Perspectives of orphaned and school-going adolescent mothers on equitable maternal and child healthcare services in Western Kenya

¹Department of Public and Community Health, School of Health Sciences, Jaramogi Oginga Odinga University of Science and Technology, Bondo, Kenya, ²Department of Health, County Government of Vihiga, Vihiga, Kenya, ³Centre for Community Health and Wellbeing, Jaramogi Oginga Odinga University of Science and Technology, Bondo, Kenya

^&Corresponding author
Martin Osotsi, Department of Public and Community Health, School of Health Sciences, Jaramogi Oginga Odinga University of Science and Technology, Bondo, Kenya

Introduction    

Provision of equitable maternal and child health (MCH) services, which include poorly implemented policy frameworks, weak referral networks, undertrained employees, insufficient mental health support, and a lack of resources tailored to adolescent mothers remains a major public health challenge, resulting in disparities in adverse health outcomes reported across different regions [1], sub-Saharan Africa (SSA) accounts for 70% of global maternal deaths [2,3]. The global Maternal Mortality Rate (MMR) was 223 deaths per 100,000 live births in 2023. This was further from the 70 deaths per 100,000 live births projected in Sustainable Development Goal 3 by 2030 [4,5]. Moreover, about 900,000 children died due to preterm birth-related complications in 2019 [5]. Gaps in the provision of MCH services result in poor growth outcomes, developmental delays, stillbirths, morbidity, and mortality among children [6]. These outcomes are aggravated in adolescent motherhood, characterized by physical immaturity and socio-economic vulnerabilities [7]. While several MCH interventions have been implemented across SSA, inequality persists [8-10], with most programs failing to address the specific needs of adolescent mothers.

Maternal and child health (MCH) services in Kenya have evolved from generalized to more tailored services. Critical MCH services include: antenatal care, child immunization, breastfeeding, family planning, and skilled birth attendance [11,12]. Several user fee-related policies have been introduced since independence to enhance access to these services [13-15]. However, the Kenya Demographic and Health Survey report 2014 revealed that 40% of women still delivered at home, and existing disparities were witnessed between wealthy and poor women [16]. To address this, the government introduced the Linda Mama program for subsidized motherhood vouchers [17] and free maternity services [18]. This increased the uptake of contraceptives and significantly reduced MMR [19]. Further, the Linda Mama program was expanded to cover maternal and child health services for one year following delivery [20,21]. Additionally, the Kenya community health strategy has deployed community health workers to augment the provision of primary MCH services [22].

Despite the implementation of these policies, Kenya still reported 362 deaths per 100,000 live births [23,24], which could be prevented with enhanced obstetric emergency services [23]. Furthermore, poor child health outcomes have been reported, including preterm delivery, poor growth and development, morbidity, and mortality, especially among children of adolescent mothers [6,25,26]. More tailored MCH services can reduce these outcomes and bridge the available inequalities. However, limited studies have been conducted on the equity of the MCH services in western Kenya, especially on the perspectives or experiences of the adolescent mothers to inform improvement of the services. Therefore, this study investigated the perspectives of vulnerable adolescent mothers on equitable MCH services in Vihiga County, Western Kenya in order to address gaps in improving services for adolescent mothers and their children.

Methods     

Study design: this study employed an exploratory study design to investigate the perspectives of adolescent mothers on MCH intervention in Vihiga County. The study involved two sets of FGDs involving school-going and orphaned adolescent mothers. Further, involved KIIs from five county management staff (CMS) working directly in the MCH units at different health facilities in the county. The study design enabled an in-depth, flexible investigation into the equitable MCH services provision for vulnerable adolescent mothers with limited research documentation or published descriptions of the situation.

Study setting and population: the study was conducted in Vihiga County, Western Kenya. Vihiga is a highly populated (1047 people km²) rural county with an estimated population of 590,013, a gross income of US $1,848 per capita, and a poverty rate of 62%. The significant burdens in the county include poor healthcare infrastructure, food insecurity, HIV/AIDS, waterborne diseases, malaria, and poor quality/inadequate drinking water, among others. The county has five sub-counties: Vihiga, Emuhaya, Hamisi, Luanda, and Sabatia. The ministry of health records show that Vihiga has high adolescent pregnancy rates, orphanhood due to HIV/AIDS in Western Kenya. Participant recruitment and data collection were done in November 2024 [27].

Study participants: study participants were purposely recruited from the sub-counties with predominant cases of vulnerable adolescents. In particular, orphaned adolescents were recruited from Hamisi Sub-County, and school-going adolescents from Mbale Sub-County. With the support of the community health attendants, participants were purposely selected from the health units. The inclusion criteria included adolescent mothers with children 0-59 months; those attending antenatal and post-natal care services were approached, and those with records of completing the attendance of antenatal and post-natal care were recruited into the study. The two sets of adolescent mothers enabled diverse and enriched discussion covering all possible perspectives on the current MCH services. In addition, CMS working directly in the MCH units were included in the study as key informants.

Themes: the thematic areas used to explore the perspectives of adolescent mothers on MCH services in Vihiga County were maternal education, social support, government policies, and challenges in accessing healthcare facilities.

Data resource and measurement

Data collection tool: unstructured FGD and KII guides were used for data collection. The tools were validated through expert review for relevance and clarity, pre-testing in a similar population, and translation to Kiswahili/ back-translation to ensure cultural and linguistic accuracy. Research assistants were trained to ensure consistency in how questions were asked and to handle sensitive topics ethically and respectfully. The FGDs examined perspectives of adolescent mothers considering the themes of the study. The KIIs provided a broader institutional and policy-level view of the problem to complement the FGDs.

Data collection: two FGDs were conducted, comprising 2 sets of adolescent mothers. The first FGD was conducted at Hamisi Sub-County Hospital and comprised 10 orphaned adolescent mothers living in Hamisi Sub-County. The second FGD was conducted at Mbale Rural Health Centre, and it consisted of 8 school-going mothers living in Sabatia and Mbale Sub-Counties. The FGDs were conducted by 2 trained research assistants, and audio recordings were made for transcription. Additional notes were taken during the discussions. Perspectives of the 5 key informants were captured. The study aimed to capture rich, detailed peer-driven insights from a specific and hard-to-reach vulnerable group of orphaned and school-going adolescent mothers, in addition to the institutional and contextual perspectives of key informants. Data collection continued until thematic saturation was achieved, as no new themes, information, or significant insights and perspectives emerged from additional FGDs or KIIs. The sample size of 23 was thus deemed sufficient as it comprehensively explored the study´s research questions; represented diverse perspectives; aligned with ethical (given the sensitivity of the topic, ethical concerns around engaging minors and vulnerable populations); and logistical feasibility for our focused in-depth qualitative study. The research team used trust-building strategies and assured strict confidentiality to encourage participation, but these barriers might have still limited the sample size per FGD.

Sampling technique: the study used a purposive sampling technique to recruit participants based on their relevance to the research topic. This allowed for the selection of participants with specific experiences and knowledge, enriching the data quality for thematic analysis. Recruitment aimed at including diverse perspectives while maintaining group homogeneity for effective interaction.

Data management procedures and analysis: thematic analysis was adopted. First, the audio recordings were transcribed and translated from the local language to English. The transcripts were then coded for themes that arose from the data itself, after which the themes were grouped into different families of related themes. This was followed by a line-by-line, micro-analysis using open coding. The codes were then assembled into potential themes, and a thematic chart was developed in MS Word. The themes were compared across the transcripts, specifically the different groups, to establish the range and similarities of the participants´ understanding and views. The interviews and discussions were coded together to produce a single codebook. To enhance the validity of the findings, data from FGDs with adolescent mothers were triangulated with KIIs data from county healthcare management staff. This allowed for cross-verification of emerging themes and provided a more comprehensive understanding of MCH services equity.

Ethical considerations: the study was approved by the Institutional Scientific Ethics Review Committee of the University of East Africa, Baraton, B2424072024, and a research permit was received from the National Commission of Science, Technology and Innovation (NACOSTI), License No. NACOSTI/P/24/38154. Authorization to access the hospital records was given by the Ministry of HealthVihiga County, and the management of the individual health facilities. Written informed consent was sought before data collection. For adolescent mothers below 18 years, parents, or the head of households, were considered “mature minors”.

Results     

Socio-demographic characteristics of participants of FGD: eighteen adolescent mothers were involved in the FGDS. There were two FGDs consisting of 10 and 8 orphaned and school-going adolescent mothers, respectively (Table 1).

Perspectives of adolescent mothers on the current MCH services: the perspectives of adolescent mothers and county health management staff revealed four key thematic areas; maternal education, social support, government policies, and accessing healthcare services.

Maternal education: this theme explored the role of maternal education on the health outcomes of children of adolescent mothers. Education affected the quality of care, confidence, nutritional choices, detection of common childhood diseases, and stigma among adolescent mothers.

Orphaned adolescent 17 years: “You realize that one who is educated and employed is able to buy for the child basic needs, unlike one who is a primary school or secondary school dropout. You have to depend on your guardian for everything”.

Respondents acknowledged the value of child healthcare notes in the MCH booklet, noting that educated mothers better understood and applied the content. However, mothers with lower education levels potentially missed out on these health benefits. The respondent also agreed that education exposed mothers to diverse knowledge on feeding practices compared to their peers.

Orphaned adolescent 15 years: “One who has attained college level is able to read a clinic/MCH booklet and understand what ought to be done”.

Orphaned adolescent 18 years: “A mother who is educated has knowledge from books on the feeding practices of children and the required dietary content. The less educated feed the baby on anything”. Participants agreed that education boosted maternal confidence and improved antenatal care (ANC) attendance.

School-going adolescent, 18 years: “There is a confidence that comes with going to school. This is seen in the clinic attendance, whereby, a young mother may be afraid to attend clinics as she feels that she may be laughed at”. Well-educated mothers could identify early symptoms of childhood illnesses, leading to prompt care and better outcomes.

School-going adolescent 18 years: “One who has been much educated is able to detect diseases and illnesses on their onset by observing the signs and symptoms. This is learnt in school”.

Government policy: this theme addressed policies and programs that strengthen MCH services in the county. The KIIs pointed out the existence of an MCH framework, non-governmental programs, and policies in the county, together with the associated challenges.

Child health focal person, 40 years: “If the existing frameworks were bound to laws, it would offer protection to these adolescents and help in planning. Implementation is also a challenge due to limited resources”.

Child health focal person, 40 years: “Financial constraints in the budget would always limit the capacity of these committees to coordinate and work collaboratively in order to execute all their plans. Increasing budgetary allocation will definitely help them work better.” Programs that identified and educated teenage mothers were reported. The trained teenage mothers would then be deployed as peer trainers.

Nurse 47 years: “The Binti Shujaa initiatives work to identify some girls in our sub-counties. They work hand in hand with our healthcare providers. This Binti Shujaa is a young girl who has also delivered and is able to talk to other girls.” The respondents pointed out the inequity caused by the shift from the Linda Mama insurance to the new insurance, which left out most adolescent mothers. The need for urgency in addressing the gap was revealed.

Nurse 47 years: “With the coming in of the new health insurance, for you to register for this health program, you must have an ID. Unfortunately, most of these young girls are below 18 years and therefore clearing of the bills becomes a challenge.” An informant felt a gap in conducting teenage pregnancy campaigns. A collaborative approach involving teachers, healthcare providers, and the community would be adopted for its success.

Health promotion officer, 47 Years: “I will advocate for a robust campaign on the prevention side. So that at schools, we are able to talk about the prevention of teen pregnancies. We promote abstinence at the school level, and those who cannot abstain should be encouraged to visit the nearest health facility for more guidance.” Local media outlets played a great role in sensitizing the community on health issues, including adolescent pregnancy. The informant revealed that financial constraints are a challenge.

Health promotion officer, 47 years: “For health promotion, we have the local media engagement; radio talk shows, radio sports/mentions, news briefs, whereby at least every week we have highlights on particular health issues such as prevention of teen pregnancies, sexually transmitted diseases (STIs). However, we have limited resources. We lack enough money for radio talks because we have to pay for broadcasting.”

Parental care: this theme describes the role of adolescent mothers in parenting. Re-entry of adolescent mothers in school affected exclusive breastfeeding, resulting in early introduction of complementary feeding, which affected the attainment of growth and developmental milestones.

Nurse 47 years: “You realize that after delivery, this girl has to go back to school. Therefore, this child will not be exclusively breastfed and will be introduced to complementary feeds quite early. If a child is not well taken care of, even achieving the developmental milestones becomes a challenge.” Poor feeding practices and poor care quality were linked to childhood infection, anemia, malnutrition, and death.

Health promotion officer 47 years: “Because of a lack of support and poor feeding, the babies turn out to be anemic and malnourished. Some of the babies even develop other congenital abnormalities or may even die.” The respondents perceived that inadequate knowledge and experience played a major role in the cited challenges.

Orphaned adolescent 18 years: “The child born to mothers of age appears to be healthy and happy. This is because an adolescent mother lacks enough knowledge to take care of the baby, and the child is subjected to poor feeding practices and general upbringing.” Conversely, postpartum depression (PPD) in teenage mothers limits the quality of parenting provided.

Nurse 40+ years: “Young mothers undergo psychological depression; PPD after they have given birth may be because the one who impregnated her went MIA. Thus, this girl may not take care of the baby well.” Spousal neglect of responsibility was also reported as a limiting factor.

Orphaned adolescent, 16 years: “I have been struggling to raise this child on my own. The baby’s father denied the pregnancy, together with the child.”

Social support: this theme explored the support structures available in health facilities, communities, and families for adolescent mothers. This study shows that the support offered is limited and inconsistent.

Health promotion officer 47 years: “There is a partner who trains girls and helps identify the other teen mothers at the community level. Encourage them, refer them to the facility, and give them support. However, the support is not very consistent.”

Programs that supported mothers living with HIV, orphaned and vulnerable children were also identified.

Nurse 40+ years: ”We have an HIV programme which handles the teenagers living with HIV. We also have the orphans and vulnerable child support.” School health teams conducting health promotion on teenage pregnancies and sexually transmitted infections were identified.

Health promotion officer 47 years: “We have a school health team that conducts health education in schools. They talk about STIs, early pregnancies, etc. So that when you prevent at that level, we shall not have many Binti shujaas.” Despite the available structures, weak family support characterized by withdrawal of basic needs, stigma, and rejection pushed teenage mothers into illicit activities like commercial sex work as they struggled to provide for their children.

Nurse 40+ years: “I had a patient who was delivering at the same time taking a national examination, unfortunately, she had no one to support her from the family. She delivered, and the baby developed complications.” Also, other rejections from religious units compounded the worst impact caused by family rejection.

Orphaned adolescent 17 years: “Even our own churches and friends do not embrace us. We are therefore not well supported.” Other challenges include financial constraints and school, and lack of support from the child´s father.

School-going adolescent 19 years: ”Among the challenges that I face is a lack of enough money for food, clothes, and going to health facilities for clinic attendance. It´s difficult to be supported with school fees and also with the baby’s well-being.”

Orphaned adolescent 16 years: “I have been struggling to raise this child on my own. The baby’s father denied the pregnancy together with the child. Thus did not get enough support.”

Access to healthcare: this theme examined the accessibility of maternal health services to adolescent mothers. Efforts to address the triple threat are underway, with adolescent mothers reaping the greatest attention from healthcare workers.

Nurse 47 years: “All of our facilities are embracing the care for these girls. Like right now, we are embracing the triple threat, which has become a common thing ---take your time to talk to her and even learn her challenges, encourage her, and educate her.”

Maternal and child healthcare (MCH) services were offered at various hospitals 5 km apart, and CHPs provided primary health services at household levels. Despite these adolescent mothers alluding that distance to the hospital and lack of fare affected access to MCH services.

Health promotion officer 47 years: “In Vihiga County, within every 5 km, you will find a health facility. Also at the community level, we have CHPs who have data for every household. We therefore have working referrals.” Although the respondents confirmed the existence of established MCH services in the county, understaffing was reported to undermine the care quality provided.

Health promotion officer 47 years: “The HCWs are not enough as some are retirees, some have resigned, and others have travelled out of the country.” Adolescent mothers perceived delivery challenges, especially at the dispensary level. Sub-optimal emergency referral services further aggravated the challenges.

Orphaned adolescent 18 years: “Dispensaries do not offer CS services, even some do not offer delivery services for a first-time mother, and you are therefore referred. This becomes a challenge because of the lack of means of transport during these referrals.” Diverse reactions were recorded regarding the cost of MCH services, with the informant arguing it was free, while the mothers reported paying for the same services.

School-going adolescent, 19 years: “There was a time I had no money, I walked on foot for quite a long distance. Upon arrival at the facility, money was needed. They did not attend to me, I was told to go back home. I was so hurt.”

Poor interpersonal skills among healthcare providers affected the quality of care given. Health promotion officer, 47 years: “Interpersonal communication is a major challenge as some HCWs are abusive to these young girls.”

We further note that both orphaned and school-going adolescent mothers experienced the same challenges as regards to the equitable MCH services. However, the orphaned adolescent mothers often reported economic challenges and inadequate support systems to seek healthcare services. In contrast, school-going adolescent mothers, particularly those with family or institutional support, reported frequent use of MCH services; nonetheless, they experienced challenges like the cultural stigma and logistics of clinic visits when schools are in progress.

Discussion     

This study revealed the contributors of inequitable MCH services for adolescent mothers, which are maternal education that affect the care quality, confidence, and timely detection of common childhood illnesses policy-which limit access to the social insurance fund, peer education, and financial constraints; parental care and social support resulting in rejection, poor school re-entry; and access to healthcare which are long distances to health facilities, drug shortages, under-staffing, and poor provider-patient communications. These findings are consistent with those reported by other studies, in particular, the education equipped mothers with necessary skills and knowledge, increasing their employment prospects and subsequently the care quality provided [28-31]. We observed in this study that educated mothers are aware of danger signs of pregnancy, and this is consistent with an Ethiopian study that reported high birth preparedness and complication readiness among educated mothers compared to their uneducated peers [28]. In this study, we also observed the participants pointing out that maternal education improves the uptake of ANC services, which is in agreement with other studies that have shown that improved utilization of ANC services and complication readiness [32]. To build on some of these successes, there is a need for advocacy to have a policy that keeps the adolescent mothers in school after delivery, with the focus on equipping them with the knowledge for making more conscious health-seeking decisions.

We have also observed that breastfeeding, early and inappropriate introduction of complementary foods, were closely linked with limited maternal education and school re-entry, and cultural factors further compounded the challenges [33]. Indeed, other studies have reported low uptake of exclusive breastfeeding among adolescent mothers. Suboptimal feeding was linked to developmental delay, congenital abnormalities, anaemia, malnutrition, and death. Poor feeding deprives children of essential nutrients required for development [34], and inappropriate complementary feeding has been associated with developmental delay. Also, the financial constraints, inadequate parental knowledge and experience, and postpartum depression (PPD) affected child quality of care among these mothers [35]. In Kenya, there is an effort to illuminate various dimensions and consequences of the hidden burden of parenting, including ensuring that orphans leave the institutional environment upon their eighteenth birthday [34]. The effort would really be helpful to the majority of first-time mothers who are in school, are in ongoing, or are orphaned.

On the social support, the non-governmental and faith-based social support programs were vital in improving the wellness of adolescent mothers, and a recent study has shown that support programs lower their risk of PPD. Likewise, the role of spiritual support in restoring hope for adolescent mothers has also been underscored [35,36]. Peer and community support has also been used to address isolation and stigma, thereby improving mental health, knowledge, and skill-building among adolescent mothers [37,38]. These existing support systems can therefore be explored for the orphaned adolescent mothers who are affected by a lack of support. We have also observed that the weak family support unit is characterized by stigmatization, withdrawal of basic support, including school fees, resulting in suicidal contemplation and forced marriages, similar to other studies. We also observed spousal neglects that force adolescent mothers into hardship in caring for their children, and this has been reported elsewhere, suggesting that this is a common problem that needs an intervention [38]. Quality spousal relationships improve the quality of care and mental wellness of adolescent mothers. Therefore, the incorporation of holistic support programs into MCH services is fundamental in improving the health outcomes of children of adolescent mothers.

The study also found an established MCH system scaling up from community health provision to referral facilities. In this study, the adolescent mothers applauded the role of CHPs in the early detection of childhood illnesses and improving contact between adolescent mothers and MCH services. Our findings are consistent with the role of CHPs as enshrined in the Kenya Community Health Strategy 2020-2025 [39]. However, long distances to health facilities, lack of transport, understaffing, and shortage of drugs were highlighted as challenges to MCH services. The are challenges that have been reported elsewhere [40-43]. Addressing these shortages is important in promoting the delivery of MCH services. Shift from Linda Mama Insurance Funds to Social Health Insurance at the time of this study left most adolescent mothers out, hindering access to MCH services. Moreover, participants proposed the integration of adolescent youth-friendly health groups in the county's MCH services. These would provide tailored services with non-judgmental, supportive, and confidential environments. Such programs would also address the sexual and reproductive health needs of youth, thus shaping their health-decision making [44,45].

The limitations of the study: recruiting the study participants was a challenge, given that most of these vulnerable adolescent mothers were not willing to participate in the study due to incomplete clinic visits, which was our inclusion criterion. However, the saturation of the emerging these was observed despite the decline in the participation. The KIIs were county management staff who may have had limited contact with the adolescents' mothers [15,44,45]. In addition, the study did not cover the perspectives of parents or guardians or other key stakeholders, such as religious leaders and community gatekeepers of adolescent mothers. We nonetheless note that our findings are very insightful, given that these adolescent mothers are part of the young population as observed in the demographies of SSA.

Conclusion     

This study highlighted significant contributors to inequitable MCH services for adolescent mothers, which are maternal education, policy, parental care and social support, and access to healthcare services. As much as these are insights that deepen understanding of equity in MCH services among vulnerable adolescent mothers, a similar study should be conducted in other settings to validate the findings for generalizability. Also, the identified contributors can inform the development of a framework for equitable MCH services for adolescent mothers. The pillars of the framework should include, but not be limited to education, government policy, support, and access to health care services. However, we recommend the inclusion of the perspectives of other stakeholders for validation and regional contextuation.

Competing interests     

The authors declare no competing interests.

Authors' contributions     

Martin Osotsi designed the study, collected data, financed the study, and wrote the manuscript; Winnie Majanga collected data, analyzed data, and reviewed the manuscript, while George Ayodo and Daniel Onguru supervised the study design, data collection, and analysis, and reviewed the manuscript. All the authors read and approved the final version of this manuscript.

Acknowledgments     

We extend our special gratitude to the Access to Medicine Platform organization for supporting part of this research and providing the resources necessary for its completion. We also thank the study participants for consenting to be part of the study.

Table     

Table 1: characteristics of adolescent mothers who were involved in a focused group discussion in a quantitative study conducted in Vihiga County, Kenya

References