Table 3.
Themes and review findings
| Theme | Review finding | Contributing papers | Supporting quote | GRADE-CERQual |
| Resources and access | Access barriers: access barriers included lack of health insurance, not having accessed ANC, cost and/or lack of transport to health facilities and direct costs associated with PNC services. | 4 studies: Atuyambe et al39 (Uganda); Dumas et al46 (USA); da Silva et al33 (Brazil); Mngadi et al38 (Eswatini) | “I stopped using Medicaid at 19 and that was really hard, and I just went to the emergency room every time. For anything…I went almost every day”.46 (USA) “When I was pregnant, what prevented me from seeking health care was lack of transport money because my legs were a problem. I used to live far away in the hills and I could not ask anyone to take me on a bicycle because I would be asked for money. So I decided to rely on my grandmother’s traditional herbs”.39 (Uganda) |
Moderate |
| Availability of desirable services: lack of availability and/or information regarding services that adolescent girls would feel comfortable accessing affected both uptake of PNC and adolescent girls’ uncertainty with available services (sometimes resulting in reliance on more familiar practices by family or other community members). | 4 studies: Muzik et al44 (USA); Recto and Champion45 (USA); Mngadi et al38 (Eswatini); Atuyambe et al39 (Uganda) | “For us the Baganda we undergo a traditional practice we call ‘OKUFUGIKA’. The practice will make the child who stays on earth to be a clever person. But if they [health workers] throw the ‘second child’ [placenta] into a latrine the child who stays on earth become dull and not intelligent”.39 (Uganda) | Moderate | |
| Facility environments and resources: the physical state and feel of health facilities and their available resources played an important role in adolescents’ desire to seek care at health facilities; cleanliness, availability of water, state of available bedding, odours and associations with illness influenced adolescents’ health-seeking behaviours. | 2 studies: Atuyambe et al39 (Uganda); Hunter et al43 (UK) | “Although we have these water tanks here water is not accessible to patients. This water is rationed for conducting deliveries and cleaning the floor. It is a problem keeping oneself [the mother] clean after delivery. No bathing”.39 (Uganda) “… and then like my Mum went home and it was just like ‘oh my God I’m here on my own … It was just really, like, creepy—I think of hospitals as where you go to, die”.43 (UK) |
Low | |
| Social norms | Feelings of stigma and judgement in health facilities: adolescent girls expressed feeling unwelcome to PNC services and judged in health facilities due to age and the stigma of adolescent pregnancy. | 7 studies: Robb et al42 (Scotland); Recto and Champion45 (USA); Atuyambe et al39 (Uganda); Hunter et al43 (UK); Peterson et al36 (Canada); Smith et al40 (UK); Muzik et al44 (USA) | “…she [midwife] kept going round to all the other women like ‘oh she’s gorgeous! What’s her name?’ [about the baby] And then she’d come to me, and she just wouldn’t ask me a thing”.43 (UK) “I was warned though, if you're a young mom you might get looked down on a little bit and I think that’s what she was doing cause she knew I was young and… she thought I was stupid and… she wasn’t that bad it’s just… I don’t know. I’d just had a baby I wasn’t in the best of moods. And she just… I guess didn’t understand. I didn’t give her a hard time or anything, but it seemed to me like she was giving me one”.36 (Canada) |
High |
| Perceptions of shame and negative stereotypes of young parents: the combination of shame due to negative stereotypes and fear of judgement affects the self-efficacy of young parents and their willingness to access care or communicate their needs when they do access care. | 8 studies: Smith and Roberts40(UK); Dumas et al46 (USA); Atuyambe et al39 (Uganda); Vieira et al34 (Brazil); Muzik et al44 (USA); Mngadi et al38 (Eswatini); Ross et al41 (UK); Robb et al42 (Scotland) |
“I don’t care really what people think of me, but it annoys me … that people are kinda like stereotypical about us”.40 (UK) “Those who become pregnant while still in school fear to go for health care at the health units. They fear to get ashamed or meet their own colleagues in schools. Such girls would, before pregnancy, have been proud and calling themselves virgins, so they find that they cannot stand all that shame, so they decide to keep at home”.39 (Uganda) |
High | |
| Experiences of care | Acknowledgement and empathetic communication by staff at health facilities: adolescents felt providers’ delivery of PNC was focused on checklists of tasks rather than responding to their needs or requests and offering care. Providers were often rushing to move through the items required for newborn care, leaving adolescent girls feeling unheard and without guidance. Lack of acknowledgement and empathetic communication between overwhelmed adolescent girls and busy health providers made experiences in PNC less helpful. | 7 studies: Recto and Champion45 (USA); Peterson et al36 (Canada); Hunter et al43 (UK); Atuyambe et al39 (Uganda); Erfina et al37 (Indonesia); Muzik et al 44 (USA); Dumas et al46 (USA) | “They just do everything so fast. They don’t speak with you. They don’t communicate with you. They don’t even want to open up a conversation. They’re just like, ‘Oh, well you came here for this and that. Okay, next’”.45 (USA) “I was not taught about way to breastfeed. [they] just checked my breast milk is in. They say that I have a lot of milk ….my baby was taken by the nurse for bathing, and I didn’t see my baby being bathed”.37 (Indonesia) |
Moderate |
| Respect and trust-building in care: where health providers took a calm and patient approach, adolescents felt more respected and comfortable enough to ask questions and voice concerns. Trust was built through offering social support, care and providing tailored information on what to expect following birth. Trust was eroded when adolescent girls felt unheard, neglected, disrespected or handled roughly during the continuum of delivery to PNC. | 10 studies: Recto and Champion45 (USA) Peterson et al36 (Canada); Hunter et al43 (UK); Atuyambe et al39 (Uganda); Erfina et al37 (Indonesia); Muzik et al44 (USA); Dumas et al46 (USA); Mngadi et al38 (Eswatini); Robb et al42 (Scotland); Ross et al41 (UK) |
“Some nurses were more, I guess, calm. So, it was easier to talk to them than the nurses that were sort of rushing through every now and then… I mean when they rush through then its uh … you sort of forget the questions that you were gonna ask in a way”.36 (Canada) “I was just left, and then when I was gonna like be moved up onto the ward the nurse come and she just like sort of grabbed [baby] and tried to like ram her on to my breast and that”.43 (UK) |
High | |
| Instrumental and informational support on newborn care: adolescent parents expressed anxiety around a lack of skill in or knowledge of newborn care (eg, feeding, bathing, cord cleaning) due to not receiving information nor guidance during PNC to learn newborn care skills; often, due to expectations of judgement around not being seen as capable, they feared asking questions or seeking more tailored support. Across participants, adolescent girls described different levels of support from providers even within the same settings. | 12 studies: Robb et al42 (UK); Vieira et al34 (Brazil); Bergamaschi and Praça32 (Brazil); Dumas et al46 (USA); Erfina et al37 (Indonesia); da Silva et al33 (Brazil); de Melo et al35 (Brazil); Peterson et al36 (Canada); Muzik et al44 (USA); Mngadi et al38 (Eswatini); Hunter et al43 (UK); Ross et al41 (UK) |
“… at the hospital I didn’t get any support at all, you were put to your ward and left. I didn’t get asked how I was feeding her, and I was bottle-feeding her, and I didn’t get told that I had to collect the bottles myself and put them away myself, so I was left and didn’t know what to do. I didn’t get asked if I knew how to change a nappy… I knew like my friend when my friend had her baby and that’s how I knew how to change a nappy …”42 (UK) “I know there would be young dads with the same worries that I have got, and I would like to find out how they are coping with it.… It would be nice to have some kind of guidance especially for first time dads or young dads as well that are kind of scared of what the future is going to be like”—young father.41 (UK) |
High | |
| Psychosocial support: in high-income and upper middle-income settings, adolescents girls feel they lack knowledge on recognising the signs of postnatal depression and have the added pressure of fear around early parenting and feelings of isolation, emotional overwhelm or failure. | 5 studies: Recto and 2018 Champion45 (USA); Muzik et al44 (USA); Dumas et al46 (USA); Vieira et al34 (Brazil); Hunter et al43 (UK) |
“He made me feel like I wasn’t crazy. He made me accept the depression… My OB/Gyn said that it’s normal for mothers to experience depression during and after pregnancy… If they say it’s normal, I think it would make them feel better knowing they're not alone”.45 (USA) “No one ever says to you … it’s like normal to not be able to do it … I just felt like a complete failure, because no one, had explained to me—that I weren’t the only one”.43 (UK) |
Low-to-moderate | |
| Sexual and reproductive health information needs: adolescent girls view sexual health and contraception as important but their access to information on this topic is limited. Adolescent girls’ preferences for sexual and reproductive health services were not always prioritised or available. | 4 studies: Mngadi et al38 (Swaziland); Vieira et al34 (Brazil); Dumas et al46 (USA); Erfina et al37 (Indonesia) | “It was hectic. I didn’t get back to the doctor until the baby was 4 months old. By then I was pregnant again”.46 (USA) “Waiting the forty days to have sex, not to get pregnant again, not to burst what we have inside, we have to be careful. Because the doctor said that we may get depressed, get a lot of things, that it shatters everything inside”. 34 (Brazil) |
Low | |
| Tailored support needs | Navigating parenthood responsibilities at a young age: adolescents feel overwhelmed by the sudden transition to both adulthood and motherhood. They feel the need for PNC to include information on childcare as well as social support in managing the next stages of adulthood and the identity transition required. They express a lack of knowledge around available PNC or parenting support services | 9 studies: Dumas et al46 (USA); Bergamaschi and Praça32 (Brazil); Muzik et al44 (USA); Atuyambe et al39 (Uganda); Mgnadi et al38 (Swaziland); Vieira et al34 (Brazil); da Silva et al33 (Brazil); Erfina et al37 (Indonesia); Ross et al41 (UK) | “We do not have jobs… have no income for survival and looking after our kids… that is why most girls have ended up becoming pregnant early or turning out as commercial sex workers in Kampala”.39 (Uganda) “Now I have more responsibility, I have to wake up at dawn to breastfeed, I worry about everything”.34 (Brazil) |
Moderate |
| Peer support: in studies from HIC settings, hearing peers experiencing similar challenges—both in terms of newborn care and parenthood during adolescence—and sharing information, through either informal and/or structured peer support, can alleviate some of the pressures and feelings of inadequacy and of being overwhelmed. Peer support groups were seen as an important source of emotional support and encouragement during the transition to parenthood. | 3 studies: Hunter et al43 (UK); Muzik et al44 (USA); Ross et al41 (UK) | “I think I’d rather hear I’m doing well from somebody that done it. Quite recently as well … than… say a midwife that’s never had children”.43 (UK) “Yeah and it’s easier to speak up if you hear somebody else talkin’ you think maybe I shouldn’t say nothing but if somebody else say something you like, ok well, I kinda understand that I could speak on some of my situations”.44 (USA) |
Moderate evidence only from HIC |
|
| Family support: family support including practical, emotional and psychosocial support—and especially from the adolescents’ own mothers—is heavily relied on during the postnatal period; therefore, family members’ engagement, opinions and guidance on health-seeking behaviours affect uptake of PNC. | 8 studies: Vieira et al34 (Brazil); Dumas et al46 (USA); Muzik et al44 (USA); de Melo et al35 (Brazil); Bergamaschi and Praça32 (Brazil); da Silva et al33 (Brazil); Mngadi et al38 (Eswatini); Atuyambe et al39 (Uganda) | “I had the support of all my family… They help me a lot… I take good care of the baby, I give baths, breastfeed, but there are several things that my mother has to watch me, to teach me… If my mother were not helping me, I do not know what I would have done”.32 (Brazil) | Moderate | |
| Partner support: the exclusion and/or lack of engagement of young partners in antenatal support also contributed to lower uptake of PNC with adolescent girls stating that partner inclusion would enhance their uptake of services. Young fathers also expressed a desire to be better informed and involved in order to more effectively support their partners. | 3 studies: Ross et al41 (UK); Smith et al40 (UK); Muzik et al44 (USA) |
“…they’ve never spoken to me, never”—young father-to-be”40 (UK) “‘midhusbands’ should be allocated to new fathers, as midwives help mothers”—focus group of young fathers41 (UK) |
Low |
GRADE, Grading of Recommendations, Assessment, Development and Evaluations; HIC, high-income country; PNC, postnatal care.