Health-seeking behaviours of pregnant adolescents: a scoping review

Adolescents (aged 10–19 years old) are an important group with vital roles in developing countries in the future (World Health Organization (WHO), 2014). However, over 1.5 million adolescents and young adults (aged 10–24 years) died in 2019, amounting to almost 5000 per day; globally, 43 births per 1000 are from those aged 15–19 years every year (WHO, 2021). In developing countries, approximately 12 million girls between 15 and 19 years old, and at least 777 000 girls under the age of 15 years, give birth annually (WHO, 2014).

Adolescent pregnancy can have a major impact on an adolescent's life. A study in Brazil found a strong cause–effect relationship between adolescent pregnancy and school dropout, bolstered by economic vulnerability (Cruz et al, 2021). An adolescent becoming pregnant may also influence younger siblings to become pregnant at a similar age (Wall-Wieler et al, 2016). Adolescent pregnancy can be linked to depression, history of abortion and relationship factors, such as partner support (Maravilla et al, 2017). Maternal mortality is reportedly highest in adolescent girls under 15 years, and pregnancy and childbirth complications more common in girls aged 10–19 years compared to women aged 20–24 years (Djuwitaningsih and Setyowati, 2017).

A study in Canada reported that during pregnancy, teenage mothers had a higher rate of depression (9.8%) than mothers who became pregnant later in life (P<0.001) (Wong et al, 2020). They were also found to use more tobacco, marijuana and alcohol (P<0.001). In addition, teenage mothers were considered at risk for developing postnatal depression, school dropout and low socioeconomic status and their pregnancy risk included premature birth, low birth weight, later developmental delays and behavioural disorders (Goossens et al, 2015).

The provision of adequate information is important for pregnant adolescents' wellbeing. According to a survey of 364 adolescents in Iran, the internet and social media were the two top sources of health information found to be related to high-risk behaviour in adolescents. Reported barriers to health-seeking for information were ‘difficulty in determining the quality of the information found’, ‘lack of appropriate information’, and ‘concerns about disclosing their problems or illness to others’ (Esmaeilzadeh et al, 2018). A study conducted in Bangladesh on health-seeking behaviour among married pregnant adolescents showed that adolescent women had little decision-making autonomy. Interpersonal and family-level factors were essential in using skilled maternal health services (Shahabuddin et al, 2017). In Ghana, pregnant adolescents were found to primarily rely on traditional sources for information on pregnancy, compared to sources such as midwives, nurses or doctors (Owusu-Addo et al, 2016).

Adolescent mothers must receive adequate antenatal care. According to the WHO (2019), all women need access to high-quality care from pregnancy to childbirth. Regular antenatal care has been found to directly impact maternal and neonatal outcomes (Afrose et al, 2021). Antenatal care provides an opportunity for early detection of pregnancy-related risks and provision of appropriate treatment. During antenatal care, pregnant women receive education and suggestions from health professionals, including how to deal with pregnancy complaints and any complications they might have. More frequent antenatal care visits is linked to a lower risk of stillbirth, as it provides more opportunities to identify and treat possible issues. Eight or more antenatal care visits can lower perinatal mortality by as much as eight per 1000 newborns, compared to four visits (Noble, 2016). Antenatal care and intervention can also help mothers achieve better outcomes after childbirth. For example, antenatal education on breastfeeding was found to improve knowledge of breastfeeding, behaviour and self-efficacy in Iraq (Piro and Ahmed, 2020). A quasi-experimental intervention study in Spanish women of at least 12 weeks' gestation reported that the prenatal education programme for pregnant women had a significant impact on infants' postnatal nutritional status 4 months after birth (Ortiz-Félix et al, 2021).

However, adolescent mothers' antenatal care and healthcare-seeking behaviours appear to be suboptimal. According to a study in Bangladesh, only 18% of mothers received the WHO-recommended optimal level of four or more antenatal care visits. Factors influencing this phenomenon were being <20 years old, living in rural areas, having no education and media exposure, being multiparous, having low wealth status and having an uneducated or unemployed husband (Islam and Masud, 2018). This study also indicated that adolescent mothers (those under 20 years old) belonged to a vulnerable group with lower antenatal attendance.

Understanding adolescent mothers is crucial, particularly in understanding their health-seeking behaviour and the factors that influence it. However, overall understanding of health-seeking behaviour among this group during pregnancy varies. This scoping review aimed to explore the literature on health-seeking behaviour among pregnant adolescents from different cultural and geographical areas. It explored their experiences seeking healthcare, based on the available services offered to pregnant adolescents, and identified associated factors and frameworks used to explore this phenomenon. This information can assist organisations to assess health-seeking behaviour among pregnant adolescents and provide insights for healthcare providers, related stakeholders and other professionals to design programs that can improve health-seeking behaviours and antenatal care among pregnant adolescents. This can improve pregnant adolescents' and babies' health and wellbeing.

Methods

This study was developed based on Arskey and O'Malley's (2005) scoping review methodology. According to this framework, there are six stages: (1) identifying the research question, (2) identifying relevant studies, (3) selecting studies, (4) charting data, (5) collating, summarising and reporting the results and (6) consultation (which is optional).

Identifying the research question

The research questions underpinning this scoping review were: what are the challenges and experiences faced by adolescents when they are pregnant? What factors influence health-seeking behaviours and antenatal care attendance among pregnant adolescent women? What are their perceptions of and attitudes to the use of health services and antenatal care?

Identifying relevant studies

Articles were included if they had at least one main finding related to health-seeking behaviour and antenatal care in adolescent pregnancy. Articles were selected if they were published between March 2012 and March 2022, written in English, used primary quantitative, qualitative or mixed-methods and addressed an aspect of adolescent pregnancy, including attitudes, beliefs and perceptions of adolescent pregnancy, healthcare seeking behaviour among pregnant adolescents, antenatal care use or use of maternity healthcare by adolescents during pregnancy (Table 1).

Relevant studies were identified by searching Science Direct, PubMed, Wiley, Taylor and Francis Online, ProQuest and Ebsco using the following search terms: (health-care seeking behaviour) AND (pregnant) OR (pregnancy) AND (adolescent) OR (teenage) AND (antenatal care).

Study selection

Following the database search, 1952 titles and abstracts were identified and uploaded into the online Covidence program. At this point, 909 duplicates were removed, leaving a total of 1043 studies. Titles and abstracts were read and 977 articles were excluded because they had irrelevant titles or abstracts. Two researchers with similar interests and expertise in their area of research reviewed the full texts of the remaining 66 articles. A total of 41 articles were excluded for ineligible population (n=13), not providing the intended information (n=18), wrong outcomes (n=6) and wrong study design (n=4). A total of 25 articles were included in the final review. The process and results of screening are presented in Figure 1.

Data collection

A data collection instrument was developed to confirm study relevance and extract study characteristics. These included, but were not limited to, year and type of publication, study design, country, population characteristics, setting, definition of health-seeking behaviour among pregnant adolescents, enabling factors and barriers related to antenatal health-seeking behaviour among pregnant adolescents, and adolescent experience in using healthcare centres. Two authors independently conducted data extraction from all included studies to ensure that all information were accurately captured. The research team compared and analysed all data and further discussion was carried out if needed to ensure consistency between both reviewers. The extracted data are available from the authors on reasonable request.

Data summary and synthesis of results

Each article included in the review was appraised using the mixed method appraisal tool (Hong et al, 2018). Critical appraisal was performed independently by two authors to better understand the significance and value of each study, and both reviewer's appraisal scores were consistent (Whittemore and Knafl, 2005; Crossetti, 2012). The tool by Hong et al (2018) was chosen as it provides a consistent and accessible method to evaluate quality of papers. The tool's checklist is also simple but comprehensive. The next step was data reduction (Tracy, 2012).

Results

A total of 25 studies were included, representing a range of low-to middle-income countries (Table 2). Most included studies were qualitative (n=13), with 11 quantitative and one mixed-methods study. Most studies aimed to assess factors influencing health-seeking behaviour and antenatal care use among adolescent pregnant women, including barriers causing delay in seeking healthcare. Most reviewed studies were conducted in Africa (West Africa=8, East Africa=7, South Africa=3). The others were conducted in Asia (n=6) and the USA (n=1).

Eight studies used theories and models of behavioural change, while the theoretical framework was not reported in the remaining 17 studies. The included studies explored different aspects of the research topic, including women's experiences of adolescent pregnancy (n=17), factors influencing health-seeking behaviour and antenatal care use among adolescent pregnant women (n=17) and use of health services and antenatal care among adolescent pregnant women (n=18).

Theories and models of behavioural change

Ten studies used theories and models to describe their study design. Three used the socioecological model for health-seeking behaviour to assess factors influencing antenatal and health-seeking behaviour and assess barriers to accessing care (Erasmus et al, 2020; Mweteni et al, 2021; Pike et al, 2021). Two used Colaizzi's method to analyse interview data (Al-Kloub et al, 2019; Astuti et al, 2020). One used the ecological-systems model theory to explore experiences and perceptions of pregnant adolescents (Asonye, 2014), and another used social exclusion theory to explain aspects of healthcare workers' poor attitudes to young mothers (Dzotsi et al, 2020). One study used the feminist theory of intersectionality to analyse sociocultural and demographic influences and how they affected adolescent participants' experiences of their first pregnancies (Hamza, 2021). One study used the three delay model to understand and explore adolescent mothers' health-seeking behaviour (Massaquoi et al, 2021). Another study used a grounded and inductive approach to explore themes identified iteratively from the data (November and Sandall, 2018).

Women's experiences of adolescent pregnancy

Women experienced a range of emotions about pregnancy as adolescents. A study by Kaphagawani and Kalipeni (2017) in Malawi indicated that over 76% of adolescent respondents had an unplanned pregnancy, and these participants were more likely to be unmarried. Factors found to influence teenage pregnancy included early sex and marriage, low contraceptive use, low educational levels, low socio-economic status, lack of knowledge of reproductive and sexual health, gender inequity and physical/sexual violence. There was a reported perception among participants that they could start having sexual intercourse and marry soon after the onset of menarche (Kaphagawani and Kalipeni, 2017).

A study in Sierra Leone showed that adolescents engaged in sexual activities for school fees, with teachers for grades, for food and clothes and to lessen the impact of time-consuming duties of water collection and petty trading (Massaquoi et al, 2021). The criminal justice system and availability and accessibility of contraception and abortion were included in this major theme. Vulnerability to death once pregnant was another important theme, under which abandonment, delayed care-seeking and being cared for by a non-parental adult were identified as contributing factors (Kaphagawani and Kalipeni, 2017).

For the majority of adolescents, once they disclosed their pregnancy, they reported experiencing stigmatisation, isolation, exclusion and shame from society. These experiences led some to consider terminating their pregnancy (Astuti et al, 2020). In Astuti et al's (2020) study in Indonesia, adolescents also expressed the desire to commit suicide. Almost all participants were ‘pressurised’ by their families to get married, in order to comply with social, religious, and cultural expectations. They reported ‘feeling powerless’ and ‘forced’ by their families to marry. They had no choice in the matter but to ‘end adolescent life’ and ‘journey into new life.’ Indonesian adolescents and young parents' experiences revealed the powerful influence of culture and religion on policy and social structure (Mashala et al, 2012).

Adolescents expressed a lack of preparedness for the challenges of motherhood, uncertainty about the future and feelings of anger, regret and anxiety. Mashala et al (2012) found that relationships were strained after disclosure, particularly father-daughter relationships. A study in Ghana similarly reported that challenges associated with teenage motherhood led to strained interpersonal relationships (with parents or partners), social stigma and survival difficulties, including financial hassles and accommodation problems.

Other challenges of adolescent pregnancy included educational disruption (the desire to return to school, but difficulties that hampered them) and a steep transition to adulthood (premature motherhood, biological and psychological facts did not support social expectations) (Dzotsi et al, 2020). Furthermore, adolescents and young adults in Canada were more likely to have experienced physical abuse in the last 2 years, initiate prenatal care late and not take folic acid before or during pregnancy. They also had poor prenatal health-seeking behaviours, lower caesarean delivery rate and lower breastfeeding initiation and duration rates, as well as experiencing more stressful life events and postpartum depression symptoms, and rating their own or their infant's health as suboptimal (Kingston et al, 2012).

Influencing factors

Various factors influenced adolescent health-seeking behaviour and antenatal care use among adolescent pregnant women, including their age, education, marriage and social status, location and family support.

Age

Studies in Zambia, Indonesia and Tanzania reported that women's age was associated with antenatal care use. Women in Zambia aged 20–34 years were less likely to book late for antenatal care (P=0.009) compared to women <20 years old (Sinyange et al, 2016). A study in Indonesia among 13 520 women aged 15–24 years found that only 17.8% attended antenatal care more than four times, and antenatal care visits and skilled birth attendants were associated with age (Andriani et al, 2021).

In Tanzania, various factors were associated with adequate antenatal care attendance, including being older (Kasagama et al, 2022). The likelihood of women using recommended maternal healthcare services increased with age at first birth (20–29 years) (Kurniati et al, 2018). In contrast, Akinyemi et al (2021) found that in Nigeria, age, religion and age at first sexual interaction were not significant predictors of visiting antenatal care more than four times (Akinyemi et al, 2021).

Education

Studies in Tanzania, Indonesia, and Nigeria showed that education was essential for promoting health-seeking behaviours and antenatal care attendance among adolescent pregnant women. In Nigeria, more highly educated women were almost three times more likely to report attending four antenatal care visits (Akinyemi et al, 2021), and those with secondary education or higher were more likely to attend antenatal care (Kasagama et al, 2022) and book early (Alex-Ojei and Odimegwu, 2021). Education and an academic partner were also associated with higher complete antenatal care use (Alex-Ojei and Odimegwu, 2021). A study evaluating factors influencing Indonesian women's use of maternal healthcare services indicated that the likelihood of using services increased with educational attainment among women and their spouses (Kurniati et al, 2018).

Marriage and social status

A study in Nigeria of family context and antenatal care use showed that marriage and social position were crucial. Further analysis indicated that among unmarried adolescents who were pregnant, those who had a higher social status were twice as likely to attend more than four antenatal care visits (Akinyemi et al, 2021). Higher wealth status also contributed to decision-making about health in Nigeria (Alex-Ojei and Odimegwu, 2021). Additionally, married women used maternal health services more than single women (86% vs 67%) (Mekwunye and Odetola, 2020). In Tanzania, adequate antenatal care attendance was influenced by household wealth index; mothers of a lower index attended fewer antenatal care visits (Kasagama et al, 2022).

Location

Studies in Tanzania and Nigeria showed that location determined health-seeking behaviours and antenatal care. Mothers in urban areas of Nigeria were almost three times as likely to have adequate antenatal care (Akinyemi et al, 2021), while those living in the northwest, south and southwest were less likely to initiate antenatal care early. Living in the southwest was also associated with higher complete antenatal care use (Alex-Ojei and Odimegwu, 2021). In Tanzania, geographical zone and distance to health facilities influenced antenatal care use (Kasagama et al, 2022).

Family support

Support from husbands and family was crucial for adolescent pregnant women. Pike et al (2021) reported that among the Bangladeshi community, families highly influenced pregnant adolescents' health-seeking behaviours. Mothers/mothers-in-law primarily took on decision-making roles, with husbands actively participating. Adolescents valued family support but felt a loss of autonomy and agency on becoming pregnant. In line with this, Hamza (2021) identified that most women in Bangladesh could not make decisions for themselves, husbands were the most critical factor in care-seeking choices. In Indonesia, attending at least four antenatal care visits and skilled attendants at birth were associated with family influence (Andriani et al, 2021).

Other factors

Other factors that influenced health-seeking behaviours and antenatal care attendance included pregnancy intention and various sociodemographic characteristics that varied by region. Young mothers in Nigeria who intended to be pregnant at the time of their pregnancy were reportedly twice as likely to attend antenatal care more than four times (Akinyemi et al, 2021). Data from the Tanzanian demographic health surveys in 2004/2005, 2010 and 2015/2016 showed that attending antenatal care in the first trimester, multiparity, wanting pregnancy later and watching TV at least once a week were all associated with antenatal care use (Kasagama et al, 2022). An early first visit accounted for 51% of overall changes in adequate antenatal care attendance (Kurniati et al, 2018).

Barriers to health-seeking behaviours and antenatal care

Various barriers were identified to encouraging health-seeking behaviour and antenatal care attendance. Difficulty obtaining permission to go to a health facility and the distance to travel were associated with a lower likelihood of antenatal care use in Nigeria (Alex-Ojei and Odimegwu, 2021). Additionally, Asonye (2014) identified that lack of money or not thinking it appropriate to start prenatal care prevented prenatal care registration. In Tanzania, perceived poor quality of care, late recognition of pregnancy and not being supported by their husband/partner were associated with later antenatal care enrolment (Gross et al, 2012).

Barriers also included negative emotional responses, lack of knowledge, fear of disclosing the pregnancy or of punishment, stigmatisation and judgment, and negative perceptions from healthcare workers (Erasmus et al, 2020). Harmful gender norms, stigma, discrimination and increased abuse and disrespect for younger, less educated or less wealthy women also hindered access to services (Hamza, 2021). During the Ebola pandemic, fear of contracting Ebola was a common reason for not seeking care or using services (Massaquoi et al, 2021). Adolescent antenatal care-seeking can be compromised by a complex power imbalance involving financial dependence, lack of choice, personal autonomy in decision-making and experiences of social stigma, judgment, violence and abuse (Mweteni et al, 2021).

Women's experiences of health services and antenatal care

In Jordan, Al-Kloub et al (2019) reported that all participants were not allowed to seek help alone at a hospital or health centre because their husbands or husbands' parents made decisions about their health, even for antenatal care. Some participants reported that they could not negotiate with their husbands on healthcare needs or family planning methods. In Bangladesh, the cultural norm to respect their husband and mother-in-law similarly gave them influence in decision making (Upadhyay et al, 2014). The authors noted that this ‘autonomy effect’ may have overestimated the influence of other family members, particularly among adolescents (Upadhyay et al, 2014).

In Nigeria, Asonye (2014) reported that most pregnant adolescents registered for and received prenatal care. However, some stated that they had registered but did not attend as they felt shy or discouraged. Some had not registered for prenatal care because of a lack of money or because they did not think it was appropriate to start prenatal care (Asonye, 2014). Almost three-quarters (70%) of pregnant adolescents in Nigeria reportedly attended antenatal care visits (Akinyemi et al, 2021), and in Zambia, pregnant adolescents experienced both positive and negative experiences related to use of health services (Rukundo et al, 2015). Opening hours for health facilities in Zambia were not considered favourable for adolescents and lack of specific spaces for adolescents as well as inadequate privacy and confidentiality were reported issues (Bwalya et al, 2018). Similarly, in Uganda, there were no teenager-friendly antenatal services; few teenagers accessed and used available general antenatal services and there was an identified need for specialised training for health workers in caring for pregnant adolescents (Rukundo et al, 2015).

The majority of pregnant women in Tanzania initiated antenatal care at an average of 5 months' gestation, while multiparous adolescents attended substantially later (P=0.157) (Gross et al, 2012). Across sub-Saharan Africa, adolescents attended more family planning care activities overall than adults (P=0.01), attending an average of 3.76 more discussion activities (such as counselling), but considerably fewer during antenatal care (Efendi et al, 2017). However, adolescents' satisfaction with care was not significantly different from that of adult women. The majority of these correlations persist in country-stratified models with additional model settings and when comparing adolescents to women 20 years of age (Piro and Ahmed, 2020).

Discussion

This review sought to systematically scope the literature on health-seeking behaviour and antenatal care attendance among adolescent mothers. It identified several factors related to adolescents' experiences, factors influencing health-seeking behaviour and barriers to antenatal care attendance. This study explored both quantitative and qualitative literature from across the globe. Notably, almost half of the studies reviewed were conducted outside western countries. Most were qualitative research. Although the studies provided clear explanations about the content, only a third reported the frameworks used to guide the research.

Antenatal health-seeking behaviour and antenatal practices have an essential role in maternal and child health during and after pregnancy. However, in sub-Sahara Africa, only 24.8–75.8% of women attend at least four antenatal care visits (Kanyangarara et al, 2017). Socioeconomic factors and complications during pregnancy have been shown to affect how often adolescent mothers access healthcare services (Ortiz-Félix et al, 2021). Women who are older, have a lower income or who experience pregnancy complications (such as fever, fetal malposition or fatigue) are all linked to attending four or more antenatal care visits (Ortiz-Félix et al, 2021).

Education strongly correlates with pregnant adolescents' health-seeking behaviour and antenatal care attendance. Adolescents and partners with higher education typically have better health awareness, enabling them to seek health services. More highly educated women are more likely to choose facility-based delivery than women with lower education (Kanyangarara et al, 2017). In Indonesia, more highly educated husbands are more aware of maternal health issues and understand how crucial it is to give their wives access to care (Kurniati et al, 2018). In Nepal, higher education in spouses was related to participation in birth preparation (Thapa and Niehof, 2013). Supporting adolescents to pursue higher education is essential them becoming more aware of health-related issues.

The present review highlighted that support was an essential aspect of health-seeking behaviour in adolescent mothers. They often rely on older women in the family with greater pregnancy knowledge and experience. Families have a significant impact on pregnant teenagers' care-seeking (Pike et al, 2021). Adolescents value parental support but can see a loss of agency and autonomy when they became pregnant. In some countries, they cannot make decisions about their own health-seeking behaviour, as married adolescents can have little influence over household or community decisions and be expected to accept instructions from male relatives and in-laws (Presler-Marshall and Stavropoulou, 2017). Empowering families and giving sufficient information about the importance of health-seeking practice is essential so they can take action to support and make appropriate decisions for pregnant adolescents.

The quality of service from care providers can affect continued antenatal care attendance. Positive reactions from healthcare providers, such as supporting adolescents and encouraging them to attend routine antenatal visits, can be beneficial. In contrast, if healthcare providers stigmatise or are unfriendly to pregnant adolescents, this may decrease their motivation to seek continuous care during their pregnancy. A study in southwestern Uganda showed that health services were not friendly to adolescents (Rukundo et al, 2015). An adolescent-friendly service offers adolescents privacy and sufficient time and patience while interacting with them. In addition, specific training in adolescent pregnancy should be provided for health workers to maintain a positive rapport between patients and midwives (Rukundo et al, 2015).

Recommendations for practice

Healthcare providers, especially midwives, must understand the psychological elements of adolescent pregnancy. Midwives should be encouraged to support adolescent mothers to visit healthcare centres and provide positive experiences of antenatal care for adolescents. Additionally, midwives and other related healthcare providers should communicate with families and relatives to allow them to support pregnant adolescent women.

Strengths and limitations

This review allowed for exploration of pregnant adolescents' experiences. A robust methodological approach was used to identify and select relevant papers according to inclusion and exclusion criteria. However, there were some limitations to the review. First, this review covered only 10 years of research, and there may be older papers with relevant data. Second, the researchers searched only for studies published in English.

Conclusions

This review revealed many enabling factors influencing health-seeking behaviour and antenatal care use among pregnant adolescent women, including age, education, location, marital status, social status and family support. Barriers to antenatal care include difficulty getting permission, distance from health facilities and a lack of money, knowledge, decision-making power, education, or wealth. Negative experiences, stigma, fear, violence and abuse can also discourage pregnant adolescents from attending antenatal care.

Key points

• Adolescent pregnancy can harm the health and wellbeing of a mother and child, and have socioeconomic and psychological consequences.
• This study aimed to review published literature to identify factors influencing pregnant adolescents' use of maternal healthcare services.
• A total of 25 articles were included, most of which were conducted in Africa, that assessed health-seeking behaviours and antenatal care use among pregnancy adolescents.
• Age, education, location, social status and family support were all found to influence health-seeking behaviour
• Adolescents, families, communities and healthcare providers should work together to promote health-seeking behaviours among pregnant adolescents.