Implications of power imbalance in antenatal care seeking among pregnant adolescents in rural Tanzania: A qualitative study

Background Adolescent girls (10–19 years) are at increased risk of morbidity and mortality from pregnancy and childbirth complications, compared with older mothers. Low and middle-income countries, including Tanzania, bear the largest proportion of adolescent perinatal deaths. Few adolescent girls in Tanzania access antenatal care at health facilities, the reasons for which are poorly understood. Methods We conducted a qualitative thematic analysis study of the experiences of pregnant adolescents with accessing antenatal care in Misungwi district, Tanzania. We recruited 22 pregnant or parenting adolescent girls using purposive sampling, and conducted in-depth interviews (IDIs) about antenatal care experiences. IDI data were triangulated with data from eight focus group discussions (FGDs) involving young fathers and elder men/women, and nine key informant interviews (KIIs) conducted with local health care providers. FGDs, KIIs and IDIs were transcribed verbatim in Swahili. Transcripts were then translated to English and analysed using emergent thematic analysis. Results Four main themes emerged: 1) Lack of maternal personal autonomy, 2) Stigma and judgment, 3) Vulnerability to violence and abuse, and 4) Knowledge about antenatal care, and highlighted the complex power imbalance that underlies barriers and facilitators to care access at the individual, family/interpersonal, community, and health-systems levels, faced by pregnant adolescents in rural Tanzania. Conclusion Adolescent antenatal care-seeking is compromised by a complex power imbalance that involves financial dependence, lack of choice, lack of personal autonomy in decision making, experiences of social stigma, judgement, violence and abuse. Multi-level interventions are needed to empower adolescent girls, and to address policies and social constructs that may act as barriers, thereby, potentially reducing maternal morbidity and mortality in Tanzania.

During adolescence, rapid physical, psychological, social, and emotional changes occur. 25 Adolescence is marked by an imbalance in brain maturity wherein, social-emotional 26 functioning matures more rapidly than the prefrontal cortex, which acts as the cognitive control 27 system (5). Adolescents thus often engage in risk-behaviors including sexual risk-taking which 28 can result in teen pregnancy (8). While social independence and decision making increase 29 during adolescence, most teens remain dependent on parents/guardians for food, shelter, 30 education, clothing and health, which may contribute to a unique set of challenges for them in 31 accessing maternal, neonatal and child health services (5,9). Globally, pregnant adolescents 32 on the socio-ecological model and explored experiences on the personal, family, community, 124 health-system and societal levels (17). All interviews and focus groups were conducted by 125 trained and experienced members of the research team. 126 127 We conducted IDIs in the location that was selected as most comfortable by the participant. 128 FGDs were held in schools, churches or local leaders' offices, based on availability and 129 accessibility for the participants. Interviewers explained the aim of the study and led all 130 participants through the informed consent process before interviews or discussions were 131 started. Interviews and FGDs were conducted and audiotaped in the preferred language of the 132 participant (either Sukuma or Swahili), and field notes were taken. All Sukuma interviews were 133 transcribed verbatim in Swahili (as Sukuma is not commonly written) by research assistants 134 who were fluent in both languages. Quality checks of the translations were conducted, wherein 135 a second bilingual research assistant listened to the audio recording while reading the Swahili 136 transcription, and added to or edited the transcript as needed, to ensure accuracy. A discussion 137 among the research assistants was used to finalize the wording in cases where direct 138 translations were challenging. Swahili recordings were transcribed verbatim in Swahili. All 139 transcripts were then translated from Swahili to English by trained bilingual members of the 140 research team for analysis. We then conducted a second set of quality checks by comparing the 141 English translations to the original language recordings in a group that included native speakers 142 of each language, to ensure that meaning nor content were lost in the translation process. 143 Participants were provided a transport allowance of 2000 Tanzanian shillings (equivalent to 144 approximately 1 United States Dollar (USD)) and health care workers were given 5000 We imported transcripts into NVIVO Ò 12 to conduct coding and emergent thematic analysis, 149 using a constant comparison technique (18). The authors read the transcripts a minimum of 150 twice each to familiarize themselves with and become immersed in the data. All members of 151 the research team jointly coded the first three transcripts and used regular meetings to arrive at 152 consensus on codes, and to create a common codebook. Subsequently we coded the remaining 153 transcripts individually, with continuous sharing for consistency of codes. We grouped codes 154 to form broader themes. An iterative process was employed, when needed, to re-categorize and 155 revisit themes. 156

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We conducted 22 IDIs with adolescent girls, eight focus group discussions (FGDs) three with 159 young husbands, three with elder mothers (or mothers-in-law) of a pregnant or parenting 160 adolescent, and two with elder fathers (or fathers-in-law) of pregnant or parenting adolescents 161 from the participants' communities. We completed nine Key Informant Interviews (KIIs) with 162 local CHWs, doctors, midwives and nurses. All IDI participants chose to have their intervews 163 in their homes. IDIs and KIIs ranged in length between 30 and 60 minutes each and FGDs were 164 75 to 110 minutes. The demographic characteristics of all study participants are summarized 165 in Table 1. 166 Our IDI participants ranged from 15-19 years of age at the time of their first pregnancies. Half 167 of the adolescents interviewed (48.8%) were either single or in a relationship, but unmarried, 168 compared with the elder parents/in-laws who participated in FGDs, of whom 82% were 169 married. All but one of the pregnant adolescents had completed some level of formal schooling, 170 with 5% having completed primary school, and 43% having partially completed secondary Four primary themes, some with sub-themes, emerged from the data:  Elder family members and other key informants echoed the stories of stigma faced by pregnant 290 adolescents, and their reluctance to be seen in the community as a result. Additionally, it is 291 noted that the stigma is primarily faced due to the reactions of men (rather than women) in the 292 community: 293 294 "…for these early pregnancies, she won't get advice from any one because she hides 295 her pregnancy a lot, for example the daughter I am living with, after school she won't 296 even go out to fetch water, if you send her to the market, she won't go" -Elder mother-297 in-law 298 299 "And the girls are very scared to come to the clinic alone, so you must take her, and 300 come with her every month. But when you just tell her to go alone, she might not reach 301 the clinic. She might be so shy, because she is so young to be pregnant. So she doesn't 302 want people to see her." -Elder mother 303 304 "They also do not show up early for ANC services as they fear to expose their 305 pregnancies to the community, as it is considered as great shame for an adolescent girl 306 to become pregnant while still living at home. This affects them a lot in early ANC "The problem is with men but not us women (laughing)… you might find that he is 311 provoking you, especially because of these adolescents who gets pregnant while at 312 school, maybe you should give men some seminars too" -Elder mother 313 314 At times the stigmatization of pregnant adolescents was blamed on the girls themselves, 315 insinuating that their experiences of stigmatization are self-inflicted: Many adolescent girls lack support from their partners and stories of the partners leaving them 344 once the pregnancy was revealed were common. Partner absence is a barrier to accessing care 345 on its own, however it is exacerbated by the common local by-laws and practices which limit 346 care to women accompanied by a partner. While this practice increases opportunities for HIV 347 testing, and aims to encourage male engagement in MNCH care, prioritizing care to women 348 with partners in attendance has potential for causing unintended harm to pregnant adolescents 349 who already face numerous barriers to accessing care. Pregnant adolescents are sometimes 350 required to get written permission from local leaders to access antenatal care without their 351 partner, which, in light of the stigma they experience, can not only prove daunting, but 352 contributes to late start of ANC, and may discourage some from accessing facility-based ANC.   In some cases, a lack of understanding about the reasons for specific antenatal 474 treatments/supplements were revealed, but they did not hinder ANC attendance or adherence 475 to treatment. Our thematic analysis results can be synthesized to highlight a complex power imbalance 491 that is faced by pregnant adolescents on multiple levels. The imbalance of power acts to form 492 a network of barriers to accessing ANC. Weber (1947) defines power as "the probability that 493 one actor within a social relationship will be in a position to carry out his or her own will 494 despite resistance, regardless of the basis on which this probability rests." (19). The things that 495 enable a person to carry out his or her own will, in a given situation, are considered "power 496 sources", and include knowledge, skills, and physical resources, among others (19). Thus, the 497 power of any given actor in a relationship can be expressed as a function of the sources of 498 power available to him or her at any given time of need (20). Power imbalance occurs when 499 power sources are unequally distributed between two or more actors in a given situation (21). 500 The imbalance of power increases as the availability of power sources to the individual in 501 need decreases (22). While our study themes can be used to create a simple list of barriers to 502 accessing ANC for pregnant adolescents, an incorporation of the concept of power imbalance 503 in their interpretation allows a much more complete picture of the complexity of the 504 adolescent girl's pregnancy experience living in Misungwi district to emerge. This in turn can 505 help to ensure that the findings of this research can inform policy change and interventions 506 that will be effective for optimizing ANC for this population.
Our participants' experiences and those of their families and community highlight how 508 pregnant adolescents in Misungwi become stuck between childhood dependence and the 509 expectation that they will take full responsibility as mothers. Nearly half of the adolescents in 510 our study became pregnant while still single, and not yet employed. Similar results were 511 reported in a South African study where 94% of pregnant teenage mothers were unemployed 512 and 82.4% were single and remained dependent on others (23). Financial and material 513 resources are an important power source in the imbalance faced by pregnant adolescents in this 514 setting. Although Tanzania's National Health System is mandated to provide maternal health 515 services free of charge (24), the reality is that those accessing ANC, delivery and postnatal 516 health care often face considerable financial burden, that leads, in some cases, to families 517 selling crops or other assets or borrowing money to afford the necessary care(25). The finances 518 necessary to engage in seeking ANC, such as transportation costs, buying maternity clothing, 519 paying for diagnostics and in some cases user-fees, are not directly available to adolescent girls. 520 Thus, the lack of financial independence reduces an adolescent mother's power to make her 521 own decisions, and take action to access ANC. The power imbalance this causes is exacerbated 522 by partner abandonment, and stigma. 523 524 Experiences of stigma were prominent in the stories of our adolescent participants. Pregnancy 525 before marriage, and at a young age remain socially unacceptable. The resulting stigma 526 adolescent girls face, to be seen in their villages, makes it more difficult for them to ask for the 527 assistance and resources they need. A previous study from Northwest Tanzania similarly found 528 that stigma was a significant barrier for unmarried women seeking reproductive healthcare 529 (26). In addition, partners frequently abandon pregnant adolescents, which not only leaves the 530 young mother to bear the full burden of the stigma, it also decreases the number of people 531 available to her to potentially provide the resources necessary for accessing ANC. Systems-level laws and policies, in place for the general good of the population might also 549 contribute to the power imbalance faced by pregnant adolescents in Tanzania. For example, 550 impregnating or marrying a primary or a secondary school pupil in Tanzania is illegal, and 551 punishable by fines of not less than five million shillings ($2600 US) or a five-year prison 552 term, or both (29). While this law aims to protect the rights and safety of young girls, it may 553 inadvertently contribute to partners (young or older) of adolescent girls who become 554 pregnant, to abandon them and remain unidentified, and thus uninvolved in the pregnancy. consequences to her family, and potentially exacerbating the stigma and judgement she faces. 558 The fear of these negative repercussions compounds the stigma and shame these adolescent 559 girls face, and may contribute to delayed ANC, as they fear revealing the pregnancy early. 560 The bylaws in Many Tanzanian communities requiring husband/partner ANC attendance 561 cause substantial difficulties for the pregnant adolescent population in accessing adequate 562 ANC as nearly half (42%) do not have a partner to accompany them to clinic (Table 1). 563 Single pregnant adolescents attempting to seek care are turned away if their partner is absent, 564 which leads to embarrassment, and undermines personal autonomy. 565 Thus, partner abandonment, lack of knowledge, resources, and decision-making, as well as 566 fears and experiences of stigma and abuse all act in combination to reduce the power and 567 autonomy of pregnant adolescents with respect to others in the family, the community and the 568 health system. This power imbalance and the resulting barriers to healthcare access may have 569 a substantial impact on the health outcomes of pregnant adolescents and those of their 570 children. Our study themes highlight several barriers to accessing adequate ANC experienced 571 by pregnant adolescents in a rural Tanzanian community. However, a synthesis of these 572 themes in the context of the social power imbalance experienced by our participants uncovers 573 a more complex picture, which will be necessary to consider if effective interventions and 574 changes are to be made to optimize ANC access for this vulnerable population. 575 576

Strengths and limitations: 577
Although we endeavoured to include the voices of pregnant adolescents aged 10 through 19 in 578 this study, were unable to identify or invite any participants aged 10 to 14 years, which may 579 have narrowed the range of experiences we were able to uncover. Additionally, the authors acknowledge that the conceptualization of pregnancy and childbirth is heavily tied to social 581 and cultural factors which can vary widely between communities. For these reasons, the 582 transferability of our study's findings beyond rural Tanzania, must be undertaken with caution. 583 However, our results echo those found in qualitative studies of similar topics in other 584 communities in South Africa and Brazil, demonstrating that the transferability of our results is 585 not entirely limited. 586 587 Our study used triangulation of data sources, and data collection methods, which adds to the 588 dependability of our results. The use of multiple coders on the team for analysis as well as audit 589 of the coding and analysis by a senior qualitative researcher have ensured the neutrality of our 590 findings. This study also included a broad range of participant characteristics, which has 591 contributed to the breadth and richness of the data. 592 593

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The transcripts are available from the corresponding authors on a reasonable request. 639