Research Article

Adolescent mothers’ non-utilisation of antenatal care services in Bulawayo, Zimbabwe

CN Chaibva, D Litt et Phil. Graduate, Department of Health Studies, UNISA and Lecturer Department of Health Sciences, Zimbabwe Open University, Bulawayo

JH Roos, D Litt et Phil Associate Professor, Department of Health Studies, UNISA

VJ Ehlers, D Litt et Phil Professor, Department of Health Studies, UNISA

Key words adolescent mother, antenatal care, Abstract: Curationis 32 (3): 14-21 Health Belief Model, midwifery in Zim­ Adolescent pregnancies are high risk obstetric occurrences. Antenatal care (ANC) babwe provides opportunities to recognise and treat obstetric complications, enhancing the pregnancy outcomes for mothers and babies. The purpose of the study was to identifyfactors influencing adolescents' non-utilisation of ANC services in Bulawayo. The Health Belief Model (HBM) was used to contextualise the study. A quantitative, non-experimental, descriptive research design was adopted, using structured interviews to collect data. Purposive, non-probability sampling was used to conduct structured interviews with 80 adolescent mothers from the postnatal wards who had delivered their babies without attending ANC. Factors influencing these adolescent mothers ’ non-utilisation of ANC services in­ cluded socio-economic issues, individuals' perceptions about ANC, limited knowl­ edge about ANC, policies and structural barriers. However, these adolescents knew that delivering their babies with skilled attendance could enhance the outcomes for the mothers and babies, would help secure documents to facilitate the acquisition of their children's birth certificates, and that obstetric complications required the serv­ ices of skilled midwives/doctors. Policy-related issues, such as requiring national identity cards from pregnant adolescents (orfrom their spouses) prohibited some of them from utilising ANC services. There is a need to improve adolescents ’ reproductive health outreach (including ANC) programmes and to offerfree ANC services in Zimbabwe. Restrictive policies, Correspondence address such as the required identity cards of the pregnant adolescents (or their husbands), impacted negatively on the accessibility of ANC services and should be addressed P rof Valerie J Ehlers, as a matter o f urgency in Bulawayo. PO Box 65075, ERASMUSRAND, Pretoria., 0165. South Africa.

Tel/fax: (012) 347-8287 (home); Tel: (012) 429-6731/6296 (work) Fax: (012) 429-6688marked FOR A TTEN- TIONPROF VJ EHLERS. E-mail: [email protected] (home) [email protected]

14 Curationis September 2009 Introduction and (HIV). Iron supplements, folic acid, teta­ lief in the value o f actions to nus toxoid vaccinations and anti-ma- prevent the condition (implying background information laria drugs are supplied to pregnant the value of using ANC serv­ Adolescents ’ pregnancies and child­ women, if necessary. If the pregnant ices to optimise the potential birth episodes are m ajor public health woman is HIV positive, the prevention outcomes for the mother and challenges worldwide, especially in of mother-to-child transmission serv­ the baby) sub-Saharan Africa (Ebeigbe & ices must be recommended to her. • Perceived barriers - one’s belief Gharoro, 2007:79). Maternal deaths are in the “cost ” to take the pre­ five percent higher forfemales younger M aternal health statistics in Bulawayo scribed action/s (in this case it than 16 years than for females in their for 2004 and 2005 indicate that 22.6% implies the perceived barriers to twenties (Mlangeni, 2003 in Grobler, of the adolescent mothers delivered accessing ANC services such Botha, Jacobs & Nel, 2007:32). The ef­ their babies without attending ANC as paying for ANC services and fective utilisation of antenatal care (MOHCW, 2005:1). Most of these for transport to the ANC clin­ (ANC) services by adolescents could unbooked mothers delivered their ba­ ics; the requirement to produce reduce pregnancy and childbirth com­ bies with the assistance of traditional a Zimbabwean identity docu­ plications, and improve the outcomes birth attendants, but some delivered ment o f oneself or one’s spouse for mothers and babies. their babies in hospitals when they prior to registering for ANC anticipated or experienced obstetric services; the intention of preg­ Adolescents ’ non-utilisation of ANC problems. No policies were imple­ nant adolescents to hide their services poses threats to the health of mented in Zimbabwe to trace unbooked pregnancies from their parents the mother and the baby and is associ­ mothers and/or those who delivered and schools until they are in la­ ated with poor birth outcomes (Leslie, their babies at home. Mugweni, Ehlers bour; fear o f being tested HIV Findlay, Frappier, Goldberg, Pinzon, and Roos (2008:11) reported that some positive) Sankaran & Taddeo, 2006:243). Obstet­ Zimbabwean women preferred home • Cues to action - strategies to ric complications are high among ado­ deliveries because they disliked any activate and sustain specific lescents who deliver their babies with­ interventions during the deliveiy of actions (factors motivating out attending ANC (Loto, Ezechi, Kalu, their babies and/or placentas. These pregnant adolescents to start Loto, Ezechi & Ogunniyi 2004:398). The authors also indicated that Zimba­ and continue using ANC serv­ status of these adolescents is referred bwean women, even those with high ices throughout their pregnan­ to as "unbooked” in Zimbabwe. Stud­ levels of education, were unaware of cies) ies conducted by Matua (2004:33) as the potential dangers of home deliver­ • Self-efficacy - one's confidence well as by Omolola, Babatunde, ies especiallyfor primigravidas. Babalola and Victoria (2004:25) con­ in on e’s ability to take action (to attend ANC clinics regularly) firmed that pregnancy and childbirth Adolescents ’ non-utilisation of ANC Actions taken to avoid the negative pose particular health risks especially sendees may be influenced by health consequences of any condition or con­ when adolescents fail to utilise ANC care providers ’ attitudes as well as by sequence resultingfrom the lack of tak­ services. the nature of these services. Aretakis ing a specific action, comprise the key (2004:818) cites barriers, especially element in the HBM (RECAPP, 2005). Zimbabwe's maternal mortality rate was among African adolescent mothers, re­ The utilisation of ANC sevices to en­ reported to be 555 maternal deaths per lated to non-utilisation o f ANC, as ado­ hance the pregnancy outcomes for 100 000 live births during 2005/2006 lescents dislike providers’ care and both mothers and babies constitutes (MOHCW, 2007:11). Zimbabwe ac­ providers ’perceived offensive attitudes cepted the Millennium Development the key element in the application of towards adolescents. Goals (MDGs), and MDG number five the HBM to this study. endeavours to improve maternal health Conceptual framework and reduce maternal mortalities bv 75% The research is based on the Health Problem statement between 2000 and 2015, by enhancing Belief Model (HBM) comprising the During 2004/5. Zimbabwe’s Minister of access to ANC and maternal health following concepts: Health and Child Welfare (MOHCW) services (MOHCW, 2007). Zimbabwe's was concerned about the 22.6% ado­ goal-oriented ANC protocol (MOHCW, • Perceived susceptibility - one's lescent mothers who delivered without 2000) specifies what activities should belief about the possibility that any ANC attendance (MOHCW be performed by midwives during each one can acquire a condition (or 2005:1), and the 49.0% who commenced trimester ofpregnancy. This ANC pro­ suffer negative consequences using ANC services only after 28 tocol recommends that every pregnant by not using ANC services weeks' gestation, as these practices woman should have six ANC visits if it • Perceived severity - one's be­ might contribute to the maternal is an uncomplicated pregnancy. The lief about the seriousness o f the mortalities in Bulawayo. The examinations that should be done in­ condition (or the potential se­ MOHCW s report (2005:1) indicated clude blood pressure, unrinalysis, his­ verity of the consequences for that 63 maternal deaths had been re­ tory taking, abdominal palpations, fun- the adolescent mother and/or ported in Bulawayo during 2004/5 and dus-symphysis pubis measurements, her baby of not using ANC that almost 50% of these deaths oc­ and voluntary counselling and testing se n ’ices) curred among adolescents. for Human Immune Deficiency Virus • Perceived benefits - one's be­

15 Curationis September 2009 The first author noticed that some Sample and sampling methods attend ANC clinics, the researchers unbooked adolescent mothers deliv­ The sample was selected from the ac­ anticipated that they might have been ered their babies in hospital when an­ cessible population of adolescents in unfamiliar with some terms used in the ticipating or experiencing obstetric Bulawayo who had delivered their ba­ questionnaire; and might have been problems. Some o f these obstetric prob­ bies in government prim ary health care unable to read and write to the level lems could have been addressed dur­ (PHC) clinics and hospitals without at­ required for the successful completion ing ANC visits, or identified and re­ tending ANC. All the government in­ o f questionnaires. ferred timeously for more specialised stitutions providing delivery services management reducing the risks for (four PHC clinics and two hospitals) in All respondents opted to use English mothers and babies. Bulawayo comprised the study sites for during the interviews, although the in­ collecting data. Consequently the terview schedule was also available in The problem was that some adolescent population o f sites were included in the the Ndebele language, and the inter­ mothers failed to use ANC services, survey and no sampling of sites took viewers could speak Ndebele and Eng­ despite the availability of these serv­ place. Purposive sampling of adoles­ lish fluently. ices in Bulawayo, and that it was un­ cent mothers was employed, recruiting The first section of the structured in­ known what factors influenced these ten adolescent mothers from each of terview schedule aimed to obtain in­ adolescent mothers ’ decisions. the two less busy clinics (10 x 2 =20) formation about adolescent mothers’ and 15 mothers (15x2 - 30) from the biographic data (age, marital and edu­ Purpose two busier clinics and (15x 2 = 30) from cational status, religion, employment The purpose of the study, on which the two hospitals. The total sample and source of income) and the second this article is based, was to identify fac­ comprised 80 adolescent mothers. section addressed obstetric aspects tors contributing to the non-utilisation (parity, gravida, obstetric history). The of ANC services as perceived by ado­ Non-probability purposive sampling subsequent sections of the interview lescent mothers and to develop strate­ was used to select adolescent mothers schedule addressed issues relevant to gies to enhance adolescents ’ effective who met the following inclusion crite­ the HBM’s major concepts such as utilisation of ANC services, ensuring ria' socio-cultural and economic factors timely management of identified poten­ • aged 19 or younger influencing their ANC utilisation, tial risk factors and the possible pre­ • delivered their babies without knowledge about ANC, perceived ben­ vention ofcomplications for both moth­ attending ANC regardless of efits o f and barriers to using ANC serv­ ers and babies. parity and mode o f delivery ices. The last section asked for sug­ gestions to improve ANC services for The research question that needed to • delivered their babies at one of adolescents. be answered was thus: ‘Why do ado­ the participating clinics or hos­ lescent mothers in Bulawayo fa il to use pitals during May and June the available ANC services? ” 2007 Validity of the interview • consented to being inter­ schedule Definitions of concepts viewed, and if younger than 18 Validity of the structured interview years of age, their parents/ schedule was enhanced because: For the purpose of the study on which guardians also had to give con­ • Questions were in line with the the article is based, the following terms sen t H BM ’s m ajor tenets and with have been defined as: • were willing to be interviewed the literature review. Adolescent mothers: Women aged 19 in the po st natal ward after be­ • Three midwifery tutors, three years or younger, irrespective of ing discharged before going senior midwifery practitioners, gravida, parity, neonatal outcomes or home, implying that they would two promoters and a statistician marital status (Ehlers, Maja, Sellers & be interviewed after they had examined each item’s appropri­ Gololo, 2000:46). received all the required post ateness in terms o f content and natal treatments and health in­ criterion-related validity. Antenatal care: ‘ ‘regular care and moni­ formation and that they had • The structured interview sched­ toring given to a woman during preg­ obtained some rest after deliv­ ule was pre-tested on five post­ nancy” (Mosby Nurses’ Pocket Dic­ ering their babies. partum adolescents who did not tionary, 2005:24). participate in the actual study, The research instrument resulting in no changes. Non-utilisation of ANC: Pregnant ado­ A structured interview schedule was • An independent researcher also lescents who failed to make use o f avail­ used to collect data because it allow ed evaluated the face and criterion- able ANC services. the clarification o f unclear statements -related validity of the struc­ and unfamiliar terms while also ena­ tured interview schedule. Reseach method bling interviewers to identify respond­ A quantitative, descriptive design was ents who might be physically and/or Reliability of the structured used to identify and quantify factors emotionally unable to respond to ques­ interview schedule influencing adolescents’ non-utilisa­ tions, and avoid interviewing these The reliability of the structured inter­ tion of ANC services. mothers. As the respondents failed to view schedule was enhanced by pre­

16 Curationis September 2009 testing it on five adolescent mothers Figure 1: Age of the respondents (n=80) who met the selection criteria and yielded similar results to those of the actual interviews, indicating consist­ ency and stability. The pre-test inter­ views were conducted by the first au­ thor and two research assistants. The information obtained by the three in­ terviewers was compared and yielded similar results, amounting to inter-rater reliability.

Ethical considerations Permission was sought from and granted by the heads o f the participat­ ing health centres and the Medical Re­ search Council o f Zimbabwe, andfrom the Research and Ethics Committee of the Department of Health Studies, Unisa. Informed consent was obtained 14yrs 15yrs 16 yrs 17yrs 18yrs \9yrs from the respondents (and their guard­ ians for those under 18 years). Re­ spondents were assured about the Research results: Age confidentiality and anonymity of the The mean age o f the respondents was information. The purpose and benefits analysis and discussions 17 years, ranging from 14 to 19 years. of the study, as well as issues o f confi­ The results and discussion o f the data Most respondents, 22 (27.5%) were ei­ dentiality, voluntary participation, pri­ analysis was guided by the compo­ ther 17 years or 19 years old as por­ vacy and anonymity were discussed nents of the HBM. trayed in Figure I. These findings are prior to each interview. in contrast with reports by other re­ Modifying factors searchers that younger adolescents Adolescents (and their guardians for According to the HBM modifying fac­ tend to delay or not attend ANC (Ford, those younger than 18) were asked to tors such as age, marital status, educa­ Weglicki, Kershaw, Schram, Hoyer & sign a consent form and drop it into a tional level, parity and income can in­ Jacobson, 2002:38; Reynolds, Wong & box provided in the postnatal ward fluence decisions to utilise ANC serv­ Tucker, 2006:9). (prior to each interview) to ensure ano­ ices. nymity during the interview. In this way no anonymously completed interview Figure 2: Marital status of the respondents (n = 80) schedule could be linked to any signed consentform. The completed interview schedules were kept in a separate con­ tainer to which only the researchers and the statistician had access.

Data collection and analysis Adolescent mothers were interviewed in the postnatal wards before dis­ charge. They were only interviewed once they had recovered from the la­ bour process and were no longer un­ duly tired. As the interviews requested information about the adolescents per­ sonal reasons for not attending ANC, no potentially emotionally traumatic questions were asked. Data gathered were coded and analysed using the Statistical Package for Social Sciences (SPSS) version 10.0 computer pro­ gramme and presented in tables, bar and pie charts.

17 Curationis September 2009 respondents had one live baby, 9 (11.2%) had two live children while 3 (3.8%) had no live children due to still­ births or neonatal deaths.

Individual factors Respondents were asked in an open- ended question to mention at least three factors that would motivate them to utilise ANC services with their future pregnancies. The main factors men­ tioned were grouped into the follow­ ing categories: • Adequate knowledge about ANC services and its benefits (n=58; 72.5%). • Accessible, acceptable and af­ fordable ANC services (n =62; 77.5%). • Favourable family and social support systems (n=55; 68.8%). • Quality services, satisfying the needs of adolescent mothers (n=49; 61.3%). • Unsure (n=16; 20.0%). Marital status and residency ployed. Those employed were mainly O f the adolescent mothers, 39 (48.8%) general workers. Their spouses (n-40; The respondents avoided initiating were single, 27 (33.8%) were married, 50%),parents (n-30; 37.5%), self (n=6; ANC because of their individual per­ while 14 (17.5%) were cohabiting (see 7.5%) and other sources such as non­ ceptions about ANC services, due to Figure 2). Thirty-six (45.0%) lived with government organisations (NGOs) their limited knowledge of, and miscon­ their parents, 32 (40.0%) with spouses, (n=4; 5%) provided them with an in­ ceptions about, ANC services, and 9 (11.3%) with other members of the come. More than half (n=52; 65.0%) of their perceptions that poor quality ANC extended family and 3 (3.8%) with their spouses were employed, 25 services would not benefit them or their friends. (31.2%) were unemployed and the re­ babies. maining 3 (3.8%) spouses' employment Educational level status was reportedly unknown. The Socio-cultural and economic Pereira, Canavarro, Cardoso and job categories of spouses included factors Mendonqa (2005:656) refer to a number skilled work (n-25; 31.2%), general According to the HBM, socio-eco- of studies (Coley & Chase-Lansdale work (n=l 1; 13.7%), self-employment nomic factors are viewed as modifying 1998; Garrett & Tidudl 1999; and (n=9; 11.3%) and professional work factors that could influence the utilisa­ Yamolskaya, Brown <£ G reenbaum (n=7; 8.8%). tion of ANC services. Reynolds et al 2002) indicating that pregnant adoles­ (2006:6) reported that poor ïnaternal cents “have lower levels of education, These findings are supported by outcomes were associated with socio­ lower educational aspirations and per­ Cassata and Dallas (2005:72), who ob­ cultural factors, restricting women’s formance, and higher levels of school served that unemployed, single and dropout". In this study all respond­ economically dependent adolescent autonomy and supporting harmful tra­ ents were literate (Figure 3). The major­ mothers were unlikely to utilise ANC ditional and/or religious practices. ity (n-60; 75.0%) had acquired some services. However, 52 (65.0%) of their Maimbolwa, Ahmed, Divan and Ransjo- secondary school education (Form 1- spouses were employed. These ado­ Arvidson (2003:33) reported that ado­ 5), while a few had studied up to Grade lescents could therefore get financial lescents were so scared of revealing 7 (n=20; 25.0%), the last year at primary support from their employed spouses their pregnancies; they risked their school in Zimbabwe. The m ajor reason (Adamu & Salihu, 2002:600; Perloff & lives by seeking unsafe abortions. for leaving school was pregnancy Jaffee, 1999:117), although these in­ (n=22; 27.5%) and a lack of money to comes might have been inadequate to Respondents were asked about the pay school fees or proceed with their pay for ANC services. type of contraceptives they had used studies (n -22; 27.5%). prior to their pregnancies. Most (n =46; Parity 57.5%) indicated that they had used Employment status and sources of Of the 80 respondents, 69 (86.3%) re­ nothing, 17 (21.3%) used male con­ income portedly had their first pregnancies, doms, 9 (11.3%) used pills, 4 (5.0%) Most respondents were unemployed while 11 (13.8%) had been pregnant for used injections while 4 (5.0%) relied on (n=70; 87.5%) and 10 (12.5%) were em­ the second time. Sixty-eight (85.0%) breastfeeding (see Table 1).

18 Curationis September 2009 Table 1: Family Planning method (n=80) study by Frost and Oslolo (1999) they required documents (Zimbabwe indicating that as many as 44.0% national identity cards) to register for of adolescents intentionally be­ ANC while two (2.5%) cited religious Method n % came pregnant. In this study nine factors. If they had money, 29 (36.2%) (11.3%) adolescents reported de­ respondents indicated they would pal 9 11.3 liberately discontinuing their con­ book for ANC while 29 (36.2%) were IUCD 00 00 traceptives because they wanted unsure, only 21 (26.2%) would defi­ Injection 4 5.0 to have babies. nitely bookfor ANC if they had money, while one (1.2%) would definitely not Condom 17 21.3 For 69 (86.3%) o f the respondents do so even if she had money. Breastfeeding 4 5.0 this was the first pregnancy and A bstinence 00 00 thus they had not experienced Respondents chose to deliver at health previous pregnancy problems. centres, even if they did not attend Nothing 46 57.5 Three respondents (3.8%) had ANC because more than half (n-42; Total 80 100 experienced problems with previ­ 52.5%) wanted safe deliveries by skilled ous pregnancies, including attendants, while obstetric complica­ neonatal deaths (n=2; 2.5%), abor­ tions forced 35 (43.8%) respondents to tion (n=l; 1.2%) and pre-eclampsia seek hospital care. Three (3.8%) re­ Respondents indicated that they failed (n=l; 1.2%). Out of the 11 (12.5%) re­ spondents delivered their babies in to use contraceptives correctly be­ spondents who had been pregnant pre­ hospitals/clinics because they wanted cause ofa lack of knowledge and prob­ viously, 4 (5.0%) had reportedly at­ birth record notification letters to ob­ lems in accessingfamily planning serv­ tended ANC and 7 (8.8%) delivered tain their babies ’ birth certificates with­ ices (n=40; 50.0%). Similar findings their babies without attending ANC. out hassles from Zimbabawe’s Minis­ (Dahlback, Maimbolwa, Kasonka, Reasons for not utilising ANC ser\’ices try o f Home Affairs. Bergstrom & Ransjo-Arvidson, during their previous pregnancies in­ 2007:670) were reported by other re­ cluded that they were feeling well, reli­ A number (n=29; 36.3%) indicated that searchers. Mbambo, Ehlers and gious factors, financial constraints and they were unaffected by complications, Monareng (2006:8) also reported that fears ofdisclosing their pregnancies to whereas 21 (26.3%) respondents agreed most South African adolescent moth­ their parents. They preferred their preg­ that some complications could have ers did not use contraceptives and nancies to be discovered when in la­ been prevented if they had attended knew little about contraceptives. Indi­ bour. This preference o f pregnant ado­ ANC. vidual perceptions about contracep­ lescents could influence their non-uti­ tives included fears of their parents’ lisation of ANC sen'ices detrimentally Factors contributing to non-utilisation reactions should it be discovered that with potentially hazardous effects for of ANC services were cited as limited they used contraceptives (Ehlers, both mothers and babies. knowledge about ANC benefits (n=25; 2003:229). 31.3%), financial constraints (n=17; Reasons for their non-utilisation of 21.3%), fears of disclosing their preg­ Sixteen (20.0%) respondents admitted ANC services during their last preg­ nancies to their parents 12 (15.0%), defaulting. Ten (12.5%) stated cultural nancies (see Table 3), included fears of unplanned pregnancies (n-11; 13.8%) and religious reasons while 5 (6.2%) disclosing their pregnancies to their and the desire to terminate the preg­ cited contraceptive method failures parents or schools (n=I9; 23.8%), they nancy (n=2; 2.5%). (see Table 2). were feeling well and their babies were kicking (n=18; 22.5%) and 16 (20.0%) Knowledge about ANC Not all adolescent pregnancies are un­ lacked money to pa y ANC fees. Knowledge was identified as the major wanted. Biyant (2006:134) refers to a structural variable that could affect Fourteen re­ adolescents ’ utilisation of ANC ser\’- Table 2: Reasons for stopping family planning (n=80) s p o n d e n t s ices. Most respondents (n = 78; 97.5%) (17.5%) re­ agreed with the statement that ANC ported limited provides increased knowledge about Reason n % k n o w l e d g e reproductive health, while 2 (2.5%) disa­ Dejault 16 20.0 about benefits greed with this statement. Almost all of ANC, while respondents (n=77; 96.3%) agreed that (X) No reason 00 7 (8.8%) were early ANC booking enhances the well­ Lack o f knowledge of family planning 4() 50.0 receiving ser\’- being of the mother and the baby and ices of tradi­ that ANC provides opportunities to Method failure 5 6.3 tional birth at­ detect and manage complications re­ Wanted a baby 9 11.3 tend a n t s lated to pregnancy and child birth; ANC (TBAs). Four provides learning opportunities ena­ Cultural and religious reasons 10 12.5 (5.0% ) r e ­ bling one to identify potential compli­ Total 80 100 spondents did cations and seek help. Only 3 (3.7%) n ot a tte n d respondents disagreed with the preced­ ANC because ing statements.

19 Curationis September 2009 Table 3: Reasons for not attending ANC with last pregnancies (n=80) the assistance o f skilled attendance by nurses/midwives and/or doctors, could enhance the health o f the mothers and Reason n % their babies, help to secure documents to facilitate the acquisition oftheir chil­ Fear of disclosing the pregnancy 19 23.8 dren ’s birth certificates and address Feeling well and the baby was kicking 18 22.5 obstetric complications.

No money to register for ANC 16 20 Adolescent mothers did not use ANC Lim ited knowledge about AN C and its benefits 14 17.5 services if they had negative percep­ tions about the quality of these serv­ No required documents to register for ANC 4 5.0 ices and/or the service providers ’ atti­ Attended ANC with TBAs 7 8.8 tudes, if they lacked knowledge about ANC’s benefits and fears of getting Religious factors 2 2.5 tested for HIV and of learning about Total 80 100 one s positive HIV status. Limitations tending ANC would be beneficial for Generalisation of the results of this All most all respondents (n-77; 96.3%) reducing the incidence of complica­ study is subject to the following limita­ indicated that ANC does provide op­ tions or preventing them, while identi­ tions: portunities to learn about sexually fying and resolving any barriers to re­ transmitted infections (STIs), HIV and productive health (Biko 2006:55). non-probability sampling methods were used, which prevent generalisation of prevention of mother-to-child transmis­ the results to the entire population. sion (PMTCT) o f HIV/AIDS, while three There was a significant correlation However, all the study health centres (3.8%) disagreed. (p=0.000;p<0.05) between identified were included in the sample meaning barriers and respondents' future that the views of the adolescents in These adolescent mothers lacked planned non-utilisation of ANC serv­ Bulawayo could have been repre­ knowledge about ANC and agreed that ices in Bulawayo. The most significant sented. The views of the unbooked adequate knowledge about ANC's ben­ barriers were high ANC fees (n=69; adolescents who delivered at home efits could motivate them to utilise ANC 86.3%), unfriendly attitudes of health were not represented in this study be­ services in future, similar to Matua’s workers (n-51; 63.8%), poor family and cause they could not be accessed. (2004:35) findings. social support systems (n=74, 92.6%), The use of research assistants could fear of testing for HIV (n = 73; 91.3%), have created variances although they positive HIV status (n=75; 93.8%) and Perceived benefits and barriers were trained and coached until they had limited decision making powers (n=67; A significant correlation (p=0.000 mastered questioning and recording 83.8), as most respondents were finan­ p<0.05) between awareness of per­ skills. ceived ANC benefits and potential fu­ cially dependent on their parents, hus­ bands or partners. ture utilisation of ANC services was The study utilised one theoretical found. Respondents’ awareness of framework (HBM) which accommo­ ANC benefits increases their intentions Conclusion dated all the key variables likely to in­ o f utilising ANC services with theirfu­ Factors influencing adolescent moth­ fluence adolescent mothers ’ utilisation ture pregnancies. Adequate knowledge ers ’ non-utilisation of ANC services of ANC services. However, different of ANC services in Bulawayo would included socio demographic factors, study findings might have emerged if motivate 44 (55.0%) respondents to individual perceptions about ANC, lim­ a multi-theory approach had been used. utilise ANC services in future; 38 ited knowledge about ANC, economic (4 7.5%) definitely perceived accessible challenges, policy-related and struc­ Recommendations and acceptable ANC as benefits; 66 tural barriers. A policy-related barrier Based on the findings of the study the (82.5%) said free ANC services would was requiring national Zimbabwean following recommendations were made: benefit them, while 14 (17.5%) felt that identity cards of themselves or their • Revision and strengthening of free ANC services would not be ben­ spouses in order to register for ANC. strategies reaching out to ado­ eficial to them. Only two (2.5%) re­ Pregnant adolescents, younger than 18 lescents who might be affected spondents disagreed with the state­ or unmarried or whose spouses did not by bio-psychosocial and eco­ ment that quality ANC services would have the required identity cards, could nomicfactors, including knowl­ motivate them to utilise ANC services, not access ANC services in Bulawayo. edge that influences their ac­ while only one (1.3%) disagreed that Some adolescents reportedly delivered cess to ANC andfamily plan­ ANC services would meet adolescents ’ their babies at health centres in order ning services. ANC programmes needs, would motivate her to use ANC to obtain birth record letters, used to should enhance reaching those services in future. get their children's birth certificates. adolescents who are still at school. Adolescents are, however, likely to uti­ However, these adolescent mothers lise ANC services if they perceive at­ knew that delivering their babies with • Offering free ANC services

20 Curationis September 2009 should receive serious atten­ ers ’ utilization of contraceptive serv­ MINISTRY OF HEALTH AND tion in Zimbabwe since the ices in South Africa. International Nurs­ CHILD WELFARE 2005. AN C and pregnant adolescents might be ing Review. 50:229-241. delivery’ registers 2004-2005. Bulawayo: unable to pay the ANC fees. Health Information Department. • Regular audits should be done EHLERS, VJ; MAJA, T; SELLERS, E of adolescents' reproductive & GOLOLO, M 2000. A dolescent MINISTRY OF HEALTH AND health programmes ensuring mothers' utilization of reproductive CHILD W ELFARE 2007. Zimbabwe that they are adolescent health services in the Gauteng Prov­ maternal and neonatal health road map: friendly. ince of South Africa. Curationis. 2007-2015. Harare: Government Printer. 23(3):43-51. • Addressing those barriers and M O H C W - See MINISTRY OF restrictive policies that interfere FORD. 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