it was revealed that health care professionals have moral, social- and gender-based uncertainties regarding the termination of pregnancy. Moreover, the uncertainties have affected their attitudes towards TOP and also affected their relationship with the pregnant woman who wishes to have an abortion [28]. In South Africa, a study by Stampler, and Flemmit, revealed that though the termination of pregnancy was legalised, most of the health care professionals are resistant to perform TOP due to moral reasons [10]. The lack of trained health care providers in public services was the main barrier for accessibility of TOP services in SA.

In conclusion, the study revealed that the teenagers who opted for TOP had different experiences related to TOP which affected how they coped. This was due to the support systems from family and health care providers. It is further concluded that consideration to opt for TOP is influenced by the community where a teenager lives, her relationship with the other parent and the behaviour of her peer group. Lack of a support system for teenagers during unplanned pregnancies does not only lead to feelings of despair and self-blame, but other negative health outcomes can affect teenagers, such as depression and suicidal thoughts. There is a need to support pregnant teenagers and assist them in their decision before and after TOP. Though TOP has been amended and legalised in South Africa, continuous awareness about TOP should be conducted in the communities and at schools.

The study was limited to one hospital which is a weakness. Nevertheless, the selected hospital is a regional hospital receiving patients from 2 district hospitals and 34 clinics.