Background
Although much progress has been made in the last two decades from maternal healthcare interventions across the world, the maternal mortality ratio is still high. Globally, 295,000 women died of pregnancy and childbirth-related complications in 2017 [
1]. The majority (94%) of these deaths occurred in low-resource settings [
1]. Therefore, Target 3.1 of the Sustainable Development Goals seeks to reduce the global maternal mortality ratio to less than 70 per 100,000 live births by 2030 [
2,
3]. Adolescent pregnancy is a risk factor for maternal mortality. Adolescent girls face a higher risk of complications, such as eclampsia, puerperal endometritis, systemic infections and death [
1,
4]. Complications during pregnancy and childbirth are the leading cause of death among adolescent girls aged 15-19 years globally [
5]. About 99% of maternal deaths worldwide occur in developing countries with the majority occurring in sub-Saharan Africa [
6].
Antenatal care (ANC) services present a golden opportunity to help reduce maternal mortality. Although many maternal complications are difficult to detect during ANC visits, some, such as hypertensive disorders can be identified and proactively managed through antenatal care visits [
4]. Pregnant women have access to skilled healthcare and early detection of danger signs in pregnancy during ANC visits. There is a positive relationship between ANC utilization and positive pregnancy outcomes [
7]. Also, ANC enables expectant mothers to learn about signs of obstetric complications and the essence of accessing skilled delivery services [
7]. ANC can help reduce perinatal and new-born morbidity and mortality [
8‐
11].
Despite the benefits associated with ANC services, utilization remains low worldwide [
1], especially among young mothers (15-24 years) [
12‐
15]. Evidence shows that adolescent mothers (15-19 years) are three times less likely to utilize ANC compared to adult mothers [
15]. The uptake of ANC is influenced by socio-demographic and behavioural factors. Prior studies have reported that the uptake of ANC was associated with proximity to health facilities, maternal educational status, partner’s educational status, geographical region, access to health information and socioeconomic status [
13,
14]. Though the World Health Organization recently recommended 8 or more ANC visits, adolescent and young mothers in Low- and Middle-Income Countries still do not obtain the previous recommendation of 4 or more ANC visits [
16].
In Ghana, the maternal mortality ratio decreased from 398 deaths per 100,000 live births in 2003 to 308 deaths per 100,000 live births in 2017 [
1]. This ratio is still high and above the Sustainable Development Goal 3 target. Adolescent pregnancy remains a public health concern in Ghana. For instance, about 109,888 adolescent pregnancies were recorded in 2020. Thus, 301 adolescent girls were impregnated every day or 13 adolescent girls were impregnated every hour [
17]. The utilization of ANC among adolescent and young mothers in Ghana is below expectation. In addition, existing studies on ANC utilization focused on all pregnant women [
18,
19], with little attention on adolescent and young mothers (10-24 years) who are at a higher risk of pregnancy-related complications. This is the maiden study to investigate the utilization of ANC among adolescent and young mothers in Ghana, using nationally representative data. Findings from this study would help inform maternal health policy and programming. Therefore, this study aimed to assess the prevalence of obtaining 4 or more ANC visits, and associated factors among adolescent and young mothers in Ghana, analyzing data from the 2017/18 Multiple Indicator Cluster Survey (MICS) [
20].
Discussion
It was revealed that the majority (84%) of the mothers obtained the recommended ANC visits. This national-level prevalence is similar to findings at the district level. For instance, a study in the Yendi Municipality found a prevalence of 83.9% among adolescent mothers [
14]. However, the prevalence in this study is higher than findings in Nigeria (35.1%) [
29], Bangladesh (30%) [
30] and India (22.9%) [
31]. The differences in findings can be attributed to the implementation of the Free Maternal Health Care Policy (FMHCP) by the government of Ghana in 2008. With this policy, pregnant women who enrol on the National Health Insurance Scheme (NHIS) have access to free maternal healthcare services, including ANC services.
On the other hand, a substantial proportion (16%) of adolescent and young mothers did not obtain the recommended ANC visits. This is likely to derail efforts towards achieving SDG 3 since optimal ANC utilization is crucial for reducing maternal mortality [
4]. The prevalence of underutilization of ANC (16%) is higher than findings in developed countries (5%) [
7]. This may be attributed to differences in contextual factors, such as socio-cultural norms and health system factors. For instance, adolescents may delay in accessing ANC services due to fear of stigma or being expelled from school [
32]. Also, negative attitudes of health providers towards adolescent mothers coupled with distance to health facilities might have accounted for the differences in the findings [
14,
33].
The salient factors associated with obtaining the recommended ANC visits were higher educational status, higher socio-economic status, exposure to the internet, and geographical region. It was revealed that adolescent and young mothers who had junior high school education were more likely to obtain 4 or more ANC visits. This finding is consistent with prior studies in low-and middle-income countries [
16,
29]. For instance, a study revealed that Indonesian adolescent mothers with higher education were more likely to utilize ANC services compared with those with lower education [
34]. Also, a systematic review of studies from sub-Saharan Africa showed that women with higher education were more likely to obtain the recommended ANC visits [
35]. Educated mothers have more access to health information, appreciate the causes of adverse pregnancy outcomes and the importance of ANC to the wellbeing of the mother and the unborn baby [
36]. In addition, educated mothers have greater autonomy to make decisions and financial access to quality healthcare [
37].
In addition, it was revealed that adolescent and young mothers in the second wealth quintile were more likely to obtain the recommended ANC visits. This finding is consistent with previous studies in developing countries where economic inequities were observed in maternal healthcare service utilization [
34]. Evidence shows that socio-economic status significantly affects ANC utilization among adolescent mothers [
15,
16,
21,
29,
32]. This finding is understandable because young mothers from poor households are less likely to have financial access to maternal healthcare compared with those from wealthy households [
31]. A previous study reported that pregnant women in Ghana still pay for some maternal health services such as drugs, urine and blood tests and ultrasound scans despite the Free Maternal Healthcare Policy [
38].
Internet use was also associated with optimal ANC utilization. This finding is consistent with previous studies in Malawi where women who received family planning messages through the internet had higher odds of antenatal care utilisation [
39]. Evidence shows that women access pregnancy-related information on the internet, which has the potential to influence their health-seeking behaviours [
40]. The geographical region was another salient factor associated with ANC utilization [
16]. Adolescent and young mothers in the Upper East region were more likely to obtain the recommended ANC visits. The Upper East region has the highest ANC coverage in Ghana [
41], hence this finding is understandable.
Implications and recommendations of findings
The findings of this study provide relevant information for maternal health policy and programming. For instance, a substantial proportion of adolescent and young mothers did not obtain the recommended ANC visits. These young mothers are at a higher risk of pregnancy and childbirth complications as well as negative birth outcomes. This may delay the achieving of Sustainable Development Goals 3, which aims to ensure healthy lives and promote wellbeing at all ages, including adolescent and young mothers. It is, therefore, necessary for stakeholders, including the Ministry of Health and Ghana Health Services, to invest resources that will help increase ANC coverage among young mothers. Stakeholders can leverage existing youth-friendly initiatives such as the Adolescent Health and Development (ADHD) programme. Currently, the ADHD programme does not cover ANC services, hence, stakeholders should consider incorporating these services. Also, the Ghana Health Service should consider separating young mothers from adult mothers during ANC visits to help encourage ANC utilization among adolescent mothers. Owolabi and colleagues [
4] revealed that adult mothers stigmatize pregnant adolescent girls. Moreover, stakeholders should strengthen efforts towards providing Focused Antenatal Care. This may help increase ANC utilization among adolescent and young mothers in Ghana.
Further, adolescent and young mothers from poor households, those with lower education and no internet exposure were less likely to obtain optimal ANC visits. This suggests that poor mothers still face financial barriers to accessing ANC services despite the Free Maternal Health Care Policy. This has the potential to delay progress towards improving maternal and child health outcomes as well as achieving SDGs 3. Therefore, the National Health Insurance Authority needs to liaise with health service providers to eliminate all forms of unapproved charges (fees for medication, ultrasound scan, urine and blood test) on maternal healthcare services as reported by Ziblim and colleagues [
14] in Northern Ghana. In addition, stakeholders must invest resources in promoting girl child education. Hence, Ghana’s free basic and secondary education policy is commendable. The internet may provide a golden opportunity for stakeholders to increase ANC coverage among young mothers. With the rapid increase in internet penetration in the country, stakeholders can leverage the internet to raise awareness and educate adolescent and young mothers about the importance of ANC and danger signs in pregnancy and childbirth.
Strength and limitations
This is the maiden study in Ghana to estimate the prevalence of ANC visits among adolescent and young mothers using national representative data. Although this study provides invaluable information for maternal health policy, it is not devoid of limitations. This study focused on socio-demographic factors and ANC utilization; hence the interpretation of the findings must be done with caution. Another limitation of this study is the small sample size. Also, quantitative surveys are unable to expose the many intricate views of participants regarding a subject matter. Future studies should, therefore, consider adopting qualitative designs as well as assessing more exposures. For instance, the 2017/18 MICS did not collect data on some potential exposures of ANC utilization among adolescent and young mothers. These exposures include school attendance, pregnancy history and violence against women, hence they should be included in future surveys.
Conclusion
This study showed high utilization of ANC services among adolescent and young mothers. Optimal utilization of ANC was influenced by higher educational status, socio-economic status, exposure to the internet and residing in the Upper East region. Efforts to increase ANC coverage among adolescent and young mothers should focus on promoting girl child education and removing financial barriers to accessing healthcare. Going forward, stakeholders must focus on addressing socio-economic inequalities as part of efforts to improve maternal and child health indicators.
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