Introduction
Adolescent pregnancy is a common occurrence in Nigeria, as nearly one-fifth of adolescent girls aged 15–19 were either currently pregnant or had given birth to at least one child in 2018, and the adolescent fertility rate is 106 births per 1000 girls in this age group [
1]. Pregnancy is often a risk-filled endeavour for adolescent girls, given their physiological development is still on-going. Pregnant adolescents are susceptible to anaemia, pregnancy complications, obstructed labour due to an incompletely developed pelvis, and other pregnancy-related morbidity. They are also more likely to have low birth-weight and preterm babies, as well as stillbirths [
2‐
9]. Additionally, about 40% of deaths among girls aged 15–19 in Nigeria are from maternal causes [
1]. In order to reduce the prevalence of adolescent pregnancies in the country, the 2007 Nigerian Adolescent Health Policy aimed to reduce the incidence of unwanted pregnancies by adolescent females by 50% by year 2015; this target, however was not achieved. In a more recent attempt to reduce adolescent pregnancy incidence, the Federal Ministry of Health in Nigeria in partnership with the World Health Organization inaugurated the Gender Adolescent School Health and Elderly Care (GASHE) programme to provide comprehensive sex education to adolescents between ages 13 and 18 in secondary schools across Nigeria. Adolescent pregnancies are more likely to be unintended in sub-Saharan Africa, especially when the mothers are unmarried [
10,
11]. Adolescent girls often have poor sexual and reproductive knowledge, leading to unintended and unwanted pregnancies [
12].
The risks notwithstanding, adolescent mothers have the lowest utilisation rates of maternal health services in Nigeria [
13‐
17], as well as in other sub-Saharan African countries [
18,
19]. Several factors influence maternal healthcare utilisation among adolescent mothers. Girls with higher socioeconomic status tend to have higher usage of maternal health services [
20‐
24]. Adolescent mothers living in urban areas have higher maternal healthcare use than rural mothers [
21,
25‐
27]. This is especially true when health facilities are distant in these rural areas [
23,
28]. Furthermore, adolescent mothers who have high media exposure and reproductive health knowledge levels have higher maternal healthcare use [
20‐
22,
24,
26,
27].
Literature shows that adolescent maternal healthcare utilisation is also influenced by sociocultural factors. For instance, unmarried adolescent mothers experience stigma regarding their pregnancies [
11,
29‐
32], and the presence of this stigma may lead to suboptimal use of maternal healthcare services [
11,
33]. Health worker attitudes also exert influence on maternal healthcare use among the youngest mothers, as previous studies show that harsh and unsympathetic health worker attitudes reduced maternal healthcare use among them [
28,
31,
32,
34‐
37]. Studies in Ghana and Zimbabwe found that adolescent mothers are more able to use healthcare when they receive social support from their families during their pregnancy [
34,
38]. Studies in Uganda and Bangladesh discovered that the adolescent mothers’ choice of healthcare provider was largely influenced by the type of healthcare preferred in the household and the wider communities where they lived, since they are more susceptible to influence from others due to their lack of experience [
28,
39].
A few studies conducted on adolescent maternal healthcare utilisation in Nigeria have largely examined the socioeconomic and demographic determinants of maternal healthcare utilisation among this group of mothers using a quantitative approach [
9,
26,
40,
41]. The previous studies which examined the experiences of adolescent mothers, as well as sociocultural factors such as stigma and pregnancy intention among them have been limited to single regions of the country [
11,
42]. While findings from these studies have provided important information on the some of the factors that influence maternal healthcare use among adolescent mothers in the country, little is known about the features of the sociocultural environment peculiar to Nigeria that either help or hinder these mothers’ access to and use of MHC services.
Therefore, this study explores the pregnancy experiences of adolescent mothers across Nigeria, their maternal healthcare utilisation, and the sociocultural factors that either aid or hinder their utilisation of healthcare services. The study adopted an ethnographic qualitative approach to obtain richer information and more in-depth understanding of adolescent mothers’ lived experiences, and the reasons behind their maternal healthcare usage patterns. Furthermore, it compares the prevailing sociocultural factors in different regions that represent the three major ethnic groupings in the country, to examine similarities and/or differences in these sociocultural influences. This is important to policy and programme designers as Nigeria is a culturally and religiously diverse country, and interventions which work in one region may not do so in others. The study answers the following questions: (i) what are adolescent girls’ pregnancy experiences across Nigeria? (ii) what types of maternal healthcare do pregnant adolescents and new adolescent mothers make use of in Nigeria? and (iii) what are the factors that guide adolescent mothers’ maternal healthcare utilisation in Nigeria?
Theoretical framework
The study used the Andersen’s Behavioural Model of Healthcare Utilisation, which examines the factors that influence healthcare use in a population. The model has been previously used to study healthcare utilisation and various health outcomes, for example, mental-health seeking behaviour [
43,
44], the healthcare cost of intimate partner violence [
45], the influence of culture on health-seeking behaviour of older immigrants [
46], patient-physician interaction [
47], access to preventive healthcare [
48], general health services utilisation [
49] and maternal healthcare utilisation [
26,
50].
The 2008 revision of the model was used as the theoretical framework for this study. While previous versions of the theory put forward predisposing, enabling and need factors as determinants of healthcare utilisation, this revision categorised these factors (predisposing, enabling and need) into individual and contextual levels. The study adapted the theory to examine the factors influencing maternal healthcare utilisation among adolescent girls in Nigeria. Using the Andersen framework, the study examined the predisposing, enabling and need factors that influenced maternal healthcare utilisation among adolescent girls at both the individual level and from their cultural environments.
Materials and methods
The study was conducted as the qualitative component of an explanatory sequential mixed methods study, where quantitative data were first analysed, and qualitative findings were used to further explain and expand on the quantitative findings [
51]. It used ethnographic qualitative methodology, using in-depth and key informant interviews to gather information from currently or ever pregnant adolescent girls, their mothers and guardians, and community leaders. The study was carried out in Nigeria, which is divided into six geopolitical zones, namely, North West, North East, North Central, South West, South East and South South, and 36 states, including the Federal Capital Territory in Abuja. Nigeria is a multi-ethnic country, with more than 250 recognised ethnic groups. The three major ethnic groups by population size are the Yoruba, Igbo and Hausa groups, with the Yoruba predominantly in the South West and parts of the North Central zones, the Igbo in the South East and the Hausa spread across the North Central, North West and North East zones of the country.
The study was conducted in three geopolitical zones that represent the major ethnic groups in Nigeria, namely the Hausa and Fulani ethnic groups in the North West zone, the Igbo ethnic group in the South East zone, and the Yoruba ethnic group in the South West zone. In each of the three zones, the state with the highest recorded pregnancy incidence as at the time the study was conducted was selected. Katsina State was selected from the North West zone, Imo State in the South East, and Ondo State in the South West. Additionally, Katsina State had the highest adolescent pregnancy rate in the entire country based on the available evidence at the time the study was conducted [
52]. In each state, two study locations, one rural and one urban, were chosen to compare the pregnancy experiences and maternal healthcare utilisation of adolescent girls in urban and rural areas. The urban research sites chosen were Akure, the capital of Ondo State, Owerri the capital of Imo State, and Katsina Township, which is the capital of Katsina State. The rural sites selected were Aponmu in Ondo State, Assa in Imo State, and Majigiri in Katsina State. Ethical approval for the study was obtained from the University of the Witwatersrand Human Research Ethics Committee (non-medical), with protocol number H18/06/03.
All of the interviews were conducted using semi-structured interview guides. A pilot study was conducted in October 2018 in Ekiti State, South West Nigeria, to examine the validity of the interview guide, and ambiguous questions were rephrased in the final guide used for the study. The data collection was conducted between November 2018 and January 2019. Purposive sampling was used to recruit willing eligible participants in the selected communities into the study. The inclusion criteria for the study were all girls aged 15–19 living in the selected communities, who were either currently pregnant or had been pregnant or given birth to at least one childas adolescents; mothers or guardians of girls who currently were or had been adolescent mothers; or female community leader. Informed consent, as well as consent to audio-record their conversations, was obtained from all participants. For adolescent girls younger than age 18, parental consent was obtained from their parents or guardians, and willingness to participate was obtained from the respondents themselves. Due to the nature of the study, participants were offered distress counselling with a licensed clinical psychologist. Only one potential respondent was unable to participate in the study, as she became too emotional to proceed with the interview. Where respondents declined to be audio-recorded, their responses were transcribed directly during the interviews. The primary language of the interviews guides was English, though some interviews were conducted in Yoruba and Hausa languages in the South West and North West zones for respondents who could not or did not want to be interviewed in English. In such cases, the interview questions were translated into the relevant languages, and responses were translated during the transcription process as closely as possible to retain the true meanings of responses. In the South East zone, all interviews were conducted in English as that was the preferred language for respondents in that zone. The number of completed interviews varied across the various study sites based on the availability of willing participants. In total, fifty-five adolescent mothers, nineteen mothers and guardians of adolescent mothers, five female community leaders and six senior health workers participated in the interviews.
Sociodemographic characteristics of participants
Table
1 shows the sociodemographic characteristics of the study participants. The adolescent mothers in the study were between 15 and 22 years old. In the South West region, 56.2% of participants were urban residents; 37.5% of participants had secondary education. More than half of participants were single, living with their parents or guardians (56.2%). The majority of respondents (68.8%) were Yoruba. All participants were Christians. In the North West region, the participants were evenly split between urban and rural areas. The majority of participants had no formal education (70.8%). The majority of participants (95.8%) were married. The majority of participants were Hausa (87.5%) and 12.5% were Fulani. All participants were Muslims. In the South East region, 80% of participants lived in the rural area; 26.7% had secondary education, Also, 26.7% of participants in this region were married, and 40.0% were single and living with their parents or guardians. All of the participants were Igbos and Christians.
Table 1
Sociodemographic characteristics of respondents
Place of residence | | | |
Urban | 56.2 | 50.0 | 20.0 |
Rural | 43.8 | 50.0 | 80.0 |
Educational level | | | |
None | 0.0 | 70.8 | 0.0 |
Primary | 12.5 | 4.2 | 6.6 |
Basic | 18.8 | 0.0 | 26.7 |
Incomplete secondary | 31.2 | 25.0 | 40.0 |
Secondary | 37.5 | 0.0 | 26.7 |
Marital status | | | |
Single | 56.2 | 0.0 | 40.0 |
Formerly cohabiting with partner | 0.0 | 0.0 | 13.3 |
Cohabiting with partner | 43.8 | 0.0 | 13.3 |
Married | 0.0 | 95.8 | 26.7 |
Widowed/divorced | 0.0 | 4.2 | 6.6 |
Ethnicity | | | |
Yoruba | 68.8 | 0.0 | 0.0 |
Igbo | 18.8 | 0.0 | 100.0 |
Idoma | 6.2 | 0.0 | 0.0 |
Ebira | 6.2 | 0.0 | 0.0 |
Hausa | 0.0 | 87.5 | 0.0 |
Fulani | 0.0 | 12.5 | 0.0 |
Religion | | | |
Christianity | 100.0 | 0.0 | 100.0 |
Islam | 0.0 | 100.0 | 0.0 |
Data analysis
Data analysis was conducted using a deductive approach, as a list of likely themes had been prepared which were derived from the theoretical and empirical background of the study. These pre-determined themes were then used in the construction of questions in the interview guides used. It also used the semantic approach, where data analysis focused mainly on the information explicitly provided by participants, and not the meanings behind them. The framework option of the codebook thematic analysis method was data analysis with the aid of the NVivo qualitative analysis software (version 12) [
53‐
56]. Data analysis started by reading through the various interview transcripts and selecting the most relevant verbatim quotes for coding. These codes were then arranged according to themes, which were then classified either as major or sub-themes, using the domain summary method [
57]. The same process was conducted for all interviews, that is, in-depth interviews with the adolescent mothers and their mothers and guardians, as well as the key informant interviews with community leaders and health workers. Data from the adolescent mother interviews were analysed first, followed by the mothers, the female community leaders and the health workers. The different perspectives from the various interviews were brought together using themes that were common across them. In total, two major themes and six sub-themes were identified.
Discussion
The study examined the pregnancy experiences of adolescent mothers in Nigeria, as well as their maternal health-seeking behaviour, and the influences from the sociocultural environment that guided their choices. Understanding the circumstances that influence adolescent mothers’ maternal healthcare would go a long way to help design interventions to increase usage of modern health services among these young mothers in Nigeria. This will enable appropriate action to be taken in reviewing the present policies on adolescent health and maternal health service provision in Nigeria.
The study found that a large number of unmarried adolescent girls reported that their pregnancies were unplanned, while married girls majorly reported having planned and expected pregnancies [
10,
11]. Among unmarried girls, this finding is a cause for concern, as it gives evidence that they are engaging in sexual intercourse without the required knowledge, motivation and means to prevent unwanted and mistimed pregnancies [
12,
22]. The study also revealed that premarital adolescent pregnancy was stigmatised, as many respondents reported being verbally abused or harassed by their community members or even complete strangers, just as previous African and global studies have found [
11,
29,
31,
32,
42,
58]. Additionally, most married and cohabiting adolescent girls regardless of their age reported no stigma, showing that being in a recognised union had a protective effect against stigma for adolescent mothers in Nigeria.
A good number of adolescent mothers who experienced stigma still made use of modern health facilities for their maternal health needs, showing that it did not necessarily hinder their using health facilities, in contrast to previous studies by Agunbiade et al. and Chikalipo et al. [
11,
33]. Inasmuch as stigma did not influence maternal health care use by some of the adolescent mothers, it may have caused them psychological stress, which may affect their health and the health of their unborn babies.
The study discovered adolescent girls relied mainly on their relatives for social and financial support. For unmarried adolescents, they often relied on their mothers to provide these kinds of support, and where their mothers were either unable or unwilling to provide this support, some relied on another older female relative for support. Married adolescent mothers, on the other hand, tended to receive support from their partners and in-laws [
34,
38]. The findings suggest that married adolescent mothers had a wider network of support than their single counterparts. Adolescent mothers were, due to their lack of experience, largely dependent on their families and /or partners for emotional support. Adolescent mothers who reported an ample amount of support from their families, especially their mothers and partners, were able to make use of maternal healthcare, unlike those who reported being abandoned during their pregnancies. This finding goes to show the importance of family support in ensuring that adolescent mothers are able to access and use adequate maternal healthcare. Abandonment by partners was a common experience reported by the single adolescent mothers. This is likely because their partners were adolescents and young adults with limited financial capacity themselves, and were unable to take care of them and their babies.
Similar to other studies [
28,
31,
32,
34‐
37], some adolescent mothers reported that health workers had negative attitudes towards them. It was discovered that adolescent girls who experienced bad treatment at the hands of health workers were noticeably reluctant to continue patronising health facilities. These findings imply that health workers may need to be trained to provide respectful and non-judgemental care to adolescent mothers.
The study participants reported different maternal healthcare service usage patterns. While some of them made use of modern health facilities, others made use of traditional healthcare practitioners, and yet others combined both modern and traditional maternal healthcare, while some girls were unable to make use of any form of maternal healthcare at all. For those who were unable to make use of modern healthcare services, some reported a lack of financial support to pay for medical bills, while some girls reported that they believed that they would be unable to afford the cost of healthcare due to misinformation. This shows that financial support was an enabler for modern healthcare access for pregnant adolescent girls, as girls who were unable, or believed they were unable to afford the cost of modern healthcare did not use it, rather relying on alternative sources of healthcare. Affordability is a major constraint to the use of maternal healthcare in Nigeria, as in many low- and middle-income countries, and the problem of affordability is worst for adolescent girls who have no livelihood, are not in a union, lack social support, and are from low-income families [
20‐
24,
34,
38].
Maternal and community healthcare preference influenced the type of providers adolescent mothers used, and they conformed to these decision makers’ preferred healthcare providers [
28,
39]. Mothers were discovered to influence their daughters’ maternal healthcare choices, and they tended to support and enable their daughters’ choices. Cultural influences also determined the types of maternal healthcare that were favoured by adolescent mothers, as adolescent girls tended to follow the type of healthcare practiced in their communities, whether it was modern, traditional or complementary. Religious leaders are important healthcare decision makers for some adolescent mothers, as some mothers reported that they were advised by these leaders to use “mission” houses, rather than health facilities for their maternal healthcare needs.
Practical and theoretical implications of the study
The study found that in addition to social support, stigma, health worker attitudes and healthcare preferences as influences for adolescent maternal healthcare utilisation, the role of maternal social support (both emotional and financial) and the influence of religious leaders were found to be important. Also, finances were found to play a major role in whether or not adolescent mothers made use of maternal healthcare services. Misinformation concerning the cost of healthcare services was found to serve as a barrier to the usage of such services for some pregnant adolescents.
The study found that individual and community healthcare preferences were predisposing factors for maternal healthcare use among adolescent mothers. The presence of social support was an enabling factor for healthcare service use, while the perception of need for maternal healthcare services among adolescent mothers, their own mothers and the wider community was discovered to be the important need factor for use of maternal healthcare among adolescent mothers.
Conclusion and recommendations
This paper brings attention to the experiences of adolescent mothers in Nigeria, as well as their maternal healthcare usage patterns and the sociocultural factors influencing their use of these services. The study discovered that sociocultural factors such as presence of social support and the type of family and community healthcare preference influenced maternal healthcare utilisation among adolescent mothers, while pregnancy intention, stigma and negative health worker attitudes had little influence on maternal health-seeking behaviour. The prevalence of unwanted pregnancies among adolescent mothers suggests the need for reproductive health programmes that enable sexually active adolescent girls to delay and prevent pregnancies. The role of social support was an important one, as adolescent mothers who had support from their close family members were able to make optimal use of healthcare services, compared with those who had little or no support. Therefore, the role of maternal and partner support must be emphasised in programmes concerned with increasing maternal healthcare utilisation among adolescent mothers. As community and religious healthcare preferences influenced choice of healthcare provider for young mothers, healthcare interventions must strive to be culturally sensitive so as to be acceptable to young mothers. Religious and cultural leaders also need to be educated on the benefits of adolescent mothers receiving maternal healthcare from recognised health facilities, and be enrolled in the effort to ensure that adolescent mothers make use of these services. Study findings underscore the need for adolescent-friendly maternal health services and training programmes that ensure that health workers provide respectful and non-judgemental care to adolescent mothers. As stigma against adolescent mothers was still very present in the study areas, behavioural change education needs to be targeted towards the wider public to eradicate stigma towards younger mothers.
Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit
http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver (
http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data.
Publisher's Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.