Date Published: June 25, 2019
Publisher: Public Library of Science
Author(s): ASM Shahabuddin, Therèse Delvaux, Christiana Nöstlinger, Malabika Sarker, Azucena Bardají, Alyssa Sharkey, Ramesh Adhikari, Sushil Koirala, Md Asadur Rahman, Tahrima Mridha, Jacqueline E. W. Broerse, Vincent De Brouwere, Marianne Vidler.
Nepal has one of the highest rates of maternal mortality in the South Asia region, partly due to the underutilization of maternal health services and the high number of adolescent pregnancies. This study explores married Nepali adolescent girls’ healthcare-seeking behaviour throughout their pregnancies, during their delivery and postpartum.
We conducted a prospective qualitative study in Banke district, Nepal. In-depth interviews were conducted with 27 married adolescent girls before and after delivery. In addition, a focus group discussion was conducted with community health works and key-informant interviews were conducted with family members of adolescent girls, representatives from the government and health care providers. We applied the Social-Ecological Model (SEM) as a framework to guide thematic content analysis and presentation of our qualitative data.
Several factors in the SEM influenced maternal health care-seeking behaviour of adolescents. At the individual level, girls’ perceptions, their lack of knowledge about maternal and reproductive health, certain traditional practices, their sole dependency on their husbands and mothers-in-laws and their low decision-making autonomy towards their own health care negatively influenced their utilization of skilled maternal health services. Mothers-in-law and other family members played a critical role in either encouraging or discouraging the use of skilled maternal health services. At the health systems level, lack of adolescent-friendly maternal health services, difficulties in accessing quality maternal health services, and the fixed operating hours of public health facilities restricted their ability to obtain services. The existence of the Safe Motherhood Programme, knowledge sharing platforms such as “women’s groups” and the active role of Female Community Health Volunteers (FCHVs) positively influenced utilization of skilled maternal health services among these girls.
Influences on married adolescent girls’ use of skilled maternal health services in Banke District, Nepal were multi-factoral. Ensuring easy access and availability of adolescent-friendly maternal health services are important to encourage adolescent girls to use skilled maternal health services. Moreover, interventions are needed to improve adolescent girls’ knowledge of maternal health, keep them in school, involve family members (mainly mothers-in-law) in health interventions, as well as overcome negative traditional beliefs within the community that discourage care-seeking for skilled maternal health services.
Childbirth during adolescence (aged 10–19 years) is associated with severe health and social consequences. However, every year about 16 million adolescent girls between the ages of 15–19 give birth, of which about 95% occur in low-income countries (LICs) .
We conducted a total of 32 interviews at baseline in August 2014, of which 22 interviews were with pregnant adolescent girls and 10 were with non-pregnant adolescent girls. During the follow-up phase of data collection (December 2015), we re-interviewed 27 adolescent girls of the previous 32 participants. We were not able to re-interview five girls, because of the change of their residence or due to their travels. Among 18 adolescent pregnant girls who participated in both phases of data collection, one had a neonatal death and one experienced a stillbirth. Among the 9 non-pregnant adolescents interviewed at baseline, at follow-up three had become mothers, two were pregnant and another girl experienced a still-birth (Table 2).
The study found that several factors of each level of SEM negatively impacted the maternal health care-seeking behaviour of adolescent girls. Individual level factors, such as perceptions, in addition to lack of knowledge about maternal and reproductive health, low decision-making autonomy, shyness toward male service providers and fear of health care providers more generally, were perceived as barriers by adolescent girls in seeking ANC, PNC and hospital deliveries. Mothers-in-law and other family members (i.e. sisters-in-law) played a critical role in either encouraging or discouraging the use of skilled maternal health services. In the case of community level factors, CHWs, neighbours and women’s groups positively influenced the use of skilled maternal care. Moreover, non-availability of adolescent-friendly maternal health services, difficulties in accessing the services were they available, poor attitudes of providers and poor quality of care were also important impediments to health service utilization of the study participants.
This study revealed that adolescent girls’ perceptions, their lack of knowledge about maternal and reproductive health, low decision-making autonomy, the role of family members (particularly mothers-in-law and husbands) and lack of access to and availability of adolescent-friendly health facilities limited their use of skilled maternal health services.