Antenatal services for pregnant teenagers in Mbarara Municipality, Southwestern Uganda: health workers and community leaders’ views

According to the study participants, there were no teenager friendly antenatal services
in Mbarara municipality. The teenagers requiring antenatal care are expected to attend
the adult oriented services. The attendance of antenatal services by teenagers is
low at all the health units in the municipality. Despite the unavailability of antenatal
services specifically for teenager, the gynecologists and midwives were aware of what
could constitute teenager friendly antenatal services.

Health workers views on what would make an adolescent friendly service

Health workers viewed a teenager-friendly service as one that could provide privacy
and sufficient time and patience when dealing with teenagers. They also described
that a friendly service would be offered by health workers with specific training
in teenage pregnancy and with knowledge of how to allocate specific time to teenagers.
They also described health education and specific space for the teenagers as key components
of a teenager friendly service. In addition, a good relationship between the patient
and the midwives should characterise the service.

‘A teenager friendly service should contain health education, HIV testing and counseling,
family planning, treatment of STIs and offering Antiretroviral Therapy to the HIV
positive youths’ (Gynecologist)

‘A service with privacy; teenage mothers need enough time, patience, specific training
in teenage pregnancy for them to know how to be allocated specific time. They need
health education, specific space for them and enough trained personnel with different
skills” (Midwife)

According to the above description, such services were not available in Mbarara Municipality
at the time of the study. However, pregnant teenagers are viewed as a special group
requiring special attention.

Health workers views on Teenagers as a special group requiring attention

The Reproductive health workers in Mbarara Municipality considered teenage pregnancies
to be among the high risk pregnancies they handled. However, they did not consider
the women’s young age as the main factor. Instead, they considered possible challenges
that may be associated with young age like contracted pelvis.

‘High risk pregnancies are those in which mothers have medical complications. High
risk pregnancies may include teenage pregnancies but being teenagers alone does not
necessarily mean that the mothers should be considered as special group that needs
special attention’. (Gynecologist)

However, the teenagers were viewed as a group for which special skills were required
when managing. The health workers reported that they did not have sufficient skills
required while handling pregnant teenagers. Being able to obtain information from
the reluctant teenagers was a skill considered essential in teenager antenatal care
services.

‘Working with pregnant teenagers is challenging; some don’t know they are pregnant,
they deny and need a lot of time to understand.’ (Midwife)

Health workers views on factors affecting accessibility and utilisation of Antenatal
Care services by adolescents

The reproductive health workers reported that teenagers were not utilizing the available
reproductive health services as expected. A number of factors were raised by the midwives
involved in the study. For example, teenagers were considered as impatient; they often
require a quick service in which they do not have to wait for long. This is usually
not possible in the general antenatal services where there are many mothers with different
concerns. In addition, the teenagers would prefer to be on their own, not mixing them
with adults.

‘Teenagers don’t want to sit with adults, they fear adults, and there is inadequate
privacy in the general antenatal services. Teenagers are afraid to go to the clinics
for fear of either being seen or abused by older women and health workers’ (Midwife)

‘Teenagers may not be aware of the available antenatal services and lack support because
most of them are dependants.’ (Midwife)

In addition, most of the girls between 13 and 17 years get pregnant unwillingly and
sometimes they are infected with HIV/AIDS and other STIs. This further complicates
antenatal care seeking. They often rejected by the men responsible for pregnancy and
stay with their parents or grandparents but with limited social and financial support.

When the teenagers gain courage or support to seek antenatal care, they often find
reproductive health services which are not prepared for them. The gynaecologists and
midwives find their experience with teenagers as challenging due to limited skills
in adolescent reproductive health.

‘It has not been easy when trying to talk to the adolescents because some girls come
when they are complaining of headache and stomachache even when they know that they
are pregnant and at the end they tell the truth but not willingly. It is so challenging
in that when young girls come, they come with the aim of aborting even when they have
been counseled.’ (Mid-wife)

Availability of support for pregnant teenagers in the community

The main support for pregnant teenagers in the community was described by Village
Health Team (VHT) members as provision of information and interventions to improve
social relations with family members (VHT member).

‘When we get some of the pregnant teenagers, we sit with them, counsel them, and talk
to their parents not to harass them but to support them.’ ‘We also tell them to attend
ANC in hospitals’. (VHT member)

When a teenager becomes pregnant, the community members find themselves ill prepared
to support the teenagers. The communities in Mbarara Municipality lack specific interventions
for pregnant teenagers. However, the teenagers benefit from the advice and support
from members of the community.

‘As VHTs, we were given first aid boxes but there is nothing in them; they are just
kept.’ ‘There is no material support given to the pregnant teenagers. We offer some
little emotional support and help in looking for the men responsible for the pregnancy.’
(VHT member)

‘We try to sensitize the communities about antenatal care services through VHTs, Local
Councils; it is every body’s responsibility since it is government policy’ (LC III
Secretary for women)

Teenagers may not be able to access and utilize the available antenatal care services
due to lack sufficient social support. As a result the teenagers tend to try many
things to survive. This further puts their lives and unborn babies at increased risk.

‘I once came across a teenager who confessed that she locked a child in the house to
go to the memory pub do prostitution to earn a living. When I asked that doesn’t the
child cry? She said, I give the child piriton tablets to sleep’. (LC III Secretary
for women)

Discussion

This study assessed stakeholders’ views concerning availability, accessibility and
utilization of teenager friendly antenatal services in three divisions of Mbarara
Municipality southwestern Uganda. The study findings revealed that although it was
necessary to have teenager friendly antenatal services, there were no antenatal services
specifically targeting the needs of pregnant teenagers in the three divisions. This
is not in keeping with the sustainable development goals in which maternal and child
health is a major focus. Having no teenager friendly ANC services seems to be a challenge
of prioritization. If Uganda was to focus on the needs of the population, children
and adolescents who contribute more than 50 % of the population would have better
services. The young people are the future of the country.

The reproductive health workers in the current study reported teenage pregnancy to
be in the category of high risk pregnancies. Pregnant teenagers face multiple challenges
and may not be able to access and utilize the available antenatal services. The fact
that teenage pregnancy is associated with poor health seeking behavior has also been
reported in previous studies 20]. In addition, teenage pregnancy can result in serious, long-term negative health
effects including unsafe abortion, missed opportunities, school dropout and maternal
mortality 1], 21], 22]. It is important to note that most of the teenage pregnancies are unintended 23]. Other issues like missed opportunities while pregnant and nursing the baby and lack
of skills for parenthood were not considered being strong enough to make teenage pregnancies
high risk pregnancies.

According to this study, providing antenatal care to teenagers is quite challenging
for reproductive health workers. This could be due to lack of specific training in
how to deal with adolescents. This finding concurs with other studies which indicated
that teenagers tend to stay away from the service or default from clinic attendance
24]. The environment in which the teenagers are expected to seek service is not conducive.
They feel uncomfortable being in the same clinics with the older mothers/women. The
age difference between themselves and other women attending the clinic may make them
perceive themselves as inferior and as being treated as such at the clinic. This may
be embarrassing to them 24].

Vague symptoms, unreliable menstrual history, and adolescent reluctance to disclose
sexual activity present challenges to early diagnosis. When pregnancy is suspected,
clinicians need skills for accurate diagnosis, conducting comprehensive assessments,
and providing options counseling. These skills seem to be missing among the reproductive
health workers in the Mbarara municipality, but also likely in other areas of Sub-Saharan
Africa as well.

This study is limited by the fact that it was conducted among few stakeholders in
teenager reproductive health. There are other stakeholders like religious leaders,
community elders and cultural leaders who were not interviewed. Due to the study design,
the findings of this study cannot be generalized to the entire population in the municipality.