Table 5 Health service delivery factors influencing ANC uptake among adolescents

Health Systems Policies

National, or high-level, rules dictating patients’ access to health services.

ANC uptake is more likely where policies do not discriminate against adolescents.

Problematic policies:

• Clinics requiring women (including adolescents) to bring their partner to ANC visits

• Pregnancy not permitted at school (Tanzania only)

“I disliked that we were told that we must bring men who got us pregnant. I disliked it because sometimes you are pregnant but the man is no longer in the picture. But still they tell you that they won’t attend you until you bring the man. Where will I get him?” [TZA-3, R3]

“I was late [in seeking ANC] because I was scared that the clinic will tell me to go with my husband.” [TZA-3, R1]

M: “Any other reason why young women are late to start attending ANC? R3: Sometimes it is when the woman is a student” [TZA-5]

Patient-provider relationships

Interactions between individual patients and their health care provider at point-of-care.

Participants described three categories of relationships:

1) Motivating and inspiring interactions with health care providers

2) Neutral, purely transactional interactions

Inhibitory and discriminatory interactions.

ANC uptake is more likely when participants developed meaningful, supportive relationships with health care providers.

Positive interactions were particularly important for motivating repeat ANC visits.

“Sometimes [the health care providers] get so angry and rude. They rip your clinic card into pieces” [TZA-3, R4]

“I was afraid that, if I went, she (the nurse) will tell me that I was going to school and had not completed but have got myself pregnant, she will insult me. But when I went she held my hand and took me to the madam who attended to me really well.” [GHA-1, R1]

“My sister-in-law said the nurses treated her harshly and rudely, so if I go they will treat me the same, but fortunately for me I experienced none of that so the nurses should treat us well.” [GHA-3, R10]

“Madam sometimes even when you are pregnant and you go there and you are shy, you are not happy and you can frown. But if the nurse likes you she can say something funny for both of you to laugh at to create happiness.” [GHA-5, R4]

“When a woman is dirty, they took a long time waiting to decide to attend you.” [TZA-6, R5]

Human and Material Resources

The resources (human and material) necessary for implementing ANC at the health centre.

ANC uptake is more likely when participants know that services and medications will be consistently available.

Key issues described by participants:

• Staff shortages

• Medication stock-out

• Lack of obstetric equipment and other materials (ANC cards)

There is no water supply at the facility. When you go there to deliver you need to bring a bucket of water with you. [TZA-4, R4]

“I disliked the waiting time. You go there and wait for many hours and the nurse says they are going for tea break.” [TZA-8, R1]

“They did everything for me but there is only one midwife so we have to be delivered by the traditional birth attendant” [GHA-4, R2]

“When you arrive at the clinic they tell you that the [ANC] cards are finished and that you should buy a notebook. Then they use that notebook to record all your details until you give birth.” [TZA-3, R1]

“Some of the nurses would also give you prescriptions to go and buy certain drugs when you don’t have enough blood [have low iron in th blood], meanwhile they have the drugs which they can give to us and we also have no money to buy them.” [GHA-3, R7]

“Sometimes, even if you have paid for the community health insurance (CHF), when you go to the facility they tell you to go outside to buy medicine, so the CHF is useless.” [TZA-3, R5]

Health Centre Practices

The operationalization of health systems policies, as well as specific approaches to scheduling and delivering services; interpretation of policies and rules may vary from one healthcare provider to the next.

ANC uptake is more likely when frontline workers are interpreting policies and practicing in a non-discriminatory manner, and when health centres are known to operate smoothly.

Key problematic practices described by participants:

• Partner testing for STIs (mainly HIV) at first visit (Tanzania only)

• Illegal fees and inconsistent provision of medications

• Opaque or unfair scheduling and triaging practices

• Problems with referrals and transfers

• Only conducting ANC clinics on specific days rather than on all days.

• Lack of privacy and confidentiality for adolescents

“When I went for ANC she asked me to sit down and I waited. But later I realized that she was attending to people who came to meet me while I was still sitting. Do you think it is good? So I dislike her a lot.” [GHA-3, R4]

“I remember that if you are new there and you are being given a card, you will not be given a drug until you have done labs and taken the scan. So no matter how many times you come there they won’t give you the drug unless you go to [The referral hospital].” [GHA-1, R8]

Sometimes we have to be transferred to [a larger facility] where we have no money for the service" [Gha-4, R2]