Individual level factors.

Among the 30 adolescent girls who took part in both phases, sixteen of them were below 18 years of age and the rest were between 18–19 years. Only one girl had completed higher than the secondary education and eight of them had primary or lower level of education. The majority of the girls had a limited knowledge on the maternal health care (ANC, hospital delivery and PNC care).

We observed that the girls’ perceived need of health care during pregnancy and childbirth influenced their use of skilled maternal health services. Most of the adolescent girls perceived pregnancy as a normal phenomenon and did not think of check-ups (i.e. ANC, PNC) or hospital delivery as necessary unless they suffered from any complication.

‘I didn’t go anywhere because I didn’t have any problem. Ruma apa (a CHW from BRAC) checked each month’

- (16 years old girl delivered at home, IDI second phase)

Almost all the girls first tried to give birth at home and when it failed, they were taken to the nearest hospital for delivery. Girls’ intention to deliver at home was because of the perceived threat of performing a C-section at the hospital and its potential consequences. During the first the interview phase one of the pregnant adolescent girls, who finally delivered her child at home, mentioned the following:

There are a lot of problems if you go to the hospital, if you do a C-section there is a problem in moving. There is a problem in eating, for three to four months you can’t do any heavy work’

-(17 years old pregnant adolescent, IDI first phase).

Three adolescent girls mentioned that they felt shy going to the hospital as there were many people at the hospital. They felt uncomfortable at the thought of being seen by male doctors in the hospital.

‘It will be better if it happens at home. It is so rush out there, there are problems and also men will be there. It is better if nurses are there to do it. I heard male doctor will be in a medical (hospital or clinic) it makes me feeling shy!’

- (18 years old girl delivered at home, IDI during the first phase)

There are a lot of people at the medical, I will be ashamed. The doctors see your body. A lot of people see your body. That’s why I didn’t feel like going to the medical. That’s why I want to deliver at home’

- (15 years old pregnant girl, IDI during the second phase)

The majority of the adolescent girls expected to have family members around them during the time of delivery. Therefore, they preferred home delivery to have direct support from the family members. Adolescent girls had little decision-making autonomy regarding maternal health care because they depended on the decisions of their husbands or parents-in-law (especially mothers-in-law) to seek maternal health care. When we asked about the uptake of ANC, one of the adolescent girls replied that:

‘He [the husband] said you have seen the doctor once so there was no need to go again. Can you see how the house is empty now, it was also empty then…Who would do the household work or take care, and then they didn’t let me go back. So I stayed home’

- (18 years old girl who experienced a neonatal death, IDI first phase)

Interpersonal and family level factors.

Use of maternal health services was shaped by the family tradition. In most of the cases, family members demanded that pregnant girls delivered at home with the help of relatives and older women who had experience in childbirth. When a girl failed to give birth at home, she was taken to the nearby hospital. One of the adolescent girls said:

‘My pain started in the evening but I didn’t realize it. At about 12 am in the night the pain was extreme, then I realized. My husband asked me to call my mother and say that my labor pain started…I tried to push a lot but the baby was not coming out. I suffered a lot and tried till morning. At dawn they took me to the medical’

- (17 years old who recently delivered at hospital, IDI second phase)

A gynecologist who had been working for more than six years at the Rangpur Medical College Hospital confirmed such experiences in a KII:

‘I would say it (home delivery) is basically happening as a part of their tradition in the family. They do not prefer to go to a doctor or taken care by nurse as they have birth attendance and they prefer to welcome this baby within their environment’

Decisions regarding the use of ANC, skilled birth attendants at delivery and follow-up through PNC were influenced by different family members. Four types of family members were found as most influential in that aspect, i.e. husbands, parents-in-law (especially mothers-in-law), girls’ parents and senior relatives.

Husbands’ perception, beliefs and knowledge about maternal health and services availability were vital on the decisions of using skilled maternal health care for their wives. While asking about the use of PNC, one of the adolescent girls mentioned:

‘My husband said ‘let’s go to the homeopathic doctor and by the blessing of Allah the baby will be well’. Whatever my husband says turns out to be right. So we went there’

–(18 years old girl recently delivered at home, IDI second phase)

Five of the girls went to their parent’s house when pregnant and expected to deliver there, but most of them wanted to delivery at their husbands’ house. Other than husbands, mothers-in law were found to be the most influential figure in decisions related maternal healthcare. They were the first contact person for the majority of pregnant girls during pregnancy and delivery.

‘I was having pain. My mother in law realized and asked me what happened. I told her that I was having pain. My father in law went to get a rickshaw van. But before he came the baby was born at home’

-(17 years old adolescent girl recently delivered at home, IDI second phase)

This was confirmed by the KII participants. One of them also stressed the important role of mothers-in-law during pregnancy and delivery care in rural Bangladesh. Mothers-in-law also were not aware about the benefits of skilled maternal health services and their traditional perceptions on maternal health led them to not to allow their daughters-in-law to seek ANC or hospital delivery.

‘It is because mothers-in-law are the decision makers, caregiver and they believe that during the time of their pregnancies none of these things are important. Lack of awareness is the main cause for this. Our girls have no means of freedom of speech…. I would not say poverty is the main reason….. Here, they are offered to get treatment almost for free. It is observed that 98% of families do not forget to take TT (tetanus toxoid) vaccine whereas when it comes to antenatal care they seem reluctant to accept it’

-(a gynecologist from Rangpur Medical College Hospital, KII)

Participants’ parents and other older family members (i.e. sisters-in-law, grandmothers) also influenced adolescent girls’ use of maternal health services. During the time of delivery, older women such as grandmothers or aunts (husband’s aunt) often assisted in the delivery process. One of the KII participants described it as follows:

‘Every family member has the role in maternal health care but in Bangladesh, mothers-in-law have the strongest influence. Look, if a teenage girl gets married the groom’s age in an average will be 3 or 4 years older than her thus; he is also not the decision-maker and not someone who is able to guide his wife…’

(NGO official, KII)

Community and social level factors.

We included the role of neighbors and community health workers, poverty-related factors, socio-cultural norms, traditional practices, religious and spiritual beliefs under the category of community or social factors influencing adolescent girls’ maternal health care-seeking behavior.

Most of the adolescent girls said that they received home-based ANC through BRAC’s community health worker (i.e. SK) as shown by the following quote:

‘Yes, when I was pregnant then they (BRAC’s SK) used to come and check me. Since I was 2 months pregnant health workers used to come… They used to check everything. They used to come every month’

- (17 years old girl recently delivered at public hospital, IDI first phase)

Another girl mentioned the role of LAMB community health workers. However, none of the adolescent girls mentioned community health workers deployed by the government [i.e. family welfare assistant (FWA)].

‘She (health worker) works at LAMB, she asked me to go to the clinic at Shekherhat (name of a place where the LAMB health center is) for check-ups, and I went there every month and did check-ups’

-(18 years old girl delivered at the hospital, IDI second phase).

Poverty was one of the reasons decisive for home delivery. Adolescent girls thought that going to the hospital might be expensive. Therefore, they preferred to give birth at home and to save the money for the expenses of the baby.

Religion played a very important role for home-based delivery and seeking care from religious scholar, instead of going to seek services from skilled health care providers during pregnancy and post-partum. Only two respondents were Hindus and the rest were Muslims. Muslim families did not want women to be seen by male healthcare providers.

‘They [family-in-law] are religious people. When a female patient goes to the hospital, there are male doctors checking them. That’s why he (husband) said it is better to deliver at home’

-(18 years age girl recently delivered at home, IDI second phase)

A community health worker from BRAC explained during a FGD that:

‘There are some Haji (who follow religious ritual from Macca, Saudi Arab) families who said, “We are haji people, why would some other men touch our wife?” That’s why they don’t take them to the health care center…this is bigotry’.

Cultural and spiritual beliefs aggravated the use of traditional and spiritual healers. Health problems of pregnant girls and newborns were often considered as the act of evil spirits. Such beliefs and myths perceived by adolescent girls and their family members inspired girls to seek care from traditional and spiritual healers.

‘Because my first baby died so everyone said there was an evil spirit on me. Then I got my house purified (ghor bondo kora). Me and the baby (newborn) got tabij (holly pendant) on our neck. That’s all’

- (18 years old adolescent girl recently delivered at home, IDI second phase)

When we asked about the care during pregnancy, one of the adolescent girls said that:

‘After taking the holy pedant I don’t go anymore, so I didn’t go to the doctor’

- (18 years old girl who’s baby was died, IDI second phase)

Organizational and health system level factors.

Availability, accessibility (i.e. distance, cost) and quality of maternal health services were grouped under organizational and health systems level factors. Organization and health systems level factors also played an important role in the use of maternal health services by adolescent girls.

In terms of government health facility, the government of Bangladesh established Community Clinics (CCs) for every 6,000 population at ward/village level to provide primary health care services including ANC, vaginal delivery and PNC services almost for free particularly to the poor. However, it was found that often a community clinic was not equipped with basic instruments for ANC demotivating pregnant girls to go there for ANC check-ups. One of the community health workers from BRAC emphasized this during a FGD:

‘Sometimes BP (blood pressure) machine gets damaged in the community clinic. After convincing a pregnant woman for the check-up from the clinic, if they can’t perform the check-up due to the damage of the machine they don’t want to go there further thus they feel so irritated. They say, “You told us to go there for check-up but they didn’t do any check-up, we won’t go there anymore…”

- (BRAC SS, FGD)

Moreover, availability of services and lack of attention by the health care providers (i.e. family welfare assistant, health assistant) at the community clinic were also mentioned by a BRAC CHW during the time of FGD.

‘In some cases if we take pregnant women to the satellite clinic, sisters don’t want to perform check-ups. They say, we are in rush so come on another day…have to go to another place so, come later!’

- (BRAC SS, FGD)

Availability of health centers and accessibility were also mentioned as the reason for not seeking ANC, as illustrated by the following quote from a CHW of BRAC in a FGD:

‘Health care centers are very few. Community clinic is too far. Satellite clinic is functional for only two days in a month. If there is one more clinic day in a month, that will be better. If we combine all these, then good care will be ensured. Have to increase CSBA training’

Five girls mentioned the low quality of the service provided by public facilities as the major reason for not choosing the public hospital for childbirth.

Two adolescent girls said that they preferred private hospitals because of its nature of fast service delivery although it was costly compared to the cost of the services provided by the public hospitals. One of the FGD participants (CHWs) mentioned that:

‘It (private facility) costs. But they work instantly. In a government hospital there is too much rush. Sometimes they say, Saturday and Sunday are day off… But for some patients it is already time to deliver a baby but they don’t come…as a result baby die.’