Implications of power imbalance in antenatal care seeking among pregnant adolescents in rural Tanzania: A qualitative study

"My father insisted that I have the baby but not in his house": Adolescent pregnancy, social exclusion and (dis)empowerment of girls in an urban informal settlement in Kenya

While the drivers of adolescent pregnancy are widely studied, few studies have examined the social exclusions associated with early and unintended pregnancy. Drawing data from a larger mixed methods study on the lived experiences of pregnant and parenting adolescents and guided by Amatya Sen's social exclusion framework, this qualitative explanatory study examines how poverty and the contestation around girls' access to comprehensive sexuality education hinder them from preventing unintended pregnancy. It also examines why adolescent pregnancy further results in girls' social exclusion with implications for their health and socioeconomic (dis)empowerment. We drew on data from in-depth interviews with purposively selected pregnant and parenting adolescents aged 15 to 19 (n = 22) and parents (n = 10), and key informant interviews with teachers (n = 4), policymakers (n = 3), community leaders (n = 6) non-governmental organization representatives (n = 2), and health workers (n = 4). Through inductive and deductive thematic analysis, we found that poverty and lack of access to contraceptive information and services contributed to girls' vulnerability to early unintended pregnancies. Becoming pregnant exacerbated girls' social exclusion, which is characterized by self-isolation, being disowned by their families, or forced to drop out of school. Shame, stigma, and discrimination of girls made girls seek antenatal care late. They also failed to complete the recommended number of antenatal care visits. Marginalization of pregnant and parenting girls results in them being out of school, vocational training, and employment, as well as experiencing mental distress. The analysis shows the social exclusion of girls is cyclical, beginning before their pregnancy and continuing into pregnancy and post-pregnancy. Their social exclusion has negative implications for their health and socio-economic empowerment. Interventions to address adolescent childbearing should holistically address the social exclusion that predisposes girls to unintended pregnancy and that follows during and post-pregnancy, as tackling this exclusion is key to improving their health and socioeconomic well-being.

Adolescent maternal health services utilization and associated barriers in Sub-Saharan Africa: A comprehensive systematic review and meta-analysis before and during the sustainable development goals

Introduction

Effective and adequate maternal health service utilization is critical for improving maternal and newborn health, reducing maternal and perinatal mortality, and important to achieve global sustainable development goals (SDGs). The purpose of this systematic review was to assess adolescent maternal health service utilization and its barriers before and during SDG era in Sub-Saharan Africa (SSA).

Methods

Systematic review of published articles, sourced from multiple electronic databases such as Medline, PubMed, Scopus, Embase, CINAHL, PsycINFO, Web of Science, African Journal Online (AJOL) and Google Scholar were conducted up to January 2024. Assessment of risk of bias in the individual studies were undertaken using the Johanna Briggs Institute (JBI) quality assessment tool. The maternal health service utilization of adolescent women was compared before and after adoption of SDGs. Barriers of maternal health service utilization was synthesized using Andersen's health-seeking model. Meta-analysis was carried out using the STATA version 17 software.

Results

Thirty-eight studies from 15 SSA countries were included in the review. Before adoption of SDGs, 38.2 % (95 % CI: 28.5 %, 47.9 %) adolescents utilized full antenatal care (ANC) and 44.9 % (95%CI: 26.2, 63.6 %) were attended by skilled birth attendants (SBA). During SDGs, 42.6 % (95 % CI: 32.4 %, 52.8 %) of adolescents utilized full ANC and 53.0 % (95 % CI: 40.6 %, 65.5 %) were attended by SBAs. Furthermore, this review found that adolescent women's utilization of maternal health services is influenced by various barriers, including predisposing, enabling, need, and contextual factors.

Conclusions

There was a modest rise in the utilization of ANC services and SBA from the pre-SDG era to the SDG era. However, the level of maternal health service utilization by adolescent women remains low, with significant disparities across SSA regions and multiple barriers to access services. These findings indicate the importance of developing context-specific interventions that target adolescent women to achieve SDG3 by the year 2030.

Long-term retention on antiretroviral treatment after enrolment in prevention of vertical HIV transmission services: a prospective cohort study in Dar es Salaam, Tanzania

INTRODUCTION

To prevent vertical HIV transmission and ensure healthy mothers and children, pregnant women with HIV must remain on antiretroviral treatment (ART) for life. However, motivation to remain on ART may decline beyond the standard 2-year breastfeeding/postpartum period. We assessed attrition and retention in ART care among women with HIV up to 6 years since enrolment in vertical transmission prevention services in Dar es Salaam, Tanzania.

METHODS

A prospective cohort of 22,631 pregnant women with HIV were enrolled in vertical transmission prevention services between January 2015 and December 2017 in routine healthcare settings and followed-up to July 2021. Kaplan-Meier was used to estimate time to ART attrition (died, stopped ART or was lost to follow-up [no show ≥90 days since scheduled appointment]) and the proportion retained in care. Cox proportional hazard models were used to estimate adjusted hazard ratios (aHR) of ART attrition in relation to predictors.

RESULTS

Participants were followed-up to 6 years for a median of 3 years (IQR: 0.1-4). The overall ART attrition rate was 13.8 per 100 person-years (95% CI: 13.5-14.1), highest in the first year of enrolment at 27.1 (26.3-27.9), thereafter declined to 9.5 (8.9-10.1) in year 3 and 2.7 (2.1-3.5) in year 6. The proportion of women retained in care were 78%, 69%, 63%, 60%, 57% and 56% at 1, 2, 3, 4, 5 and 6 years, respectively. ART attrition was higher in young women aged <20 years (aHR 1.63, 95% CI: 1.38-1.92) as compared to 30-39 year-olds and women enrolled late in the third versus first trimester (aHR 1.29, 95% CI: 1.16-1.44). In contrast, attrition was lower in older women ≥40 years, women who initiated ART before versus during the index pregnancy and women attending higher-level health facilities.

CONCLUSIONS

ART attrition among women with HIV remains highest in the first year of enrolment in vertical transmission prevention services and declines markedly following a transition to chronic HIV care. Targeted interventions to improve ART continuity among women with HIV during and beyond prevention of vertical transmission are vital to ending paediatric HIV and keeping women and children alive and healthy.

Mental health outcomes beyond the post-partum period among adolescent mothers: a systematic review and meta-analysis

Background

Adolescence is the most crucial part of life. The vulnerability of adolescent mothers is even more pronounced and can affect various health aspects. While they suffer from social and emotional stresses shortly after giving birth, the long-term effect after the post-partum period of adolescent pregnancy on the mental outcomes holds prime importance. Thus, this systematic review aims to ascertain the association between adolescent pregnancy on mental health outcomes.

Methods

The search strategy was run in June 2023 on databases including PubMed, CINAHL, Scopus, Psych Info, and Embase . Quality assessment of the studies was done using the National Institute of Health (NIH)'s National Heart, Lung and Blood Institute (NHLBI) tool for observational studies. For studies that measured similar outcomes, a meta-analysis was conducted.

Findings

The search strategy yielded 21 results from all databases and cross-referencing. Of these, all except for one (case-control) were cross-sectional and cohort studies. The pooled analysis found a significant association between adolescent pregnancy and depression (RR 1.34; 95% CI 1.05, 1.72, 6 studies, heterogeneity: Chi2 P 0.01; I2 = 60%); however, no association was found in anxiety (RR 1.05; 95% CI 0.26, 4.14, 2 studies; heterogeneity: Chi² P = 0.0003; I2 = 93%) and suicidal ideation (RR 3.21; 95% CI 0.17, 59.33; 3 studies; heterogeneity: Chi2 P < 0.00001; I2 = 98%).

Implication

These findings suggest that the mental health needs of adolescent mothers must be addressed and innovative and effective interventions that support and address the mental health needs of adolescent mothers are needed to improve their mental health.

Adolescent perspectives on peripartum mental health prevention and promotion from Kenya: Findings from a design thinking approach

In Kenya, approximately one in five girls aged 15-19 years old are pregnant or already a mother. Adolescent girls and young women experience significant mental health vulnerabilities during the pregnancy and postpartum periods, leading to poor antenatal and postnatal care attendance and inferior infant and maternal health outcomes. Pregnant adolescents often experience stigma and disenfranchisement due to their pregnancy status and at the same time lack access to mental health support within health settings, schools, religious institutions, and communities. This paper presents the results of qualitative interviews embedded within the human-centered design (HCD) process used to adapt the Helping Adolescents Thrive (HAT) program for Kenyan peripartum adolescents including young fathers. This qualitative study used two phases. First, a HAT advisory group participated in a series of four workshops to help identify and articulate mental health promotion needs and deepened the team's understanding of youth-centered thinking. Second, qualitative interviews were conducted with 39 pregnant and parenting adolescents to understand their perspectives on mental health prevention and promotion. Pregnant and parenting adolescents articulated different needs including poor support, stigma, and psychological disturbances. Parenting adolescents reported disturbed relationships, managing motherhood, poor health, and social empowerment. Participants highlighted sources of stress including economic challenges, fear of delivery, strained relationships, rejection, and stigma. Participants described psychological disturbances such as feeling stressed, worthless, withdrawn, and suicidal. Coping mechanisms reported by participants included engaging in domestic activities, hobbies, and social networking. Peers, family and spirituality were identified as important sources of support, as well as school integration, livelihoods, support groups and mentorships. Findings from this study can be used to strengthen and adapt HAT program, policy and practice for mental health prevention and promotion for pregnant and parenting adolescents.

Navigating antenatal care: The lived experiences of adolescent girls and young women and caregiver perspectives in Zambia

INTRODUCTION

Adolescent pregnancy remains a global concern, especially in low- and middle-income countries. Sub-Saharan African nations, including Zambia, bear a disproportionate burden of adolescent pregnancies, contributing to high rates of maternal and child mortality. Despite efforts to improve antenatal care (ANC) services, utilization rates remain suboptimal, especially among adolescent girls and young women (AGYW).

OBJECTIVE

To explore the barriers and facilitators to ANC services among AGYW and how these factors might differ by age and HIV status.

DESIGN

This qualitative study employs a combination of in-depth interviews (IDIs) and focus group discussions (FGDs) to gather comprehensive insights into the experiences of AGYW regarding ANC services. The study design follows a socio-ecological framework (SEF) to identify multiple levels of influence on ANC utilization.

METHODS

We conducted 40 IDIs with AGYW aged 15-24; and 2 FGDs with caregivers of AGYW (n = 16). IDIs explored AGYWs barriers and facilitators to accessing and utilizing healthcare services during pregnancy, as well as social support and HIV treatment and prevention. FGD topics included social support, barriers and facilitators to ANC, and HIV services. We developed a codebook based on the SEF and coded transcripts using Dedoose software.

RESULTS

Results showed that early pregnancy knowledge did not always translate to AGYW seeking ANC services right away or within the first trimester. More than half of the AGYW did not initiate ANC until well into the second trimester. Factors including lack of motivation, denial of pregnancy, desires to terminate pregnancies, social norms, policies, clinic environment, and financial constraints contributed to delays in ANC initiation. Social support from family, partners, peers, and the community were crucial motivators for early ANC. Lastly, challenges to ANC continuation included lack of transportation, long clinic waiting times, perceived provider indifference, and stigma at both community and clinic levels.

CONCLUSION

In conclusion, gaining insights from qualitative data is essential for comprehensively understanding the barriers and challenges to accessing ANC among this specific age group. By identifying and addressing these barriers while enhancing facilitators, effective programs can be developed and implemented to improve the health and well-being of young mothers and their children.

Evaluation of a comprehensive maternal newborn health intervention in rural Tanzania: single-arm pre-post coverage survey results

Background

In Tanzania, maternal and newborn deaths can be prevented via quality facility-based antenatal care (ANC), delivery, and postnatal care (PNC). Scalable, integrated, and comprehensive interventions addressing demand and service-side care-seeking barriers are needed.

Objective

Assess coverage survey indicators before and after a comprehensive maternal newborn health (MNH) intervention in Misungwi District, Tanzania.

Methods

A prospective, single-arm, pre- (2016) and post-(2019) coverage survey (ClinicalTrials.gov #NCT02506413) was used to assess key maternal and newborn health (MNH) outcomes. The Mama na Mtoto intervention included district activities (planning, leadership training, supportive supervision), health facility activities (training, equipment, infrastructure upgrades), and plus community health worker mobilization. Implementation change strategies, a process model, and a motivational framework incorporated best practices from a similar Ugandan intervention. Cluster sampling randomized hamlets then used ‘wedge sampling’ protocol as an alternative to full household enumeration. Key outcomes included: four or more ANC visits (ANC4+); skilled birth attendant (SBA); PNC for mother within 48 hours (PNC-woman); health facility delivery (HFD); and PNC for newborn within 48 hours (PNC-baby). Trained interviewers administered the ‘Real Accountability: Data Analysis for Results Coverage Survey to women 15–49 years old. Descriptive statistics incorporated design effect; the Lives Saved Tool estimated deaths averted based on ANC4+/HFD.

Results

Between baseline (n = 2,431) and endline (n = 2,070), surveys revealed significant absolute percentage increases for ANC4+ (+11.6, 95% CI [5.4, 17.7], p < 0.001), SBA (+16.6, 95% CI [11.1, 22.0], p < 0.001), PNC-woman (+9.2, 95% CI [3.2, 15.2], p = 0.002), and HFD (+17.2%, 95% CI [11.3, 23.1], p < 0.001). A PNC-baby increase (+6.1%, 95% CI [−0.5, 12.8], p = 0.07) was not statistically significant. An estimated 121 neonatal and 20 maternal lives were saved between 2016 and 2019.

Conclusions

Full-district scale-up of a comprehensive MNH package embedded government health system was successfully implemented over a short time and associated with significant maternal care-seeking improvements and potential for lives saved.

Determinants of health facility delivery among young mothers in Ghana; insights from the 2014 Ghana Demographic and Health Survey

Background

Globally, young women deliver at home, often under unhygienic conditions and without skilled birth attendants. This study identified the determinants of health facility delivery among young mothers in Ghana.

Methods

We analysed secondary data from the 2014 Ghana Demographic and Health Survey, which collected data across the former ten administrative regions of Ghana. This study analysed data from the ‘women file’ by adjusting for the sample weight. STATA/SE version 16 was employed to analyse the data by computing descriptive statistics, Chi-square, and Binary Logistic Regression.

Results

Seven in ten young mothers gave birth in a health facility. Young mothers who had secondary school education were over three-fold more likely to deliver in a health facility (AOR = 3.5, 95% CI: 1.33–9.23) compared with young mothers with no formal education. Young mothers who resided in rural areas had lower odds (73%) of delivering in a health facility (AOR = 0.27; 95% CI: 0.14–0.514) compared with those in urban areas. Young mothers within the richest wealth quintile also had higher odds (8 times) of delivering in a health facility (AOR = 8.24; 95% CI: 0.95–71.77) compared with those within the poorest wealth quintile. Young mothers who obtained four to seven antenatal visits (AOR = 0.53; 95% CI: 0.27–1.03) had lower odds of delivering in a health facility compared with those who obtained eight or more antenatal visits.

Conclusion

The majority of young mothers in Ghana gave birth in a health facility. The likelihood of delivering in a health facility was influenced by socio-demographic factors, economic factors and utilization of antenatal care services. Therefore, interventions aimed at increasing utilization of skilled delivery among young women should focus on promoting girl child education, economic status and antenatal care visits.

Utilization of antenatal care among adolescent and young mothers in Ghana; analysis of the 2017/2018 multiple indicator cluster survey

Background

Complications during pregnancy and childbirth are the leading cause of death among adolescent girls. In Ghana, the prevalence of adolescent pregnancy remains high. Yet, little is known about ANC utilization among adolescent and young mothers. This study aimed to assess the prevalence of obtaining 4 or more ANC visits and associated factors among adolescent and young mothers.

Methods

We analysed secondary data from the sixth round of the Ghana Multiple Indicator Cluster Survey. A total of 947 adolescent and young mothers were included in this study. Data were analysed using STATA/SE, version 16, employing descriptive statistics and Binary Logistic Regression.

Results

It was found that majority of the participants were aged 20-24 years (70%), married/in union (61%) and non-insured (64%). The prevalence of obtaining 4 or more ANC visits was 84%. Adolescent and young mothers with junior high school education, in the second wealth quintile, exposed to the internet, and resided in the Upper East region had a higher likelihood of obtaining 4 or more ANC visits (p < 0.05).

Conclusions

This study demonstrated that optimal ANC utilization among adolescent and young mothers were determined by socio-economic factors. Going forward, maternal healthcare interventions must prioritize adolescent and young mothers from poor socio-economic backgrounds.