Assessing the experiences of teenage mothers in accessing healthcare in Rwanda | BMC Public Health

The primary aim of this study was to identify the major interconnected themes related to the health care seeking experience of teen mothers during their pregnancy in Rwanda. The four overarching themes emerged were related to the challenges in accessing healthcare services due to the overall system, the judgement they faced at various levels, the financial difficulties, and the need of mental health support.

The data collected in the study represented a sample teen mothers’ views and experience. To a larger extent, the results showed how unprepared the society as well as the teenagers themselves were when it comes to teenage pregnancy.

The CBHI was introduced in 1999 in Rwanda as a vehicle to achieve universal access to health care (MINECOFIN, [31]). It is available to all Rwanda citizens, especially for those working in the informal sector [ILO Social Protection, [21]; Lu, Chin, Lewandowski, Basinga, Hirschhorn, … & Binagwaho, [29]). CBHI has achieved remarkable accomplishment towards effective universal health care and has made Rwanda the most advanced country in Africa regarding universal health care [(Evans et al. [15]; , Lagomarsino et al. [27]; , Saksena et al. [47]),Binagwaho, Farmer, Nsanzimana, Karema, Gasana, de Dieu Ngirabega,… & Drobac, [3]; (Makaka et al. [30]),Nyandekwe, Nzayirambaho, & Kakoma, [39]; (Sanogo et al. [48])). However, this study reviewed some gaps within the system.

Many participants highlighted a challenge in accessing health care services for themselves and their babies due to inaccessible community-based health insurance. The current CBHI system focuses on household registration as a unit. Teens who were disowned by their families have no means of registering and eventually being left off by the system. The Rwandan government needs to re-evaluate the existing CBHI system so that this vulnerable group has more autonomy in purchasing health insurance, instead of being completely dependent on the decision of the head of household.

One participant mentioned about the requirement of an authorization letter from village heads also created an extra layer of challenges for teen mothers to access health care. We could not verify the magnitude of this issue, nor could find out the origin or actual rationale for such practice. However, the execution of such practice could be a barrier itself. According to General Medical Council (General [18])of United Kingdom, the patient confidentiality is an essential part of good care and must be respected. This confidentiality applies to both adults as well as to children or young persons. While fully supporting the principle of confidentiality and privacy must be respected, we also recognize many habits and preferences about privacy and confidentiality is often culturally informed (Estroff and Walker [14]). It would be easy, yet risky, to recommend eliminating the practice of acquiring authorization letter from village heads, without fully investigating and understanding the rationale behind that traditional practice. Further study to understand the implication is needed. Another barrier to access to healthcare was specifically related to this age group of our study participants. In Rwanda, the legal age to be get an identity card is 16 years old (NIDA [38]). Without the identity card, pregnant teen under the age of 16 would not be able to access any government services.

At the services delivery level, ANC is typically and traditionally offered to couples expecting babies – as that’s the assumed clienteles. It is understandable that the materials were all catered to such audiences. As this study results have reviewed, this group of patients were left out from the services, either due to the materials were not relevant or appliable to their situations. There is a need for the health programs to update and modify the information, training, and materials to become more diversified and inclusive.

As indicated in many previous studies, teens with pre-marital pregnancy often faced stigma (Atuyambe et al. [2]; , Dlamini [10]; , Ellis-Sloan and Ellis-Sloan [12]; , Jones et al. [23]; , SmithBattle [51]; , Wiemann et al. [56]). Our study results showed the stigma they faced came from many sources – from being disowned by their family members, to being judged by health care providers and other pregnant women at the health facilities. All these have created a sense of both guilt and shame to these teens. In addition to the abandonment from their parents, many were also abandoned by the men impregnated them. Many studies have suggested sensitivity trainings should be provided to health care providers to various clinical situations (Douglas [11]; , Senanayake et al. [49]),Isano, Yohannes, Igihozo, Ndatinya, Wong, [22]). It is arguably that such training would not be sufficient unless it is extended to the larger community. Acceptance is not only limited to the teens, but also to their families. Many families disowned the teens as the pre-marital pregnancy brought shame and disgrace to the families (Ruzibiza and Ruzibiza [45]),Saim, Dufåker, Ghazinour, [46]). Such abandonment at a time when they needed family support the most, subsequently caused many challenges to both the teen mothers and babies in receiving proper health care.

Many of our participants also mentioned that the men impregnated them were no longer in any part of their lives. The act of fleeing from the responsibility directly put the teen girls in all kinds of hardships from social stigma to financial burden. Further investigation is required to identify appropriate interventions. Potentially, a multipronged solution including education, policy and punishment, would be needed if sexual coercion was involved.

Getting pregnant at a young age can be scary for women, especially if they were not married. Many teen mothers found the CHW helpful, as they provided them support, encouragement and accompaniment to seek care at health facilities. The actions of CHWs were greatly appreciated by the participants. Such best practice should be promoted. At the same time, many respondents mentioned that they did not go back to the health facilities after the poor treatment they had received during the first treatment; highlighting the importance of how health care providers’ attitude could affect the potential health outcome of the teen mothers, regardless the quality of services. Health care providers awareness on this must be enhanced.

The study results also highlighted a few aspects of supports were missing in the care of teen mothers. The findings showed that teen mothers face numerous challenges that place demands not only on their physical health, but also on their mental wellness. The need for mental health support for most mothers was not addressed at most health services. The positive experience of our respondents from the peer support group served as an example of the importance of providing them a venue to discuss freely, feel accepted, share experience and know they are not alone (Bunting et al. [5]; , Klima and Klima [25]). Such practice should be encouraged or even institutionalized by health facilities. Mental health currently is not part of the maternal services and should be considered to be incorporated as a routine service. Mental health wellness should be routinely checked at the ANC. In addition, family and community are important sources of social support (Evans, Katz, Fulginiti, Taussig, [16]). Further supporting the importance of sensitivity training to the larger community in promoting acceptance. The need of providing them with a sense of acceptance, socialization, and stability are important (DeVito and DeVito [9]).

Financial challenge is not only a common barrier for teen mothers to access health services, but to achieve overall health in general. Caring for their newborns with virtually no financial means was challenging. Even if they had access to CBHI, they still faced difficulties in paying for the remaining 10% designed by the system on items not covered. In addition to health care cost, they also need to meet the basic needs of their infant as well as theirs, including food and shelter. Government should consider incorporating more financial supports and career opportunities to this particular group of citizens not only to ensure they can access health services, but also optimize their development as well as their children’s.

Despite the physiologic immaturity of the girls, the stigma they faced from different aspects of the society, the financial hardship, they managed to carry their pregnancies to term and did not resort to abortion. Showcasing how resilient they could be. They represent a group of citizen who could be productive members of the society if proper investment and support are provided. Evidence has shown investments in the health, education, and development of the young people can have long term benefits throughout their lifetime for the individuals as well as the society for a strong national polity and economy (UNICEF [54]).

Limitations

This research provides data for understanding the experiences and challenges faced by teenage mothers when seeking health services in Rwanda. However, it is a qualitative study, its results are not mean to generalize and represent all teenage mothers’ experience in Rwanda.

The study also has a potential selection bias, since the participants were contacted through an NGO, making them to be more likely to already have better access to healthcare services compared to those who are not supported by any NGO. And we could not eliminate the possibility of recall bias.