Background
Approximately 99% of the world's maternal deaths occur in resource-limited settings [
1]. Sub-Saharan Africa (SSA) alone accounts for two-thirds (66%) of deaths [
1], with a number of 2017/2018 publications reporting maternal deaths of 546 per 100 000 live births in the region [
2,
3]. The lifetime risk of death for women in high-income countries (HICs) is as low as 1 in 2400, compared to 1 in 180 in low-income countries (LICs) [
1,
4]. In September 2000, world leaders signed the United Nations Millennium Development Declaration, which committed countries to reducing child mortality by two-thirds (MDG 4), reducing the maternal mortality ratio by three quarters (MDG 5A), and achieving universal access to reproductive health (MDG 5B) between 1990 and 2015 [
5]. There are now new global commitments, such as the new Global Strategy for Women's, Children's and Adolescents' Health, ending the AIDS epidemic by 2030 and the sustainable development priorities. Namibia was a signatory country to the United Nations declaration [
5]. While Namibia, as an upper-middle-income country in SSA, has achieved the target for births to be attended to by skilled health providers, it fell short of meeting the target for the expired Millennium Development Goals (MDGs), which aimed to reduce maternal deaths to 56 for every 100 000 live births by 2015 [
5].
In Namibia, adolescent pregnancy has increased from 15% in 2006 to 18.6% in 2013 [
6]. The number of adolescent pregnancies has remained high in the country, with some areas recording up to 38.9% adolescent pregnancies [
5]. Adolescent girls are more likely to experience pregnancy-related complications due to obstructed labour and eclampsia, thereby increasing their risk of death [
7]. Children born to adolescents are also more likely to have a low birth weight, ill-health, stunting, and other poor nutritional outcomes [
1]. Most of these complications are preventable if pregnant women are prepared and they timeously access and utilize necessary MCHI for childbirth [
4,
8]. Information and education are basic sexual and reproductive health rights; hence, increasing access to information on reproductive rights gives people choices and a sense of entitlement to quality services [
5]. The implementation of the above mentioned new global targets and goals is anticipated to improve the maternal healthcare of many women and children, especially in resource-limited settings.
There are several challenges that hinder the achievements of global targets to improve maternal and child healthcare, and these include accessibility and utilization of MCHI [
9,
10]. The literature has shown that continued poor and unequal access to skilled maternal and child healthcare services remains a major challenge, not only in Namibia, but in the majority of resource-limited settings [
10‐
13]. The challenges further contribute to poor accessibility and utilization of MCHI, since adolescent girls mostly get information when they present at health facilities for maternal health services [
8]. In most Low-Middle-Income countries, there are a number of challenges that hinder the access and utilization of this health information, and these include distance to the nearest health facilities, delay in decision-making, financial constraints, and the attitudes of health professionals [
8,
14].
There are multiple potential explanatory factors for the under-utilization of maternal and child care services, such as young maternal age; religion; poor education; unskilled occupation; poverty; low caste; parity (higher birth order were less likely to access antenatal services); lack of autonomy; poor familial support; lack of access to transport; and the high cost of care, and when it is accessed, the poor quality [
15‐
17]. While some studies have also highlighted a wide number of factors that influence the utilization of MCHI, including education, distance to the nearest health facilities, lack of network coverage, family members, lack of involvement in community engagement activities, lack of youth-friendly initiatives, socio-economic and cultural factors, literacy levels, economic status, lack of health outreach programmes and language [
18‐
20], the effect of information and access to it and how it influences maternal health remains unknown, especially in marginalized and rural communities.
Namibia is committed to reducing maternal mortality, and this is evidenced by the implementation of life-saving skills training of trainers, routine maternal death reviews, improved infrastructure, strengthened adolescent sexual and reproductive health and rights, and improved prevention of mother-to-child transmission (PMTCT) strategies [
15]. However, these initiatives need to be supported by local data from appropriately designed studies.
We, therefore, explored the user-provider perspectives towards the accessibility and utilization of MCHI by pregnant adolescents in the Ohangwena Region in Namibia. The study was underpinned by the Theory of change, which asserts that change is a rigorous yet participatory process whereby groups and stakeholders in a planning process articulate their long-term goals and identify the conditions they believe have to unfold for those goals to be met [
21]. These conditions are modeled as desired outcomes, arranged graphically in a causal framework. It covers the following elements: basic elements of needs (the initial problem being addressed), inputs (resources), outputs (intended activities) and outputs (desired changes for service users) [
22].
The main aim of the study was to explore the perspectives for pregnant adolescents and nurses on accessing and utilization of maternal and child health information in Ohangwena Region, Namibia. It is anticipated that the results of this study will be useful to the Government of the Republic of Namibia, the community, and non-governmental organizations in improving the accessibility and utilization of maternal and health information by adolescent girls, in order to improve maternal health outcomes among this population group.
Methods
Research paradigm
This study was guided by the interpretive paradigm due to its ability to explore the phenomenon from the perspectives of the service users (adolescent girls) and service providers (nurses) [
23,
24]. By applying an interpretive paradigm, the researchers had a chance to view the world through the lenses and experiences of those participating in the provision and use of MCHI in their region.
Study design
An exploratory qualitative design was applied to explore the experiences of service users and service providers pertaining to the accessibility and utilization of MCHI during pregnancy in the Ohangwena Region in Namibia.
Study setting and study population
The study was conducted in the Ohangwena Region, which is one of the 14 political regions in Namibia. It shares international boundaries with Angola to the north and regional boundaries with the Kavango region to the east, Omusati region to the west, and Oshana and Oshikoto regions to the south. It is the second-highest populated region in Namibia with a population of 274 650 [
25]. Ohangwena is a rural region and one of the most poverty-stricken areas in the country [
26]. In 2017, Ohangwena was rated as one of the regions with the highest prevalence of teenage pregnancy [
26]. The major diseases in the region are pneumonia, malaria, diarrhoea, and HIV/AIDS [
26]. The total population of pregnant women between the target ages of 15 and 19 was 693. The total number of registered nurses and enrolled nurses and midwives working at the selected health centres and clinics was 57.
Sample size and sampling strategy
The study participants included twelve (12) pregnant adolescents from different villages across Ohangwena Region and eight (8) Nurses from two different health professional categories (registered nurse and enrolled nurse and midwifery) who were working in health centres and clinics, Ongha Health Centre, Odibo Health Centre, Engela Clinic and Eenhana Clinic in Ohangwena Region.
A purposive sampling strategy was applied to identify 12 participants out of the 98 potential participants from four purposively selected sites. The identification of potential participants was based on their professional categories: one nurse dealing with antenatal consultations per professional category per site (enrolled Nurse and registered nurse), culminating in the selection of two nurses per site. Furthermore, these potential participants were considered information-rich, based on their inputs into the quantitative aspects of the study.
Only the adolescents who were pregnant at the time of the data collection, aged 15 to 19 years old, 1–40 gestational weeks pregnant and resident of the Ohangwena Region, were considered for inclusion in the study. Excluded in the study were women below the age of 15 or older than 19, not from the Ohangwena Region, and not pregnant at the time of data collection. For the selection of the nurses, the following inclusion and exclusion criteria were applied: Inclusion criteria: any year of age, working at ANC clinics, registered nurses or enrolled nurse and those from midwifery, male or female; Exclusion criteria: staff members who were not nurses, nurses who were not working at antenatal clinics, nurses who had worked less than one month at an antenatal clinic.
Data collection
This study was conducted over a three-month period (December 2018 to March 2019). The lead researcher, who had some training on qualitative research, conducted semi-structured in-depth interviews with pregnant adolescents who presented for ANC visits at the four sites and with eight nurses from four different health centres and clinics. An interview guide used to generate data covered the following areas: Reasons for late to start of antenatal care, mode of transport to the clinic, the distance to the nearest clinics, waiting time and challenges affecting access to MCHI. Questions pertained to how pregnant adolescents accessed ANC clinics, including the factors that affected the utilization of services. Questions directed to the nurses pertained to the observed ANC clinics attendance patterns by the pregnant adolescents, including the challenges viewed to affect the service uptake by this age group.
A maximum of four interviews per day were scheduled through telephonic appointments. Each interview lasted for about 30–40 min per participant and no follow-up interviews were conducted. The interviews were conducted in Oshiwambo, since the participants were more comfortable to talk in their own language. The interview venues were determined by the participants to ensure that they were less inconvenienced. A majority of participants preferred to be interviewed at the nearest clinics and some preferred to be interviewed at their place of residence and maternity shelters, as they were closer to their time of giving birth. The interviews for nurses were conducted either at their clinics or health centres. With the participants' permission, note-taking and digital audio-recordings were used to record the data. Code saturation was reached at 10 interviews, as data collection and analysis were conducted iteratively. However, the meaning saturation was reached after interviewing all twelve selected pregnant adolescent girls.
Data management
Two university students experienced in qualitative research were recruited to transcribe the audio materials verbatim. For quality-check purposes, the lead researcher listened to the audio materials while reading the transcriptions, in order to assure the quality of transcription prior to translating from Oshiwambo to English. Notably, the lead researcher (JS) is competent in both Oshiwambo and English. Furthermore, a Ph.D. graduate from the University of Namibia independently verified the quality of the transcriptions. Data were exported into NVivo computer software version 12 for analysis.
Data analysis
Thematic analysis techniques were applied to analyze the data, the following process of thematic analysis being followed: Data was condensed in small units, and then the coding process was conducted. The process of categorization of the data followed and, finally, thematic analysis was conducted by classifying the data into sub-themes and main themes. The lead researcher (JS) immersed herself in data through several readings of the transcripts in order to generate concepts. To support the findings, verbatim quotes were extracted from the transcripts.
Five main themes and eighteen sub-themes were identified. The main themes were: Reasons for late starting of ANC, mode of transport to the clinic, the distance to the nearest clinics, waiting time and challenges affecting access to MCHI.
Discussion
This study aimed to identify challenges facing adolescent girls in accessing and utilizing MCHI during pregnancy. This is consistent with the SDG 3, which emphasizes ensuring universal access to sexual and reproductive healthcare services, which includes family planning, IEC, and the integration of reproductive health into strategies and programmes [
27]. This study conforms to the Global Strategy for Women's, Children's and Adolescents' Health (2016–2030). The main findings revealed that accessibility and utilization of MCHI were major challenges, with special reference to long distances to health facilities, necessitating pregnant adolescent girls to walk long hours to the nearest clinics. Another finding was lack of road infrastructure and unavailability of transport which exacerbated accessibility challenges. Insufficient financial support for transport fare further limited access to MCHI services. Family dynamics added to pregnant adolescents' barriers to access and use of information. Parental controls were also key determinants of whether or not pregnant adolescent girls accessed and utilized clinic-based health services. Moreover, pregnant adolescents' fear, guilt, and anticipated parental reaction made it difficult for them to disclose their pregnancies.
Our study results compare well with what is documented in the literature regarding the long travel distances endured by pregnant women to access maternal healthcare services, which, in turn, affect access and utilization of health information [
3,
27‐
31] and lack of transport and poor road infrastructure increased the challenges. This is consistent with the results of a study conducted in Odisha in India, in so far as accessibility and utilization of MCHI, are concerned [
32‐
34]. Additional studies conducted in Nepal Chitwan district also point to the non-availability of transport and lack of road infrastructure as major challenges to pregnant adolescent girls' access and utilization of health information [
29]. Consistent with findings from several other studies conducted in sub-Saharan Africa, lack of financial support from family members and partners also affected pregnant women's ability to access and utilize maternal health services [
28‐
32,
35]. Only a few of the adolescent pregnant girls were receiving financial support from their partners or from their parents, but the majority were struggling to reach the clinics and health centres. In addition, a systematic review conducted across sub-Saharan Africa revealed that the positive economic status of adolescent women is associated with the use of maternal healthcare services [
34‐
38]. Studies conducted in America revealed similar findings that pregnant adolescents experience financial hardship during pregnancy [
39,
40].
Furthermore, some studies have revealed that poor adolescents are more likely to disengage from social networks, making them less likely to be reached by programmes aimed at improving maternal health service utilization of adolescent mothers [
3541
Limitations
The following limitations were observed: the study was confined to adolescents presenting to health facilities for ANC, therefore those were not attending ANCs were not included. These were likely to be the most affected people in so far as accessibility and utilization of MCHI is concerned; the study focused on the age group 15 to19 and the perspectives of other young women are missing. In addition the translation of the study from Oshiwambo to English risked the loss or distortion of some meanings during the interpretation process.
Conclusion
From the pregnant adolescents’ and nurses’ perspectives, long travel hours to reach the nearest clinics, in terms of road infrastructure, non-availability of transport and transport fare were the key barriers to accessibility and utilization of clinic services. Sound justification required for pregnant adolescent girls to be supported with transport fare inadvertently resulted in early and ill-considered pregnancy disclosure, which often culminated in harsh treatment by parents, thereby further limiting access to maternal and child services. Even in instances where these hurdles are surmounted, long queues at the clinic and the alleged cheekiness of staff and other peers deterred them from finalizing the antenatal care, often resulting in these adolescents giving up the process. Therefore, we recommend a holistic approach inclusive of the community leaders, parents, adolescents themselves and other stakeholders. Most importantly, adolescent girls need to be empowered with information on reproductive health matters.
Publisher’s Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.