Date Published: June 7, 2019
Publisher: Public Library of Science
Author(s): Nicole B. Carbone, Joseph Njala, Debra J. Jackson, Michael T. Eliya, Chileshe Chilangwa, Jennifer Tseka, Tasila Zulu, Jacqueline R. Chinkonde, Judith Sherman, Chifundo Zimba, Innocent A. Mofolo, Michael E. Herce, Mellissa H Withers.
Pregnant and post-partum adolescent girls and young women (AGYW) living with HIV in sub-Saharan Africa experience inferior outcomes along the prevention of mother-to-child transmission of HIV (PMTCT) cascade compared to their adult counterparts. Yet, despite this inequality in outcomes, scarce data from the region describe AGYW perspectives to inform adolescent-sensitive PMTCT programming. In this paper, we report findings from formative implementation research examining barriers to, and facilitators of, PMTCT care for HIV-infected AGYW in Malawi, and explore strategies for adapting the mothers2mothers (m2m) Mentor Mother Model to better meet AGYW service delivery-related needs and preferences.
Qualitative researchers conducted 16 focus group discussions (FGDs) in 4 Malawi districts with HIV-infected adolescent mothers ages 15–19 years categorized into two groups: 1) those who had experience with m2m programming (8 FGDs, n = 38); and 2) those who did not (8 FGDs, n = 34). FGD data were analyzed using thematic analysis to assess major and minor themes and to compare findings between groups.
Median participant age was 17 years (interquartile range: 2 years). Poverty, stigma, food insecurity, lack of transport, and absence of psychosocial support were crosscutting barriers to PMTCT engagement. While most participants highlighted resilience and self-efficacy as motivating factors to remain in care to protect their own health and that of their children, they also indicated a desire for tailored, age-appropriate services. FGD participants indicated preference for support services delivered by adolescent HIV-infected mentor mothers who have successfully navigated the PMTCT cascade themselves.
HIV-infected adolescent mothers expressed a preference for peer-led, non-judgmental PMTCT support services that bridge communities and facilities to pragmatically address barriers of stigma, poverty, health system complexity, and food insecurity. Future research should evaluate implementation and health outcomes for adolescent mentor mother services featuring these and other client-centered attributes, such as provision of livelihood assistance and peer-led psychosocial support.
The rate of adolescent pregnancy in sub-Saharan Africa (SSA) is much higher compared to other regions in the world, with a birth rate among adolescent girls (15–19 years) over 200 births per 1,000 girls . Adolescent girls also experience worse pregnancy and health outcomes compared to adult mothers. Available evidence indicates that adolescent girls have higher risk of preterm delivery, eclampsia, stillbirth, and maternal mortality, and their infants are more likely to have low birth weight and neonatal complications [2–4]. Additionally, many girls who become pregnant during adolescence drop out of, or never enter, secondary school, which limits both their educational and economic opportunities and may further perpetuate poverty and gender inequality .
Our qualitative findings illustrate the main barriers to engaging and retaining HIV-infected adolescent mothers and their infants in the PMTCT cascade in Malawi, and how existing PMTCT support programs can be tailored to better meet the unique needs of adolescent mothers living with HIV in sub-Saharan Africa. We provide some of the first qualitative descriptions from the region about the service delivery preferences of HIV-infected adolescent mothers, including their wish to receive support from trained lay providers in their peer group who have experience successfully navigating the PMTCT cascade and who may be younger than existing mentor mothers in traditional m2m programming.
In conclusion, adolescent mothers living with HIV in SSA face multi-level barriers to PMTCT care and express preferences for peer-driven support services. The desired support services should be delivered by young women who are mothers living with HIV themselves, relatable, and uphold privacy and confidentiality. These women should offer services that are non-judgmental, bridge communities and facilities, and address barriers of stigma, poverty, health system complexity, and food insecurity, among others. Future mentor mother programs focused on adolescent mothers living with HIV should incorporate socioeconomic interventions, such as cash transfers, income generating activities, or other social protection approaches that pragmatically lower structural barriers to HIV care. To engage and retain adolescent mothers in the PMTCT cascade, they need opportunities to build their own livelihoods and meet their basic needs, feel empowered to stay in care to promote their own health and that of their children, and access to high-quality, longitudinal, peer-led psychosocial support touching on multiple aspects of their lives.