Background
The West African Ebola epidemic (2014–2016) was the largest and most complex Ebola outbreak since the virus was first discovered in 1976 [
1]. It is estimated that more than 1 million women in the affected regions of Guinea, Sierra Leone, and Liberia were pregnant during the outbreak [
2]. These women were faced with a triple burden of mortality, by being at risk of dying from the Ebola virus disease (EVD), dying during pregnancy or childbirth [
3]. Sierra Leone has one of the highest rates of maternal mortality in the world, with a staggering 1360 deaths per 100,000 live births in 2015 [
4]. According to national statistics, 34% of all pregnancies in the country are related to adolescent pregnancy and 40% of maternal mortality occurs as a result of adolescent pregnancy [
5]. The high rates of pregnancy may impair their future social, economic and political empowerment because many adolescent girls get pregnant before they complete primary level education [
6]. Additionally, infants born to young mothers under the age of 20 also have a 50% higher risk of newborn mortality [
7]. Findings suggest, that the level of maternal and newborn mortality had increased by 30 and 24% between 2014 and 2015 [
8].
In light of the high rates of maternal and child mortality, the government launched the Free Health Care Initiative (FHCI) in 2010, providing free maternal and reproductive health for lactating mothers and children under five to utilise medical facilities [
9]. The initiative led to a subsequent 45% increase in institutional childbirths [
10]. However, mass relocation of health funds was utilised to fight the EVD, deprioritising obstetrical services and placing pregnant women at an increased risk of undetected complications and maternal mortality [
2,
3,
11]. The risk of infection during childbirth, due to blood and fluid exposure resulted in health care workers refusing to treat pregnant women for fear of contamination [
12]. During the EVD one-third of healthcare workers who died between April to September 2014, where maternal health care professionals. The EVD also affected the health-seeking behaviour and utilisation of health care services among pregnant women resulting in 11% decrease in deliveries at health facilities, 18% decrease in accessing antenatal care and 22% decrease in accessing postnatal care [
8]. According to UNFPA report, pregnant adolescents are less likely to seek medical assistance because they have easier access to TBAs and community health workers [
13].
In 2013, Sierra Leone was ranked among the 10 countries globally with the highest rates of adolescent pregnancy, with 28% of girls aged 15–19 years being pregnant or already experienced childbearing and about 40% of women aged 20–24 had already experienced childbearing before turning 18 [
11,
14]. Due to the high rates of adolescent pregnancy, the government launched the nationwide programme of action in 2013
Let girls be girls, not mothers! National strategy for the reduction of teenage pregnancy in Sierra Leone (2013–2015). Unfortunately, the initiative was disrupted by the Ebola epidemic [
5]. Additionally, emergency measures such as enforced quarantines households on affected by Ebola, three-days national lockdowns and school lockdown between June 2014–April 2015 were implemented as a strategy to reduce the spread of Ebola [
6,
12].
Prior to the EVD, other factors such as cultural norms, beliefs about disease and perceptions of the quality of care provided, household power relations and social networks dictated health-seeking behaviour [
3]. Furthermore, a multitude of challenges were identified following the Ebola epidemic, ranging from the economic recovery to (re) building trust in the health system to repurposing the Ebola Treatment Centres. One of the challenges not immediately apparent to many outside the country was the subsequent increase in adolescent pregnancy during the epidemic [
3]. In April 2015, the Sierra Leonean government took controversial measures by banning visibly pregnant adolescents from finishing their education [
6]. This policy was revoked in 2016, after international donors aided the government in supporting more than 14,500 pregnant girls, by initiating educational programmes and Community Learning Centres [
4].
During infectious diseases outbreaks, sex, gender, and age play important roles, particularly for pregnant women who are more vulnerable to the effects of the disease [
3,
6]. In Sierra Leone, adolescent girls were more susceptible to sexual exploitation, sexual assault and rape. Reports found that girls suffered far more violence and sexual exploitation when they were isolated, quarantined or moved to other areas to escape the EVD [
3,
15]. Research from the Eastern region of Sierra Leone found that adolescent pregnancy increased by up to 65% in some target communities due to the socio-economic conditions affected by the EVD [
16]. Limited research has been done pertaining to adolescent mother’s health-seeking behaviour during Ebola. The study aimed to explore health-seeking behaviour and the use of health services among adolescent mothers who were pregnant during the Ebola outbreak in Freetown, Sierra Leone.
Discussion
The aim of the study was to explore how the EVD outbreak influenced the use of health services among adolescent mothers who were pregnant during the outbreak. This study, therefore, attempts to shed light on attitudes, perceptions, experiences and barriers participants faced in attempt to health-seeking during the EVD.
The results from this study contributed to the Three Delay Model by indicating how an external factor such as the EVD added new complexities to each of the delays. The Three Delay model also recognises the interrelated factors that create barriers to health-seeking. Although there were several factors affecting adolescent mother’s health-seeking behaviour the association between these factors were not always linear. Rather fear and socio-economic factors cut across the three delays. The fear of contracting the EVD from both participants, community members and health professionals was an underlying factor, in (delay 1 and 3). Some participants fear of taking public transportation (delay 2).
First, the scientific literature suggests, mistrust and fear were exacerbated in the community as conspiracy theories and rumours regarding the EVD and health facilities spread. Rumours and misconceptions also acted as a direct barrier to health-seeking in both Guinea and Liberia [
22]. Jones et al. reported that as a result of fear participants would often arrive at the facility after conditions had worsened, leading to poorer health outcomes [
8].
Secondly, many participants feared being exposed to EVD in health facilities which prevented them from seeking obstetric care. Instead, most of the participants decided to seek a TBA and deliver at home without qualified assistance translated to obstetric complications and fatal neonatal or maternal outcomes. Similarly, a Liberian study found that births in public facilities decreased from about 54 to 27% during EVD, because women were afraid of seeking health care in government hospitals. The study also found a decrease in supply as many health care workers did not want to treat pregnant women due to fear [
23].
Thirdly, the loss of relatives and community members also added feelings of mistrust towards health care facilities as they failed to provide adequate care and treatment, which became another reason for not seeking care. Research suggests pregnant women trusted TBA more because they were less likely to discontinue maternal services due to fear [
22,
23].
Fourthly, the lockdown and quarantine, lack of income and road restrictions were considered as significant barriers to accessing prenatal and obstetric care. In Guinea, resources and health facilities were also directed towards controlling the EVD, which limited the access to health facilities for pregnant adolescents [
24]. This was also reflected in Liberia, where the largest group unable to access prenatal care during the EVD were pregnant women [
25]. Evidence shows that ambulances were available for referrals prior to EVD, but the numbers of vehicles were limited and not always in working order. When ambulances were available, the poor infrastructure was another existing challenge for referring women [
8]. Participants from high spread EVD areas in Waterloo usually had to walk for miles before they could access public transportation, as many drivers refused to take passengers from these areas. During the EVD motorbikes, even though more expensive, became the preferred mood of transportation in both rural and urban areas [
13,
25].
The perceived discriminatory and disrespectful behaviour from midwives and nurses caused adolescent mothers to avoid seeking health care, combining elements in the third delay (the quality of care) with the first delay (previous experience with health care providers) [
19]. Moreover, the study considered maternal age as a factor that could potentially become a barrier to health-seeking, considering that adolescent mothers statistically are proven to be at a higher risk of maternal mortality [
5]. However, findings revealed that the quality of care was not only determent by participants’ personal assessment of service delivery; perceptions were also shaped and influenced by the experience and opinions of community members. Evidence reports that the perception of adolescent pregnancy out of wedlock in most sub-Saharan African settings are negative [
3,
23,
26]. Single adolescent mothers are in most communities considered to be less respectable, a disgrace to their parents and they are deemed as idle and promiscuous, usually subjected to shame, gossip and rejection in their community [
26]. These findings are aligned with a previous study from rural Sierra Leone, where adolescent mothers were more likely to be stigmatised and experience additional barriers [
26].
The inability to correctly diagnose the EVD especially during the beginning of the epidemic was also an interesting finding. The fear of pregnancy symptoms being mistaken for Ebola symptoms caused participants to avoid seeking health care. The hidden fees and out-of-pocket payments participants encountered at the health facility was also a barrier to receiving quality healthcare. This barrier was also found in among the rural population in Sierra Leone during Ebola [
26]. While some participants bribed their way through the system others sought to traditional medicine and other alternatives. Out-of-pocket expenses for unexpected charges raised concern among participants, causing confusion as to whether or not the Free Health Care Initiative was still available. In Liberia evidence revealed that pregnant women and women suffering from obstructive labour were also refused treatment from health care facilities during Ebola because they were unable to pay the required health charges, subsequently leading to some women dying from maternal mortality [
3].
Limitation
The study had several limitations. Firstly, the findings are not representative of other parts of Sierra Leone and are restricted to Western rural Area. The sample only consisted of adolescent mothers who had been in contact with prenatal and obstetric services. Due to the high rate of participants who delivered with assistance from a TBAs, it is possible that many adolescent mothers did not have any contact with health facilities throughout their pregnancy.
Recommendation
Pre-Ebola initiatives such as the FHCI led to an increase in institutional childbirth. However, during the EVD certain pre and postnatal services were no longer free of charge. Therefore, additional attention must be paid to improving and strengthening policies to includes EVD and disease outbreaks in order to deal with fear and mistrust and some of the other underlying challenges that exacerbate due to the EVD [
27,
28].
Moreover, policies should also ensure that adolescent mothers are allowed to continue their education to promote their future socioeconomic and political empowerment [
4]. In accordance with articles 24 and 27 of the Convention on the Rights of the Child, States parties should provide health services that are sensitive to the particular needs and human rights of all adolescents [
29]. Lastly, in order to improve adolescent’s uptake in Sierra Leone efforts must be made towards improving health systems and promoting initiatives that address the barriers related to the first, second and third delay. Doctors, nurses and midwives must be adequately trained for future responses to EVD or other disease outbreaks, enabling them to safely continue caring for patients. Moreover, developing sustainable measures such as training TBAs and equipping them with proper supplies is crucial in order to improve the capacity to manage the future spread of disease.
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