Volume 12, Issue 4 (Jul & Aug 2022)                   J Research Health 2022, 12(4): 239-252 | Back to browse issues page

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Namusana R, Namyalo J M, Otieno E D, Basaza R K. Experiences of Seeking Antenatal Care and Delivery Among Teenagers in Kibuku District, Uganda. J Research Health 2022; 12 (4) :239-252
URL: http://jrh.gmu.ac.ir/article-1-2066-en.html
1- Department of Public Health, Faculty of Public Health and Nursing, Uganda Christian University, Mukono, Uganda.
2- School of Public Health, Gudie University Project, Kampala, Uganda.
3- Department of Public Health, Faculty of Public Health and Nursing, Uganda Christian University, Mukono, Uganda. , rbasaza@gmail.com
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1. Introduction
Teenage pregnancy occurs in girls aged 13-19 years [1] and continues to be a public health concern globally. According to WHO [2], about 21 million girls aged 15-19 and 2 million girls under age 15 become pregnant in developing countries annually. Additionally, approximately 16 million girls between 15-19 years and 2.5 million girls under 16 years give birth annually in developing countries. It is noteworthy that 18 out of the 20 countries with the highest teenage pregnancy rates are from Africa [3, 4]. 
In Uganda, teenage pregnancy and childbearing have been among the major social and health concerns for a while. The country was ranked 14 out of 54 countries in Africa with the highest level of teenage pregnancy [5]. Currently, the average prevalence of teenage pregnancy in Uganda is as high as 25%, with 19% having had a live birth and 5% pregnant with their first child [6]. Close to a third (27%) of these teenage pregnancies occur in rural areas and almost a fifth (19%) in urban areas [7]. The eastern and east central regions showed the highest teenage pregnancy rates in Uganda, with 30% and 32%, respectively [8]. 
The teenage pregnancy in Kibuku District in 2016 was 35.8%, high above the average rate in Uganda (25%). It was also above the average for rural areas in Uganda (27%) [6]. The findings suggested that teenagers generally lacked knowledge about sexual and reproductive health [9]. Despite the overwhelming number of teenage pregnancies, very few teenagers sought antenatal care (ANC) services delivered in health facilities [10]. 
In the Kibuku District, 11025 mothers attended ANC first visits to the 16 health facilities in 2017. Of these, 2275 (25%) were teenagers aged 10-19 years. Among those who delivered ANC services at the health facilities, 1643 were teenagers (25%) [11]. Unfortunately, there is limited information on the experiences of seeking antenatal care and delivery among teenagers in the district. A study by Manzi in Kibuku, for example, focused on ‘Factors associated with teenage pregnancies and its effects in Kibuku Town Council, Kibuku District’ and did not cover the entire district [8]. This paper explored what these teenagers experienced when they sought services at health facilities, including personal, interpersonal, and health facilities-related experiences of seeking ANC and delivery at health facilities in Kibuku district, Eastern Uganda. The results of this study were to inform medical practitioners and policymakers to provide better health services.
2. Methods
Respondents and the study area

The study was conducted in Kibuku District, located in Eastern Uganda. Kibuku has a high teenage pregnancy rate with low ANC seeking and delivery in health facilities in the country. The district has a total population of 202033, with 27373 female teenagers aged between 10-19 [11]. The district has 16 health units of different categories by ownership: 4 government health centers II (sub-dispensaries), 7 health centers III (dispensary), and 1 health center IV. It also has 4 privately owned small clinics. All the health units are evenly distributed around the district but lack the basic equipment to offer reasonable services and require renovation. The respondents were pregnant teenagers aged 14-19 years or teenage mothers from any of the sampled health facilities. This population was targeted because of having teenagers who are more disadvantaged in healthcare-seeking behaviors and are therefore in a better position to put forward their experiences of seeking ANC and delivery in the facility.
Study design and variables
This study adopted a phenomenological design. It focused on describing what all participants had in common as they experienced a phenomenon. The design allowed us to explore and develop an in-depth understanding of the experiences of seeking ANC and delivery among pregnant teenagers or those who had delivered ANC in the health facilities in the district. In this study, in-depth interviews were used to explore the experiences of seeking ANC and delivery among teenagers. This method provided a situation where the participants’ descriptions could be explored, probed, and elaborated. A single-interview-per-participant qualitative approach was used so that the deep, case-oriented analysis of this qualitative data is allowed [12]. The data were collected from December 2019 to January 2020. All interviews were conducted at the health facilities selected; a quiet and private room was used for interviews. Semi-structured interviews were used to collect data. The interviews helped us in gathering views the pregnant adolescents had regarding ANC and the delivery services they received. The interviews allowed each participant to share her personal perspectives and avoid contaminating the data. The duration of the interview varied between 60 and 90 minutes. The interviews were audio-taped, and field notes were taken to incorporate contextual experiences that could add meaning to the research findings. The inclusion criteria were pregnant teenagers or mothers aged 14 to 19 years who consented to participate in the study. The study included teenagers who had already delivered babies because they heard full exposure to the health system. It was also another way of guaranteeing the availability of respondents. The teenage mothers who delivered ANC outside the district were excluded. Three research assistants who were fluent in English and a local language ‘Lugwere` were identified and trained for three days in data collection. The training lasted 4 hours per session and focused on information about assessing teenagers seeking ANC and delivery, methods of study, a perusal through questionnaire, and interview skills.
The sample size was determined using the qualitative method since the estimation of sample size was done from a homogenous population of teenagers seeking ANC and delivery in the Kibuku District by using the code frequency counts approach to achieve saturation [13]. In this study, the data saturation criterion was used to determine the sample size. Interviews with 27 participants saturated the data. In the first phase, Kibuku District was purposively selected because it is one of the districts in Eastern Uganda with high teenage pregnancies and low ANC-seeking behavior, yet not much is known to justify the low behavior. In the second phase, five health facilities were randomly selected from the 16 health units using a simple random technique as opposed to the community because it was easier to access pregnant teenagers seeking ANC or those who had delivered. This sampling was made easy by finding out days when the sampled facilities offered ANC or identified those who had delivered it from the facility. At the next stage, the participants were selected purposively and informed about seeking ANC and delivery with an experience in this field. Nine health workers in the maternity wards were purposively selected and assigned to recruit teenagers who sought ANC or delivery. To attract the participants, posters and banners were put in the ANC clinics of the health facilities. 
Data analysis
All data were analyzed using the thematic analysis approach. Themes were created from the codes by grouping similar codes that emerged from the data. To facilitate the analysis, the interviews were first transcribed verbatim by checking the transcripts against the audio recordings for accuracy. The field notes were added to the interview transcripts to provide a complete dataset for analysis. This process allowed themes to be modified as the data analysis process unfolded. The combined transcript (interviews and field notes) were read several times to identify meaningful units of the text. 
The research team created initial codes for segments that were of particular interest. Codes were developed from the keywords in the transcript to ensure that the participants’ voices were accurately captured to preserve the richness of the data and the context of the interviews. The team also sorted out codes valuable for addressing the research questions into categories reflecting dominant themes within the data set. From the initial codes, the team proceeded to create themes. The team read the themes several times to ensure they accurately reflected the data. Common themes were grouped to create thematic networks to link related responses under a main theme or heading. The data was then interpreted to describe the emerging findings. The themes were developed inductively to stay close to the data. During the data analysis, the research team kept cross-checking the themes with the transcripts and analytical notes to ensure that they were coherent and consistent with the data to maximize their reliability.
3. Results
Teenagers demographic characteristics

The sociodemographic characteristics of the respondents are presented in Table 1.

Twenty-seven teenagers in the age range of 14 to 19 years participated in the study. Most cases (24/27) claimed to be married, while 3/27 were single. Regarding religion, 9/27 were Catholics, 8 were protestant, 2 were Born Again Christians, and 8/27 were Moslems. Their levels of education ranged from 4 years to 11 years (primary four to senior 4 in the Ugandan system), with the majority (20/27) not going beyond their primary levels of education. The majority were unemployed (14/27), whereas over a third were farmers (11/27), one was a shopkeeper, and one was a housewife. The majority were pregnant for the first time (21/27), three had their second pregnancy, and the rest had their first child.
Themes and sub-themes
Original experiences gathered from the teenagers were directly quoted to enhance the description of experiences and findings of the study. The results were organized into themes and sub-themes. The predetermined themes were three: personal, interpersonal, and health facility-related experiences. Each of the three themes had emergent sub-themes. The emerging themes were from the findings, and the sub-themes were developed. The predetermined, emergent, and sub-themes of the study are presented in Table 2.

Personal experiences
Timing and decision to go for ANC

Some of the teenagers (6/27) had attended ANC at least three times, while others (10/27) were just reporting for the first time. However, many of the teenagers initiated their ANC visits later than expected. Many of them came when their pregnancies were more than five months. Some were five, others six or seven months. Only a few (2/27) teenagers reported before five months of pregnancy. 
“I always come for antenatal care. I first came when the pregnancy was 6 months because I had a fear. For the second pregnancy, it is 8 months, and I started coming at 6 months also. My husband is, at times, not around. He is the one who delays me. We are told to always come with our husbands when coming for tests” (age: 19 years, P.6, second pregnancy).
Some teenagers had been abandoned by their husbands either at home or with their relatives and showed no signs of returning.
“This is my first time to come for antenatal care, and it is 7 months. I delayed waiting for my husband, hoping that he would come back, but he did not. He is in Kampala where he works as a porter” (age: 19 years, P.5, first pregnancy).
“I have just returned today. I was asked to return on January 9. I first came when it was 7 months. They used to say you come with a husband when you are pregnant. The man had left me at my brother’s home, and there was no kind of support he was offering, so I decided to go back home. For me, I am home now, but I don’t know where he is and what is happening to him. So, when I returned to my parents’ home is when I started coming here” (age: 18 years, P.6, first pregnancy).
Lack of money to procure the necessities required for ANC was also one of the reasons for the delay in coming to the facility.
“This is my first time to come for antenatal care, and it’s 4 months (smiling). My husband delayed me from coming. He says there is no money to buy the polythene bag we use whenever we go for ANC or in preparation for delivery and other things” (age: 18 years, P.4, first pregnancy).
“I have just started antenatal care today, and the pregnancy is 5 months. I delayed coming because the facilitation I have is also little. I didn’t have the money to buy polythene, yet they wanted it. So for today, I got some money to buy it then I came. My husband himself is in Entebbe (over 100 Km from home), and that is where he works, and that is their home. He doesn’t send any assistance even when I call they don’t pick me up, I don’t know what the problem is” (age: 19 years, P.7, first pregnancy).
One of the participants just decided that she wanted the baby to grow first before she could come to the facility.
“Yes, I have come for antenatal care before. This is the third time. I first came when the pregnancy was 5 months old and is now 7. Nothing stopped me from coming. I decided personally that let this pregnancy first grow, then I will go” (age: 17 years, S.2, first pregnancy).
Importance of ANC
Many of the mothers were aware of the importance of ANC to their health and that of their babies. They said that when they came for ANC, they were checked to find out the condition of the baby in the abdomen, and they were also given medicines that help the baby. Several teenagers brought out this issue:
“Yes, it is good to come for antenatal care. You can be able to tell how the baby is, maybe you can get enough care, and be able to tell whether the baby is okay in the abdomen or not” (age: 17 years, S.4, first pregnancy).
Other respondents also reported this issue:
“It is good to come for antenatal care because they examine me and see what illness is in the abdomen. In case there is any, they give me the treatment, they give me medicines, and for me, I see it as a good thing” (age: 19 years, S.2, first pregnancy).
“Hmm. It is good to come for ANC. Why it is good is that, at times, I may have an illness, and the second reason they have to see how the child is developing in the abdomen, and the third thing they have to see whether the child is alive or has some deformity. That is what brings us for ANC” (age: 18 years, P.5, second pregnancy).
Motivation to come for ANC
Many of the teenagers were motivated to come for ANC because they felt that it was the best opportunity for them to know the condition of their unborn babies. A few were motivated after they had got what the health workers required them to always come along with to the health facility. 
“What motivated me to come today is because my husband bought some requirements though he has not bought all, I am hopeful that he will buy the rest” (age 18 years, P.4, 1st Pregnancy).
“For the first pregnancy, the money was there, we got it fast, and we bought the requirements. For this one, I have come now because I got the requirements” (age: 19 years, P.5, second pregnancy).
Some of them came because they were feeling unwell and wanted the health workers to help them. 
“I came today because I was feeling some pain, so I decided to come” (age: 19 years, P.5, first pregnancy).
“When the pregnancy was still young, about 4 months, I experienced some pain as if I wanted to get an abortion, but that was before I came, so I decided on my own that I should come to the health facility” (KT, 17 years).
One of them was also not staying at their home, but when she got back home, she started attending ANC.
“What encouraged me to come is that I came back home, then I started coming for antenatal care” (age: 18 years, P.6, first pregnancy).
However, one of the participants had a personal drive that pushed her to come: 
“What encouraged me to come? I just wanted to come” (age: 18 years, P.5, second pregnancy).
Interpersonal experiences
Support from spouses, family, and friends

Many teenagers felt supported by their families, including their husbands, parents, grandparents, and even friends. They reported being supported in various ways, like being given money for transport and feeding. Others would accompany the teenagers to the facility, and some offered guidance about ANC and visiting the health facility.
“The people I stay with encourage me to come and see that I do not get other diseases like tetanus. They also give me some transport. They educate me as well” (age: 18 years, S.3, first pregnancy).
“I stay with mummy, daddy, and my husband himself. They give me a ride, and at times, they accompany me; they come and wait for me, and after receiving care, we go back. My husband accompanied me, and my mother also accompanied me. They also teach me that going to the health facility is good so that we know what is in the abdomen” (age: 17 years, P.5, first pregnancy).
“I stay with my granny and my husband. They bought me some requirements. They also tell me about the goodness of antenatal care. They tell me that it is good to go to the health facility and the health workers see the condition in which you are in because there might be things or medicines that are required that you can keep using” (age: 18 years, P.7, first pregnancy).
“I stay with my husband and his parents. They all decide for me to come for antenatal care. They educate me, give me a ride and even accompany me. Hmm… (thinking); most importantly, is that they educate me on hygiene and my husband is the one who in most cases accompanies me for antenatal care” (age: 19 years, P.7, first pregnancy).
Some of the teenagers also offered some pieces of advice to their fellow friends. This issue was obtained in an interaction with one of the teenagers:
“My friends tell me to go for antenatal care and get to know how the child is growing, and every pregnant mother goes for antenatal care. It helps to know how the child is growing, and they ask me how I am feeling (age: 18 years, S.3, first pregnancy).
Despite the majority of the participants being supported by the people they stayed with, some did not get that kind of support. Therefore, whatever they did was a result of their personal drive, including decision-making. This issue was noted in an interaction with one of the participants:
“I stay with my mother-in-law and brothers-in-law. I told them that I was coming to the hospital. I just came with my husband, so those I stay with have not in any way helped me as far as ANC is concerned” (age: 19 years, P.5, first pregnancy).
Decision-making power
The majority of teenagers did not have decision-making power. Most of the decisions to come for ANC were either made by their husbands because they claimed it is their husbands who control them and for some others because they are the heads of the families.
“My husband decides for me on whether to come for antenatal care because he is the head of the family” (age: 18 years, P.7, first pregnancy).
“My husband is the one who decides for me to come for antenatal care because at times I can forget the date, then he reminds me. I have to ask permission from him” (age: 18 years, P.5, second pregnancy).
For others, the decisions were made by the people they stayed with, like their parents and grandparents:
“Now the fact that I am staying at home, I first have to request daddy that I am going to the health facility then he allows me. Indeed, he could not refuse because it is mandatory that I have to come” (age: 19 years, P.7, first pregnancy).
“Mummy decided for me to come for antenatal care today because I was afraid to come because if I come without a husband, am not attended to. I can be sent back home” (age: 18 years, P.6, first pregnancy).
Only a few made personal decisions to come for ANC, as seen in some interactions:
“I decide myself come for antenatal care. No one at home tells me to come for antenatal care. I am always encouraged to come to be checked. I don’t feel well when I don’t come for antenatal care” (age; 14 years, P.6, first pregnancy).
“I decided to come by myself for antenatal care today. I said let me go to the chairman and go to the health facility. When I went to him, he wrote for me a letter, and I came before they accepted to attend to me” (age: 19 years, P.5, first pregnancy).
Health facility-related experiences
The comfort of using a health facility

Many teenagers said they felt comfortable when they came to the health facility. This is because they felt they had come to the right place and would therefore receive what they have always anticipated: treatment and going back home better. 
“I feel comfortable at the health facility because I come and they palpate my body and give me some tablets to take with me” (age: 19 years, P.6, first pregnancy).
“I feel good when I come to the health facility for ANC because the health workers attend to me well, and I go back home happy” (age: 18 years, S.4, first pregnancy). 
“I have felt some comfort coming here today because I have been tested, given some medicines, palpated, and I feel life is not like it has always been” (age: 18 years, P.4, first pregnancy).
This was the first time for some respondents; they were anticipating comfort only after they had interacted with the health workers and received some medication:
“I have not yet felt some comfort. I will feel it after I have got some medication” (age 19 years, P.7, first pregnancy).
“I didn’t feel comfortable the first time I came because I was feeling some pain, but today I am fine” (age: 16 years, P.5, first pregnancy).
Treatment given
Many of the teenagers who came were given some kind of medication, including vaccination. Some of them had some slight idea of the importance of the medication they were given, and they subsequently promised to continue coming to the facilities for the ANC services.
“I was given some iron tablets and some which are two when I first came; whether they are two or three Fansidar tablets? I will be coming back for antennal care here” (age: 17 years, S.4, first pregnancy).
“I got some medicines when I came here. Some are for blood when you have delivered when you over bleed, and for some, I was told that I had some flu. I will continue coming for antennal care and will even deliver from the health facility because I intend to produce more children (age: 18 years, P.7, first pregnancy).
“I was immunized and given some tablets when I came for antennal care and palpation. I hope to come back for the remaining time (laughing), the remaining two times because I still have months to delivery and I think it is good (laughing)” (age: 18 years, P.7, first pregnancy).
However, some of them did not really understand why they had to swallow some of the tablets. Despite the limited knowledge of the importance of the treatment they received, they also promised to continue coming to the facility.
“I was injected, and they gave me some medicines. They didn’t tell me the importance of the injection. I hope to deliver from the health facility because, sometimes, you never know; you can get a problem and fail to deliver from the village. I will continue coming here because pregnancy things are difficult” (age: 18 years, P.5, second pregnancy).
Unfortunately, some teenagers also said they had never received any kind of medication from the health facility. Whenever they came, they were told that there were no medicines, so they got a prescription and were asked to buy from private pharmacies:
“When I came for antennal care, the staff just wrote for me on a piece of paper. They just write for me, and I go and buy. I hope to continue coming because of the help I am rendered” (age: 19 years, P.6, first pregnancy).
“For me for the times I have come, they have not given me any medication, but they gave me a mosquito net. I sleep under it and will continue coming for antennal care, but I don’t know why” (age: 17 years, P.5, first pregnancy).
Health worker attitude
All the teenagers reported that the health workers (HWs) treated them well. Thus, they did not have any problem with how the HWs treated them. They said that the HWs always talked to them calmly. Even in instances when they failed to do what was expected of them, the HWs were a little hard on them but later attended to teenagers. The HWs were also noted to be patient and kind to the teenagers.
“There is nothing bad the health worker can do to us but only give us advice” (age 17 years, S.4, first pregnancy).
“The health workers treat us well. They first educate us when we have come with our husbands and further ask our partners to buy us clothes. They are not rude” (age: 19 years, S.2, first pregnancy).
Education offered
Some teenagers acknowledged receiving some education when they came for ANC, which was important for them as young teenagers.
“They educate us to come to the health facility with our husbands. However for me, I didn’t come with mine because I didn’t know. They tell us that both of you have to be tested. They also tell us what is required when coming for delivery like a polythene sheet, clothes and on a diet, we were told that we need to eat some pineapples” (age: 17 years, S.2, first pregnancy).
However, while some claimed that education was adequate, others felt there was more they needed to know.
“They educate us like preparing for antenatal care; clothes, polythene, and panties (Hmmn). They also educate us on what to eat, like taking millet porridge. We still need to learn more, like going for family planning” (age; 19 years, P.5, second pregnancy).
“They have educated us to always be prepared with items like polythene sheets, gloves, underskirts, and knickers when we are going to deliver because some teenagers, when they come for delivery, they don’t even have requirements. Like us first-time mothers, there is a lot that we really need to know because since this is the first time of being pregnant” (age: 19 years, P.7, first pregnancy).
On the contrary, some teenagers did not receive any education when they visited the health facility. These were captured during interactions with them:
“No, the health workers have never educated us. Even what is required when we are preparing for delivery, they have not yet told us. They have never told us anything, so it is about seeking to know what is required” (age: 17 years, P.5, first pregnancy).
“For me, they have not yet given me any kind of education, but I think the education is necessary” (age: 19 years, P.6, first pregnancy)
Availability and accessibility of utilities
Some teenagers noted that the utilities were enough, but others found they were inadequate and more needed to be added. These included beds, equipment used for checking them, medicines, and the limited number of HWsas well.
“They have never given me any medicines; they told me to buy since they were out of stock in the facility. They told me to buy medicines, but I didn’t buy, so there’s nothing I am swallowing” (age: 17 years, P.5, first pregnancy).
“Me, if I was to go by what I think, the utilities are not enough. The beds themselves that they use for delivery are few, where the patients themselves rest are few, the medicines, they can tell you to come back another day, you come back, and they tell you that there are no medicines and you come back another day, then you come back again, and in the end, you feel tired, and yet you must come” (age: 17 years, S.4, first pregnancy).
Challenges faced: accessibility, distance and affordability, working hours, stigma and fear
Many of the teenagers claimed that the health facilities were accessible and felt that, in most cases, HWs attended to them on time, except for a few of them who delayed once in a while. However, one outstanding challenge that most teenagers kept identifying was that there were many clients in most cases with only one HW attending them. 
“At times, you come here early, but you leave the place late. Only one health worker attends to the patients, and yet the people are always many. You feel some fear as well, but it is now gone. I overcame this fear by involving in conversing with other mothers (age: 17 years, S.2, first pregnancy).
“Oh! At times you come here and sit before the health workers have even arrived; like today, we came here and found some man complaining that the HWs have delayed coming. I can never get fear to come to the health facility because I decided that I want marriage and what I want is a child” (age: 18 years, P.4, first pregnancy).
“… I don’t blame this on health workers but us as individuals as well, we have our lifestyles that are bad like you can be told to come early, and you reach at your own time when the health workers are finishing to work, and they are tired and lose temper. Sometimes they are also caught up, and they delay to reach, and at times you come, and you are told that they won’t work, and you go back home, or you come, and you have not come with what they want, and you don’t have money to buy them. You can be attended to, but they also first make you feel the pain because you did not also think of what you received during the previous antenatal check” (age: 17 years, S.4, first pregnancy).
The teenagers did not also have any stigma apart from a few who were coming for the first time but were later able to get over it.
“The second time I came, the staff were in a meeting; we were advised to go back home. However, when they attend to us, they do release us early. Transport has never been a problem for me because from where I stay to come here is 500 Uganda Shillings (USD 0.14), and going back is also 500 Uganda Shillings only. I only had stigma the first time, which was when my mother-in-law accompanied me because I had fear then. The next time I came back, I came alone and had no fear anymore” (age: 17 years, P.5, first pregnancy).
“I have got a challenge coming here at times when I lack requirements, but I was attended to on time. I at times fear to come here because people will look at me as pregnant, but it’s about staying strong” (age: 18 years, S.4, first pregnancy).
Health facility compared to services by traditional birth attendants 
Many of the teenagers preferred using the health facility as compared to the traditional birth attendants (TBAs) because, at the health facility, one easily gets immediate attention and assistance. 
“I have not yet gone to a traditional birth attendant and do not really hope to go there. Why? Hmm…Only a few things do they know from what is at a health facility” (age: 18 years, P.7, first pregnancy).
“I prefer to come here because here I find a lot of reference points because a health worker can tell me, ‘Go and swallow this medicine, go and do this and don’t do that because it is going to hurt you, but when you go to a traditional birth attendant, she will continue giving you medicine, and you take” (age: 19 years, P.6, first pregnancy).
“I will continue coming here to the health facility. Why? (laughing); There are some traditional birth attendants in the village who can tell you that your pregnancy is unhealthy, and you come here, to the health facility, and they tell you that the illness is not there, which shows that the TBAs are deceiving” (Age: 19 years, S.2, first pregnancy).
However, a few of the teenagers said they would go to the TBA only to take medicine and be palpated depending on the nature of the circumstances, but they would deliver ANC from the health facility due to the nature of assistance offered.
“There are traditional birth attendants in the community where I stay, and I hope to go there to be palpated. I plan to go to the health facility because I may decide to deliver from home and fail” (Age: 19 years, P.6, first pregnancy).
“I went to a traditional birth attendant during delivery, but I had never gone there before but only to deliver; the service was good. I am sure I can go back” (age: 17years, S.4, first pregnancy).
One of the teenagers felt that the HWs were better confidantes than the TBAs:
“Aaah! I have never thought of going to a traditional birth attendant. We have one near our home, but she talks about the ones she helps deliver, so I would rather come to the health facility” (age: 14 years, P.6, first pregnancy).
4. Discussion
Teenagers’ personal experiences of seeking ANC and delivery

Some of the teenagers delayed visiting the health facilities due to the absence of the company of their husbands as demanded by health workers. Also, some teenagers just decided that they wanted the pregnancy to first develop before they could go to the health facility. These instances increased the chances of pregnancy-related complications either during pregnancy or delivery. Respondents were motivated to get to the health facility after getting the necessities or their husbands’ return home. However, some came because they were feeling unwell despite the absence of their husbands, whereas some were encouraged to come and check the conditions of their unborn babies. The findings from this study indicate that many teenagers were aware of the importance of seeking ANC and delivery services from health facilities. 
Few of them initiated the ANC visits and delivery services from health facilities, and in most cases, it was late for those who did it. This finding is in line with studies carried out in Masaka and Wakiso districts in Uganda which conveyed that teenagers often found it hard to visit the antenatal clinic due to the lack of money to facilitate their movement and necessities that might be required at health centers [1415]. This is further related to findings in other studies showing that teenagers are less likely to receive ANC, compared to older women, often seeking it only in the third trimester, if at all they did [1617]. This finding was also attributed to several reasons, like lack of monetary resources to acquire necessities required by the HWs. 
Interpersonal experiences of seeking ANC and delivery
Many teenagers affirmed receiving support from the people they stayed with or those around them. However, one of the respondents also claimed not to have received any kind of support from the people she stayed with. Only a few of the teenagers in this study made personal decisions to come for the services at the facilities. As far as decision-making is concerned, the findings from the study indicate that most of the decisions were always made by the people these teenagers stayed with, including their parents and spouses. These results are in agreement with the findings of a study that was carried out in Lesotho, which showed that support during pregnancy had been associated with positive outcomes [181920]. This finding further agrees with a study in Bangladesh where the parents or spouses made most decisions for the teenagers since men were usually the heads of the families and therefore took most household decisions while the mothers-in-law made decisions on healthcare [21]. 
Health facility-related experiences
Many teenagers claimed to feel comfortable when they came to the health facility. During the interaction, all teenagers said that the HWs treated them well. They said that the HWs were always calm in how they talked. The health workers were, at times, patient with them and showed kindness. This finding coincides with a study in Malawi, where most teenagers felt they were cared for by HWs [22]. 
The teenagers in this study further said that even in instances when they failed to do what was expected of them, the health workers were a little strict with them but later attended to them. This finding is unlike other studies carried out in other countries. In Bangladesh, for example, findings suggest that the quality of healthcare services and the attitudes of the health personnel were mentioned as a barrier to using maternal healthcare and less attention by the healthcare workers [23]. Some teenagers acknowledged receiving some education when they came for ANC. This finding agrees with a study carried out in 2015 by Rukundo et al. in Mbarara, Uganda [24]. However, while some claimed the health education was adequate, others felt there was more they needed to know. On the contrary, some teenagers said they had not received any kind of education for the times they had visited the health facility. Similar findings were found in studies conducted in Ghana, Australia, and India, where teenage girls had an unmet need for information delivered at health facilities [2526, 27].
Some teenagers noted that the utilities, including delivery beds, diagnostic equipment, medicines, and the limited number of health workers, were inadequate and needed to be improved. Similar findings were noted in a study by Atuyambe in Wakiso, Uganda [15, 28]. Many teenagers also said that the health facilities were accessible and felt health workers, in most cases, working on time save for a few who had delays. However, one outstanding challenge that most teenagers kept identifying was the high number of clients in most cases with only one health worker attending them. Thus, in most cases, delays were due to many clients. This finding agrees with studies conducted in Ghana and Lesotho [29, 30]. The teenagers did not have any stigma apart from a few coming for the first time but later getting over it.
As such, most teenagers preferred using health facilities compared to TBAs. Most teenagers said that at the health facility, one easily got assistance. This finding is unlike a study in Bangladesh where adolescent teenagers relied on past events when other women gave birth at home without any problem. As such, they felt comfortable giving birth at home [21]. The teenagers said that HWs are better confidantes than TBAs. Teenagers would rather prefer to continue seeking services from a health facility. This is contrary to a finding in Wakiso by Atuyambe, where the teenagers identified the unprofessional nature of the HWs who shared their secrets with their parents and other people [15]. However, few of the teenagers in this study said they would go to the TBA only to take medicine and be palpated depending on the nature of the circumstances but would deliver any additional assistance offered by the health facility. 
5. Conclusion
The findings of this study provide insight and understanding of what teenagers experience as they seek antenatal care or delivery at health facilities in the Kibuku District. Seeking antenatal care and delivery among teenagers is influenced by the personal, interpersonal, and health facility-related experiences of participants. First, the participants expressed their personal experiences that they knew the importance of seeking ANC and delivery at health facilities. Second, interpersonal experiences played a significant role in offering support to teenagers. Third, their experiences with the health facilities enabled them to elucidate how they managed to cope with some of the challenges they encountered while some suggested recommendations to avert some of the challenges they experienced. Finally, strategies recommended include empowering the expectant teenage mothers, health workers, social workers, and people with whom these teenagers stay with adequate health education focused on antenatal care in teenagers. In addition, health facilities in charge are urged to make use of essential medicines and supply redistribution systems to resolve the deficits and shortages of medicines for expectant teenage mothers. This study could be useful to health workers and policymakers in Uganda and similar settings to better understand and plan for services for teenage mothers seeking maternal and child health services. 
Limitations and strengths
Most respondents were quite timid at the start of the interviews; they feared to respond to the questions and, in most cases, gave scanty information. The research team kept reassuring respondents of the confidential nature of the study and the findings gathered. This action led to the opening up of most respondents. Some of the teenage girls had a recall bias—especially those who had already given birth to a child. As a necessity, constant probing was done to help them share their actual experiences, not what they thought they should be or what they could have heard from their friends or other people. The study had strength in presenting the voices of the participants, thus reflecting the real situation the teenage mothers experienced.
Ethical Considerations
Compliance with ethical guidelines

Ethical clearance was granted by Uganda Christian University Ethical Review Committee, with approval number 1311-600-0228. Also, permission to conduct the study was obtained from the District Health Officer of Kibuku District. The respondents were given a detailed explanation about the study before interviews and the right to exit the survey. Informed consent to participate in the study and audio recordings of the sessions were obtained from participants. Before each interview, respondents were informed that the content of the interview would be confidential and coded. Their information shall be accessible only to the people involved in the study and kept in a secure place, only accessible by the investigators. The calls for participation in the survey at health facilities in different locations in Kibuku District were initially done, and several participants expressed their willingness.
This research did not receive any grant from funding agencies in the public, commercial, or non-profit sectors.
Authors' contributions
All authors equally contributed to preparing this article.
Conflict of interest
The authors declared no conflict of interest.
The authors would like to thank the staff of antenatal clinics and respondents in Kibuku District, Elizabeth P. Kyasiima, for the critical review of the manuscript.

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Type of Study: Orginal Article | Subject: ● Psychosocial Health
Received: 2022/03/20 | Accepted: 2022/05/25 | Published: 2022/07/1

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