‘Just because she’s young, it doesn’t mean she has to die’: exploring the contributing factors to high maternal mortality in adolescents in Eastern Freetown; a qualitative study

Transactional sex

Despite use of language such as ‘being in love’, the context for much of the sexual activity discussed in this study appears to define it as transactional; as a way of minimising the burden of the time-consuming duties of petty trading or water collection; for money to pay for school fees and other expenses; and as a condition proposed by school teachers for girls to pass exams or be promoted to the next school year. The lack of adult care and financial provision for girls who were living with extended family instead of their birth family seemed to exacerbate their exposure to all of these risks, although girls living within their own birth families were also under pressure to have transactional sex.

Clearly, the task of collecting water during the dry season can present girls with difficult choices in terms of sexual behaviour, particularly in terms of freeing up time for study and school attendance.

School attendance presents teenagers with a raft of financial challenges, even if their basic school fees are being paid. Having to find the extra money needed to access all of the curriculum, to ensure that assignments are graded or even to pay what are essentially bribes to teachers to pass exams and progress through school can put girls under pressure to have transactional sex with older men who can provide for them.

Sex for grades

An even more direct risk associated with schooling is the sexual abuse perpetrated by teachers whereby they arrange to have sex with female students in exchange for academic achievement [8–11]. This is identified as a pervasive issue, but one which young people are reluctant to discuss [8].

Various methods are used by teachers to pursue and control girls such as buying the girl a mobile phone, which she is then expected to use to send sexually explicit photos. This study data would indicate that this practice is commonplace, but that the taboo around it is stronger than the ‘sex for school fees’ issue.

It seems apparent that for teenage girls in Sierra Leone, graduating from secondary school is not a simple matter of completing assignments on time and studying for exams. On the contrary, for some young women, pursuing an education seems to be a minefield of risk and difficult decisions where the benefits of an education have to be weighed against the risks of pregnancy, infection and the trauma of unwanted sex.

The criminal justice system

Despite a legislative framework being in place to deal with sexual abuse, there currently appear to be a number of barriers to fully implementing this legislation, including a lack of political will to take the issue seriously, a lack of logistical infrastructure to facilitate trials and prosecutions, and a lack of support to girls who choose to put their heads above the parapet and challenge the inherent gender norms and power imbalances to which society generally and the education system specifically are subject.

Contraception and abortion

Access to contraception is recognised as a vital component in reducing adolescent pregnancy and maternal death [12–14], and an important part of the national strategy is to make contraceptives more accessible, available and affordable for adolescents. There is work in progress to train health workers in family planning methods, including implants, and to make government clinics adolescent-friendly by allocating trained staff to treat teenagers, with, in some clinics, a separate room to accommodate them. Marie-Stopes and other NGOs are also popular providers. Health workers made a distinction between Freetown and the provinces in regard to contraceptive services, saying that they are well stocked with contraceptives in Freetown, but this is not always the case in the more remote rural areas. Despite availability, health workers identified ongoing stigma as the major reason why girls do not access family planning in Freetown.

And several told of how boyfriends or parents had tried to persuade them to have an abortion, but they had refused or avoided it.

Despite significant advances in the supply and range of contraception available to women in Sierra Leone, there are persistent issues of availability in rural areas, and accessibility for stigmatised groups such as adolescents. The use of unregulated contraception and abortion put these younger women at additional risk.

Abuse and abandonment

Other studies have found that this arrangement confers higher risk of emotional and sexual abuse for the girl, and higher risks of physical and mental health problems [8, 15].

Increased birth complications

They reported teenagers often not registering at all with a health care provider in pregnancy, then presenting late in labour, often only accompanied by friends and lacking any adult support, and they related concealed pregnancies directly to maternal death.

Clearly, teenagers who die around the time of childbirth suffer from the same obstetric conditions which befall older pregnant women, but youth in itself should not confer additional risk when considered as part of a risk assessment – a concept which the midwives clearly articulated. Obstetric risks were perceived to be magnified by delayed care seeking and the poor physical condition in which girls go into labour.

Risk of death from Anaemia and PPH

The severity of the situation was all too apparent when the first author donated her blood at the country’s main referral hospital; it was the only unit of A+ blood in the blood bank.

Mentoring

The literature from Sierra Leone consistently points to good parental communication, especially with mothers, as a protective factor for risky sexual behaviour and early pregnancy, but that parents lack confidence to discuss these issues [15, 16]. This study aligns with that; the country director of an international NGO addressing teenage pregnancy prevention in a rural area described ‘overwhelming numbers of parents wanting to join in’ with their interventions to equip parents with knowledge and skills to support their children.

She also described her strategy to ensure that the girls had enough money to feed themselves well and buy things for their baby; supporting them to start a small business and supervising their savings.

Considering the recent EVD epidemic in Sierra Leone which left many stigmatised orphans, and the effect of the internal migration of teenagers away from families in the provinces to Freetown, this simple community-based mentoring intervention has the potential to benefit other orphaned, abandoned or otherwise isolated adolescent mothers in Freetown.

Community-based blood donation

Other potential barriers to a local community register was the fear that donors might be taken for granted when there were other family members able to donate; this would need to be part of a further consultation on compensation mechanisms and eligibility.

Transactional sex

It is evident that in Freetown, adolescent transactional sex, whether for water, money, or grades, is a social norm which is in some cases encouraged by family members, ignored by school authorities and for which legislation appears not to be effective. In many cases, expectations are placed on girls to provide for their own financial needs, and for many girls, the only option is to meet those needs with their one available resource, their bodies.

This study indicates that girls who live with extended family rather than with a parent are more vulnerable to the pressures of transactional sex and exploitation, and the literature echoes this finding [9, 15]. One 2010 study showed large anomalies between the intended reason for children being moved from rural areas to urban households and the endpoint reality for the child [15]. Sixty-seven percent of these children said they initially moved to Freetown to go to school, but only 38 % were attending school, and 60 % said they ‘worked’, the majority ‘working in the house’ [15]. Regarding pregnancy, 58 % of teenage mothers or pregnant teenagers were not living with either biological parent [15].

The more specific issue of ‘sex for grades’, where girls have sex with male teachers in exchange for passing exams or being promoted to the next year in school is also widely mentioned in the literature [8–11]. In Coinco’s 2008 qualitative study [9] focussing on the plight of ‘out-of-school’ primary-aged children, the issue is discussed in some detail, with a case-study on ‘teachers’ sexual advances’. A 2010 joint NGO report showed that some 30% of coerced or forced sex of adolescents is by teachers [11], and a 2013 study [8] acknowledges the issue of teacher coercion, but found that participants did not talk about it, concluding that increased awareness of child rights has increased the taboo around the issue with fears of recrimination and shame acting as deterrents to fuller discussion or disclosure.

This approach seems rather simplistic in the light of key informant data in this study, which indicate that, contrary to perceptions that keeping girls in school will solve the problem of teenage pregnancy, for some girls, school is a risky environment where transactional sex is a necessary evil to ensure academic success.

Much of the messaging on early sex and teenage pregnancy appear to be presenting the issue within a ‘blame frame’ [21]. Girls’ behaviour is perceived as the problem, with little being said about the role of men and boys, the impotence of the justice system, or the significant contributors within the structural environment such as the deficient water supply or lack of female teachers. Posters generally target girls themselves, urging them to avoid under-age sex and teenage pregnancy, with the implicit message that they are free agents, making choices around their sexuality and fertility. Whilst the 2014 communications strategy rightly proposes messages to both young men and women, to parents, carers and community leaders, some of the key messages belie the baseline premise that girls have agency and are in a position to choose their sexual behaviour: ‘Abstinence is the safest way to avoid pregnancy and diseases. Young women who choose this path should be praised and encouraged’. [16](Page 41).

Some studies rightly identify that girls have transactional sex in order to access clothes and belongings which would be inaccessible without it [20]. There is a danger that this too can feed into the blame narrative, as though having sex for basic needs is more acceptable than having sex for ‘luxuries’. Again, this oversimplifies the lived experiences of girls in Freetown. Seminal literature on ‘the body as an asset’ asserts that for a poor farmer or factory worker, the physical body is the one asset a person has to produce wealth [22]. For a girl in Freetown, her body is such an asset, and equipping herself with the right clothes, hair and accessories could be seen as a way of maximising on her potential to pay for ‘necessities’ such as schooling, which is widely viewed as the only exit from poverty. For example, a mobile phone could be viewed as a luxury, but with the ‘body as an asset’ lens, a mobile phone is to a teenage girl as a scythe is to a farmer – an essential tool to maximise one’s potential to secure a livelihood.

Data suggests that sexual exploitation by teachers is not restricted to senior secondary schools, but also directed towards primary age girls in early puberty with no transaction apparent. However, the language used to discuss this issue lacks clarity, with phrases such as ‘institutionalised child abuse’, or even ‘child abuse’ not being part of the dialogue. One key participant, describing his discomfort with the situation where a teacher keeps a pubescent girl after class to ‘touch her breasts and buttocks’ proposed tentatively that ‘this might be called abuse?’ The exception to this was a child protection worker pushing for a teachers’ charter and awareness-raising amongst students on the law around sexual abuse and child rights. In the recent years of the implementation of the national strategy, efforts have been made to educate communities about gender-based violence and child rights, but there is clearly more work to be done in this area.

In many ways, this lack of conviction about what constitutes child abuse is unsurprising, since the waters are muddied by the strong gender norms which normalise early marriage and motherhood, often viewed by families as a way to prevent the risk of the stigma of teenage pregnancy outside of marriage, and boys’ education is often seen as a more worthwhile investment than girls’, with the expectation that early motherhood will limit educational potential. Though reported elsewhere [15], there was no evidence in this study of boys being sexually exploited by teachers. However, they are not exempt from ‘money for grades’ by both male and female teachers, and often do hard manual labour outside of school to pay for additional charges. All these factors undermine the education system and therefore economic growth and development. A unique finding in this study was the use of boys by teachers to scout out and groom girls, promoting and reinforcing a gendered stereotype of adult male sexual behaviour to boys through negative role modelling.

Training and employing more female teachers is recognised as important to turn the tide in this issue, but it seems that this very strategy is undermined by the issue itself; only 12% women aged 20–24 in Sierra Leone are educated to secondary level or higher, compared with 20% of men [1] and the data suggests that sex for grades is also a common barrier for women in university. This under-education of girls has serious implications for the health and economic wellbeing of the country as a whole; an international study shows that when women and girls earn income, they reinvest 90% of it into their families, compared with only 30 to 40% for a man [23].

Regarding the ‘water for water’ issue, the same message persists; posters encouraging girls to avoid early sex and stay in school are strategically placed near water wells [16]. The irony of this message is hard to miss when one imagines a girl considering her options of staying in the water queue and missing school, or of bypassing the queue for sex to ensure she attends school or sits an exam. A more upstream solution, to upgrade the failing water supply problem, is not mentioned as a potential strategy in policy documents.

Abandonment

The association between poverty and adolescent maternal death was pervasive in this study. This was particularly clear within the themes about the treatment of girls once pregnant, with clear differences between social groups. Poorer families normally see the girls as the responsibility of the father of the baby, and an opportunity to gain some financial support, even if he is a teacher or older married man. Support deals are often brokered by community leaders for the man to support the girl during the pregnancy and pay for the child’s education, even if she stays with her family. Girls who are forced to marry or to live at the man’s house are often treated badly, exposed to further risks of STIs, malaria, anaemia and the additional risk of second pregnancy; compounding mortality risk.

This is in stark contrast to girls from professional families. Many of the professional women within health services, NGOs and government departments described being introduced to a colleague’s son or daughter who was clearly the result of a teenage pregnancy. One participant related this phenomenon to Krios, an ethnic group within Freetown who tend towards professional occupations. She described how girls as young as eleven would be taken to a different community (‘to the hills’) and given caesarean sections, only to return to school without the knowledge of their peers.

This practice of the family concealing and dealing with the pregnancy and sending the girl back to school is very difficult for poorer families, yet one local woman advocated strongly for a similar mindset, articulating a view not commonly heard in poorer communities; of families continuing to treat the girl as a child, and taking the baby as a sibling of the daughter. She stressed the importance of helping girls to develop aspirations, and the need for strong role models. Much has been written about the influence of positive role models in the Sierra Leone context [8, 9, 15], and examples such as this one point to grass-roots advocacy as a powerful tool for change in tackling the inherent social inequalities of teenage pregnancy outcomes.

Delayed care seeking

In addition, despite health care for pregnant and lactating women and children under five being free since 2010, there is a perception that government clinics still charge for their services, and in reality, informal charges are still common.

Viewing the situation from the health worker’s point of view, training for health workers is rife with corrupt practices such as ‘under the table’ payments to invigilators, for forms to be processed, and for graduation, and health workers often leave their training in huge debt; this inevitably plays out in the clinics and hospitals. A key NGO participant leading a community development project aimed at reducing maternal mortality through community engagement, highlighted the importance of a strong advocate as a protective factor against these informal charges; a respected individual who could challenge disrespectful care or corrupt practices. Girls who are only supported by peers or young boyfriends are particularly vulnerable and may not return to a clinic or hospital setting if their first experience is disrespectful or corrupt, risking complications and death. One young mother who experienced abusive care in labour vowed she would never use the services again, and joked that she would protect herself with six ‘captain bands’.

Midwives talked about how the combination of FGM, early marriage, polygamous households and delay in seeking care mean that girls from rural areas often arrive at the referral hospital in Freetown at the point of death. Their general feeling is that physically, girls ‘shouldn’t have to die just because they are young’, but lack of agency means that girls have little control over their fertility or health seeking, and this makes them much more vulnerable. Midwives expressed strong emotions when talking about the helplessness they feel when girls die needlessly. One interviewee reframed the harsh treatment of women who seek health care late as an expression of frustration and helplessness as ‘when they yell at you it’s because they love you and don’t want these things to happen to you’.

There were numerous examples in the data of midwives going ‘above and beyond’ for women, including doing a home visit to site implants for girls who were too ashamed, donating blood for a dying woman, and paying for a taxi to transport a woman to hospital who was bleeding. This is not to say that the promotion of respectful free care is unimportant, but gives another perspective to the ‘disrespectful care’ narrative which needs to be considered in the bigger picture of resolving the issue. Starting a career without the debt from bribes paid to move through the training process would undoubtedly affect the issue of informal charges, for example.

Mentoring

Historically, sex and relationship education in school has been limited to lectures by teachers or nurses on contraception use, with little opportunity for real discussion with adults [8, 16, 19], and studies show that adolescents are strongly influenced in their attitudes to sex, and gain most of their information about sex from pornography and other media [8, 20].

Although evidence which specifically relates to mentoring of young mothers is sparse [26, 27], with most research looking at black American adolescents, limiting applicability to the African setting, there is strong evidence that connectedness with an adult, be it a parent or a non-parental adult, appears to be foundational for adolescent health and well-being more generally [26, 28], including delaying rapid second pregnancies [27]. Regarding studies in SSA, Coinco asserts that a protective factor for adolescents against risky sexual behaviour and early pregnancy in Sierra Leone is having a consistent trustworthy adult or role model involved in their lives [15], and studies in South Africa and Uganda demonstrate that AIDS-orphaned children and adolescents in a natural mentoring relationship showed significantly lower distress and mental health factors (child abuse, social discrimination, anxiety, and depression) than those not in a mentoring relationship [29, 30]. A review of the determinants of delivery service use identified low maternal age as a determinant for not accessing skilled care for delivery [31].

Within this current study, issues of abandonment leading to poor mental health, poor health-seeking behaviour and lack of knowledge about pregnancy, birth and baby care all indicate that a mentoring scheme may be effective, and evidence from other community projects indicate that having an advocate when accessing health care can mitigate against some of the barriers such as disrespectful care and informal charges (personal communication).

Following the findings of this study, a pilot mentoring scheme for younger and more vulnerable pregnant teenagers is currently underway, in order to establish feasibility to trial a scaled-up intervention. Mentors have four key roles; helping girls to re-establish family connection and support; encouraging health seeking behaviours and advocating for respectful care at clinic, in labour and in the postnatal period; providing practical advice and support with parenting; and providing support and training in a small business and to re-enter education or vocational skills training. Some outputs will be quantitative measures such as the number of antenatal visits, uptake of tetanus toxoid, uptake of prophylactic medication, sleeping under a bed net, and uptake of infant immunisations. Others will be qualitative in nature; the impact of the mentoring relationship on the young person’s mental health, the impact of having an advocate on experience of antenatal care, and the impact of mentoring on family support mechanisms.

Community-based blood donation

The Guidance from the World Health Organisation (WHO) and the President’s Emergency Plan for Aids Relief (PEPFAR) recommends that countries aim by 2020 for 100% blood to be donated by non-remunerated volunteers rather than family members, primarily for reasons of sustainability and safety of the service [32]. The need for an understanding of the SSA context and how this differs from the primarily European and American contexts where most of the research which underpins the guidance is carried out, was emphasised in two recent literature reviews around blood donation behaviour in SSA [33, 34]. Both reviews identify altruism as the common primary motivator for donating blood, whether to a stranger or a family member, but show that other motivators and barriers vary between countries. For example, the opportunity to have a health check and discover and treat any infections was considered a motivator in a study from South Africa, but a deterrent in studies from many of the other SSA countries. Regarding barriers to donation, a mixture of cultural and religious beliefs, myths about the dangers of donation, and lack of information about the process were all cited, and their analyses indicate the need for programming at a national or even tribal level rather than global or regional level. For example, in several of the thirty-five studies in one review, there was a belief that giving blood could cause male impotence [33]; where this is known, interventions with older repeat male donors with children as donor champions could be strategically effective.

Regarding the distinction between regular volunteer donors and those who donate to family members in an emergency, the evidence behind the rationale of safety and sustainability of the former has been challenged, with further analysis of the data showing no difference in safety and a two to five times increased cost per unit for this policy [35].

In a culture where blood is not readily available and blood donors must be brokered within the family setting, it is unsurprising that young girls in Freetown who have been rejected by their families are at higher risk of death from bleeding than women with higher levels of social capital. This is in addition to risks due to increased anaemia from poor diet and limited antenatal care. Social norms dictate that it is close relatives rather than husbands or partners who donate to women, putting young girls in an even more vulnerable situation. If a blood donor is not available, blood must be purchased which is likely to be outside the reach of more isolated teenagers.

One potential solution being considered here is to set up a local register of donors from a discreet community, linking directly to the three PHUs in that community, where donors who have already been screened are called upon in an emergency. This system would engender a sense of ownership, and allow for compensatory mechanisms between families and donors not possible within a wider donation programme. With an asset-based lens, the community in question has particular favourable assets for such a scheme; the hub of this community is a faith-based project set up during the civil war to rescue child soldiers, and which now accommodates and trains young people, based on common values such as altruism and caring for the poor. There is strong body of literature on the benefits of maximising on faith-based groups as sites for public health interventions [36], with potential for scale-up in similar communities.

In this study, compensation to eat and travel to the blood bank were considered minimum requirements to donate, with this donation still being considered voluntary and altruistic. Since paying large sums to ‘professional’ blood donors outside the hospital was commonplace, a system where the family ‘gifts’ the donor a modest amount of money to travel and eat could be reasonably considered as a sustainable model. The importance of recognition was also seen as important, and if the system was being managed within a discreet community there would be scope for developing this particular incentive.

The biggest barrier to blood donation was the fear of a positive HIV status, with the belief that this was a death sentence and would lead to social ostracization. Other barriers were fear of the process and fear that the donor would be unwell after donation. More exploration needs to be done with this community about the best ways of addressing these barriers. For example, in the focus group with young men from LNP, the fact that one young man had donated blood five times and described the process as ‘like having a drip – you’ve all had a drip!’ seemed to quickly dispel the fear in the whole group. Equally, meeting a person living with HIV, or hearing stories from community members whose lives have been saved by a voluntary donor could be important strategies for recruitment of local donors, and would need to be further explored.