Table 4 Social & Cultural factors influencing ANC uptake among adolescents

Family and social support

The degree of involvement of other household members and parties associated with the pregnancy.

ANC attendance is more likely in situations where there is a male ‘taking responsibility’ (financially) for the pregnancy or where there is support from family members. This includes financial and psychosocial support.

“If she has someone who supports her then she will be able to go, if not she cannot go. There are some who are unable to go because when they got pregnant they were sacked from home by their parents. So when it happens like that she has no helper who will support her financially to attend ANC.” [GHA-2, R6]

“It was my partner who gave me money to begin attending antenatal.” [GHA-2, R4]

“Sometimes too your husband does not have money to give you and you have no other place to get money from. You will have to wait for him to get money from wherever he can get if from.” [GHA-5, R10]

“I was living with a sister of mine who has delivered two children. So even when my mother mentioned it, I said I was afraid and all that. She was the one who advised me that they were good and they will give me drugs for me to deliver safely” [GHA-1, R1]

Social referents

People in the individual’s life with the power to influence the individuals’ perceptions of a behaviour.

ANC uptake is more likely when the individual has social referents who believe ANC is important.

Types described by participants:

1. Formal authority figures

2. Role models with relevant lived experience

“It is because she [her mother] is the one who gave birth to me and knows what happens during pregnancy so that is why if she tells me to go, I would go.” [GHA-2, R2]

“Our fathers have never delivered a child before and they know nothing about pregnancy; that is why if they tell us to go we are less likely to go.” [GHA-2, R1]

Normative Beliefs

(Social norms)

An individual’s perception of pressures to perform (or not to perform) a behaviour based on prevailing ideas, culture and value systems.

ANC uptake is more likely where normative beliefs encourage ANC attendance and are tolerant of adolescent pregnancy.

Participants described prevailing beliefs/norms which impacted ANC use:

• Best source of care (western vs. traditional medicine)

• Acceptable age for motherhood

• Who ‘ought’ to attend ANC

• Stereotypes of nurses’ personalities

“During the older days there was no hospital so our mothers never went for antenatal. But now with modernization there are hospitals, so those who refuse to go are still living in the past” [GHA-3, R3]

“For some people they take local medicine at home. So they know that even if they do not go to the hospital, because they take local medicine from home they will give birth [at home]” [GHA-1, R6]

“[Our peers] say it is stupid that we are going for antenatal. Because the new crop of nurses they are young so if you go there and you are young they insult you so they tell us not to go but take medicine from home.” [GHA-1, R6]

“Some of the girls also say that they’re already pregnant and they only must be sure their baby kicks in the stomach. And so God will take care of them until they deliver. They also have the notion that even if they go for those sessions, the midwives only give them lots of drugs which do not help them in any way.” [GHA-6, R3]

“We are females, but there is an age you must first attain. When we were going to school we were taught the age we must attain first before we get pregnant but for us we didn’t attain that age… that is why we are shy.” [GHA-5, R5]

Stigma

Negative stereotypes perpetuated by individuals’ opinions and behaviours.

ANC uptake is more likely where there is lower stigmatization of adolescent pregnancy (or where there are positive social referents challenging the prevailing stigma on behalf of the pregnant adolescents).

As described by participants, main sources of stigma arise from:

1. Peers and social circle

2. Health care providers

"Sometimes, if we go for the test and it is confirmed that we are pregnant and we go back home and tell our friends, when we are passing by our friends will be murmuring saying, “look at this girl she is not grown and she is pregnant and look at what it has done to her.” [GHA-5, R4]

“Sometimes too they [healthcare providers] complain, saying that we are not grown and have gone following after boys then we get pregnant we come and bother them at the hospital” [GHA-5, R4]

“Because the elderly are around [during ANC clinics] they keep on staring at you and then you begin to feel embarrassed” [GHA-4, R3]

“Some of the nurses are rude and ill-mannered. There is one at [the clinic], because of her I don’t like going there, they look down on you and they think [more] highly of themselves than others.” [GHA-3, R4]