Of the 19 participants, 12 were isiXhosa speaking and were Black African and 7 were Afrikaans speaking and were of mixed race (“Coloured”).Footnote 1 It must be noted that there was a limited number of very young adolescents aged 13–15 years at the facilities during the recruitment period. The mean age of the participants was 18.6 years. More than half of the participants reported being out of school (59%), more than a quarter were in school (26%) with the least number of participants attending university (16%). The majority (84%) of the participants were pregnant for the first time and 16% had a previous pregnancy.
Experiences with HCWs that would both reinforce and discourage antenatal attendance were found, with the discouraging experiences being reported far more frequently. The results are presented according to the following themes and sub-themes: Experiences that reinforce antenatal clinic attendance: 1. Respectful and supportive treatment; and Experiences that discourage antenatal clinic attendance: 1. Victimization, 2. Discrimination against being pregnant during the teenage years, 3. Experiencing disregard and exclusion, 4. Inadequate provision of information about pregnancy, health and childbirth, 5. Clinic attendance discouragement and alienation and 6. Mental health turmoil. Direct quotations are presented to support the description of the results for each theme.
Reinforcing experiences
Respectful and supportive treatment
Some pregnant adolescents reported being treated with respect and kindness by some of the HCWs. They felt supported, comfortable and welcomed by these HCWs. They also reported appreciation for being able to ask questions and have information provided to them.
“there’s some nurses that’s nice to you and show you respect and they always helpful, talk to you, ask you questions …Treat you with love and respect. They made me feel welcome.”
Participant IDI 4
“When you tell them, you have a certain pain somewhere they tell you what is happening. Like the nurse that we were saying is nice, I really like that nurse”
FGD 1, Participant 1
“They will come and tell you ‘it’s just you and me, there’s no one here whatever you ask me will stay between us and if you don’t want your husband here then only me and you can chat’. They make you feel relaxed. They make you feel at home –where you can talk and they have been there. They are interactive with you”
Participant IDI 4
“It depends on the person! If the [nursing] sister looks like someone – she is friendly. Like the sister [nursing] who examined me, took my blood pressure, and such things. I asked her many questions!”
Participant IDI 3
Discouraging experiences
Victimization
Many pregnant adolescents felt that they were treated unfairly when they visited the facilities and their visits felt unpleasant because the HCWs behaved more rudely and offensively towards them than towards older pregnant women. They indicated that due to their young age, HCWs saw them as immature, promiscuous and shameless. They felt that they were treated differently from their older counterparts. They reported that the treatment by the HCWs made them feel as though they were guilty of committing a crime or doing something seriously wrong. Participants felt that their reputation was being blemished and that the rudeness of the HCWs led the older pregnant women to gossip about them. The adolescents felt that the actions of the HCWs were demeaning and belittling, and alienated them, even though they were at the clinics for the very same treatment as the older pregnant women.
“They [health care workers] mistreat us; they shout at us and are very rude. …. But the other [nursing] sisters, their faces show ‘No, don’t ask me’ –unapproachable.”
FGD 1, Participant 1
“But what I don’t like about the clinic, is there’s people that is very rude. They’re very rude they don’t ask you; they just assume.”
Participant IDI 4
Rudeness by the HCWs was reported as frequent among the participants and the dissatisfaction with the relationship with HCWs could be noted in the tone in which the participants spoke. In addition, one narrated a patient-provider interaction that she had witnessed during one of her clinic visits, whereby she felt that the HCW was judgmental and embarrassing in the approach of a pregnant teenager:
“The girl that was with me was 15 or 16. She was very thin and you could see in her face she is young. Her mother came with her and then the mother went home because she was hungry. So, she told her [asked] mother if she can go home, she also wanted to leave the day hospital. So, the [nursing] sister said ‘why do you want to go with your mother, you did not sleep with your mother!’ La la la… the [nursing] sister scolded the girl. It is almost like because she is young. ‘There is a thing like a condom –Why don’t they use condoms?’”
Participant IDI 3
Another participant reported unpleasant encounters with HCWs, and she was rebuked when she requested a pregnancy test. The encounter below indicates a failure by the HCW to carry out the duties of a health professional in a professional and respectful manner:
“I started suspecting I was pregnant when I was a month far along, and then I went to the clinic to ask for a pregnancy test but the nurses told me to go buy myself a pregnancy test and bring it. When I told her that I saw the sign which clearly states that free pregnancy tests are offered at the clinic she shouted at me saying they don’t test for pregnancy so I just walked away because she was shouting at me in front of other patients and saying out loud everything I had come to do at the clinic”
FGD 2, Participant 4
Discrimination against being pregnant during teenage period
According to the participants’, their age was a big issue of contention, as they felt stigmatized because of this. The participants felt that this led to the HCWs being particularly intolerant and impatient with them. Furthermore, they saw the differences in the attitudes and behaviours of the HCWs towards older pregnant women and themselves as younger women and did not understand why there was differentiation in treatment, or the harsh, judgmental attitude that they had to endure just because they were younger.
One participant said, “with the nurses, if you are young, they are nasty to you”.
The majority of the participants agreed that the HCWs did not have a right to be judgmental. Participants expressed concern about how a HCW would treat adolescents who fell pregnant due to being raped and who presented at facilities for healthcare along with the other pregnant adolescents. They were concerned that these adolescents may be humiliated by the HCWs without knowing the context of their situations and needs. Participants also reported that being in a relationship and becoming pregnant was not a reason for HCWs to treat them unfairly and negatively. Some participants felt that if a woman asked for contraceptives, the HCWs should have been happy that she was practicing safe sex. They preferred purchasing contraceptives from a pharmacy, where they were not judged, or they asked their partners to buy it for them.
The excerpts below demonstrate the stigmatizing treatment received when pregnant adolescents went to health care facilities:
“Just because I’m a teenager and pregnant –doesn’t mean you (health care workers) have to treat me, well, differently towards a married woman. It doesn’t mean that you have to. “oh, ok you are a teenager, come, come, come and this and that.” No. We all…I have the same…we all are pregnant you can’t treat me different you don’t know the reason, maybe I got raped and felt pregnant or maybe I was in a relationship and then fell pregnant. So, basically you can’t treat me differently”
FGD 4, Participant 2
“They say negative things about the fact that you are young and pregnant, they even go as far as telling others to look at you, saying “look at this one, pregnant at this age.” But the strange thing is that even when a young person goes to the clinic for contraceptives, they are rude and ask questions like “why do you wanna get contraceptives at such a young age”. Worst thing is one falls pregnant and they still give you a hard time!”
FGD 1, Participant 1
Another participant whose late arrival for her consultation resulted in her being shouted at when a nurse reportedly said to her:
“Why are you late, you fall pregnant at such a young age but can’t even do something as simple as getting here on time!”
FGD 1, Participant 2
Experiencing disregard and exclusion
The participants also felt that they were neglected when they attend their clinic appointments, because they were not attended to on time, and the HCWs were unhelpful and made them feel unimportant. Some participants felt that the HCWs were possibly under pressure in their work, and their lack of understanding of pregnant adolescents led to their neglecting the needs of the adolescents.
“No, the nurses make you feel like you are wasting your time, they act like you have nothing better to do by making you wait there and not helping.”
FGD 2, Participant 2
“Sometimes they just go into that examination room and sit there and the worst thing about being at the clinics is that when it gets to tea or lunchtime they leave.”
FGD 2, Participant 4
“They wait for you to ask questions, and if you don’t then they don’t care”
FGD 3, Participant 2
“Basically, you just going to collect your tablets and they tick it off, they don’t still speak much to you.”
FGD 3, Participant 1
One participant expressed being ignored by administrative staff when she was referred to them to collect documentation:
“You can stand almost for how long and calling someone and no one is coming…they [administrative staff] just walk past you like you not even standing there.”
IDI 4
One participant resorted to using other resources as substitutes for antenatal clinic attendance, due to the neglectful behaviour of the HCWs, which deterred her from going to the healthcare facility.
“I’ve been at home for a long time, I just didn’t come to the clinic because the nurses are useless, they were not helping me, so I whenever there was something I wanted to know I would just log onto Facebook and find out.”
FGD 2, Participant 2
Inadequate provision of information about pregnancy, health and childbirth
The adolescents reported that HCWs withheld information regarding the mothers’ and unborn children’s health and when asked specific questions they were unhelpful. Participants said that although very expensive, visiting a private doctor or another clinic further away that they perceived as being more youth-friendly, was a preferred choice as it gave them the information required and their questions were answered with clarity and care. All participants reported that they feared asking pregnancy related and general health questions as they often received negative responses resulting in them being humiliated and feeling disempowered, or that the HCWs displayed an unwillingness to respond to the questions. The narratives below also indicate that the young women were able to compare the services and assistance they were receiving in comparison to what they should have been receiving, thus seeking help from the internet and private physicians.
“Huh-uh I don’t yet have enough information. Okay, yes they gave us a list of things to pack for the baby. But how will I know how I must lay –I didn’t practice this process before!”
Participant IDI 3
“Like –if come here –there are times where they don’t tell you –like this is how far your baby is. Your baby is fine nothing like that. They do their tests; they don’t tell you like there’s no movement in the baby. Like if I go to the doctor [private] or something or for a test they will tell you like okay your baby is moving. That’s – the baby is on the right tract now. Then there’s just that people who don’t tell you at all. You are like ‘what’s happening, wondering’”
Participant IDI 4
“Look, I asked the [nursing] sister what they were doing, and she just shouted at me asking me why I wanted to know saying “you like to be forward, why you want to know everything”! So, I was never even able to ask for a test and didn’t even know whether I was tested or not.”
FGD2, Participant 2
“Not at all, because they (health care workers) are always rude or they tell you to go ask your parents, or even ask you, “When you were making the baby did you not know what would happen?”
FGD 2, Participant 1
“Some of the nurses are intimidating, because you just take one look at them and they seem so unapproachable that you feel scared to ask questions.”
FGD 1, Participant 2
When the participants were asked how they respond to a HCW who is perceived as unapproachable, one of them said “then I will rather not ask them any questions, or I will go and ask that other [nursing] sisters.”
The nurse’s unwillingness to provide answers to their questions also resulted in a sense of helplessness and confusion as illustrated in the quote from another participant:
“They even tell you, you are too big for your shoes you should know, even the fact that you are pregnant means that you already know a lot, so I don’t know what they expect us to do or where they expect us to go when they tell us that we have information which we don’t.”
FGD 2, Participant 2
Clinic attendance dissuasion and alienation
The participants’ experiences with HCWs greatly influenced their clinic attendance. A key finding was that the participants felt discouraged to seek antenatal care early in their pregnancy, or they discontinued their attendance because the quality of care did not meet their expectations and they wanted to avoid encountering the HCWs. Some even resorted to changing to a clinic further away in the hope of receiving better treatment and care.
“First of all, I don’t want to be there… Just that they think that you from [name of community], you are like [that community] and so they have to treat you like [the community]”
FGD 4, Participant 2
“It hurts a lot because when you come to the clinic you expect that you will get help and get support and advice so when these very people that you trust to give you information are rude to you it’s very discouraging.”
FGD 2, Participant 1
One participant confirmed her pregnancy early on, but only sought antenatal care a few months later due to an earlier encounter with a HCW who was rude:
“I left, went to buy my own pregnancy test and it came out positive. But I only went back to the clinic three months later to start receiving antenatal care.”
FGD 2, Participant 4
One of the girls had resolved to change clinics with hopes of getting better treatment:
“So that’s why I’m saying I’m going to start over from [Name of facility]. I’d rather start over.”
FGD 2, Participant 2
Mental health turmoil
Participants recognized that although they were young, they had made the choice to keep the baby after birth as some of them had support from their families and partners. They felt that not providing the information and services for pregnancy and birthing needs forced some adolescents to consider abortion. They reported that abortion was a legitimate option for some adolescents to be away from the discriminating maternal health care environment. Due to the discrimination they faced some young women were in emotional turmoil and opted for the unsafe option of abortion by themselves.
“And the [nursing] sisters –it feels as though –especially with the young girls that are pregnant. They are discriminated against because we are pregnant. The nurses shout at us ‘you had to know you must not have sex, there is a thing like a condom now you sit with this thing!’ I told the one I’m studying sports management, so she said ‘now you sitting with a sport management. Do you know how it is to raise a child blah blah blah’? That also puts off the girls, the [nursing] sister shouting on their heads. Then they decide they’re going for an abortion. They don’t have time for nagging, that’s what aggravates me the most is the lots of tests they must do.”
Participant, IDI 3
Another participant mentioned that some adolescents opt for unsafe abortion as they “abort the child themselves”, and not in a hospital or clinic.