The aim of the study was to explore how the EVD outbreak influenced the use of health services among adolescent mothers who were pregnant during the outbreak. This study therefore attempts to shed light on attitudes, perceptions, experiences and barriers participants faced in attempt to health-seeking during Ebola.
The Three Delay model recognises the complexities and interrelated factors that create barriers to health-seeking. Although the original model was a framework for understanding obstetric emergencies and the factors contributing to maternal mortality, it is evident that the delays are not always limited to emergencies during pregnancy but can also be applied to disease outbreaks. Additionally, the model does not consider that in the absence of health complication a woman might still experience delay in seeking care [18].
Categorising the contributing factors in this study according to the Three Delays Model helped determine where improvements could best be made to reduce the risk of maternal mortality. The results from this study contributed to the model by indicating how an external factor such as the EVD added new complexities to each of the three delays.
There were several factors affecting adolescent mother’s health-seeking behaviour, but the association between these factors was not always linear. Rather some factors may have affected more than one delay point. The barriers posed by fear of contracting the EVD from both participants, their communities and health professionals may have also been an underlying factor, in (delay 1) deciding to seek care, as well as affecting the ability of health staff to deliver adequate care (delay 3). Moreover, the model does not regard maternal age as a factor that could potentially become a barrier to health seeking, considering that adolescent mothers statistically are proven to be at a higher risk of maternal mortality [5].
First Delay: Fear Of Ebola
Central to the findings in this study was the way in which fear was constructed during the EVD outbreak, which influenced the behaviour of participants.
Similar studies conducted in Sierra Leone identified fear as a direct barrier to health seeking behaviour [6, 21]. This also led to delay in health seeking as participants would arrive at the facility after conditions had worsened, leading to poorer outcomes [8].
Participants also discussed the dilemma between seeking a TBA or giving birth at a health facility, as they were aware of the risk of delivering at home without qualified assistance and supervision could lead to complications and result in a fatal outcome.
According to UNFPA report, pregnant adolescents are less likely to seek medical assistance because they have more access to TBAs and community health workers. Adolescent mothers in low income setting also relied more on TBAs which could explain the general norm and tendency in Sierra Leone, even before the outbreak [22]. Similarly, a Liberian study found that births in public facilities decreased from about 54–27% during EVD, because people were afraid of government hospitals. The common perception was that Ebola was being contracted in public clinics and hospitals. This study also found a decrease in supply as many health care workers did not want to treat pregnant women due to fear [23].
Prior to Ebola, other factors such as cultural norms, beliefs about disease and perceptions on the quality of care provided, household power relations and social networks dictated health seeking behaviour [3]. These factors subsequently exacerbated during the epidemic. The loss of relatives and community members also added feelings of mistrust towards health care facilities as they failed to provide adequate care and treatment, which became another reason for not seeking care.
Second delay: Limited Access to Health Care
Apart from the lockdown and quarantine, lacks of income and road blocks were seen as significant barriers to accessing health care. Evidence shows that ambulances were available for referral prior to Ebola, but the numbers of vehicles were limited and not always in working order. When ambulances were available, the poor infrastructure was another existing challenge for referring women [8]. Findings revealed that adolescent mothers had better access to services prior to Ebola, which did not require payment. However, the most important constraint was still the question of poverty, and the inability to provide finances for transportation, medication and health related services [22]. From the FGDs it was apparent that many of the adolescent mothers went into extreme poverty after losing relatives. Participants discussed how economic limitations were common in their communities during the outbreak leading adolescent girls to engage in transactional sex out of desperation to survive. Similar behaviour was identified in other studies, where women and girls engage in transactional sex when faced with vulnerable structures or humanitarian crises that were associated with displacement, financial strain and limited livelihood opportunities [24].
Interestingly, none of the participants openly confessed being involved in transactional sex and while discussing the topic they would refer to transactional sex as “doing bad thing”. The moralising discourse was mutually and implicitly understood in the discussion, as most participants would use the same phrase to address the topic. The phrase also adds emphasis on the moral shame connected to prostitution and selling one’s body. Transactional sex was seen as prominent in their communities and during Ebola the phenomenon had increased significantly, resulting in the outcome of unintended pregnancy, which ultimately perpetuating the vicious cycle of poverty. It was unclear if the unmarried girls in the study had been impregnated through transactional sex, sexual violence or by their boyfriends. Previous reports from Sierra Leone revealed, that girls commonly engage in both transactional sex while also having sex in a committed relationship [14].
Third delay: Experience at Health Care Facilities
The discriminatory and disrespectful behaviour from midwives and nurses caused adolescent mothers to avoid seeking health care, combining elements in the third delay (the quality of care) with the first delay (previous experience with health care providers) [18]. However, findings revealed that the quality of care was not only determent by participants’ personal assessment of service delivery; perceptions were also shaped and influenced by the experience and opinions of community members. In Uganda, health care providers were also described as verbally abusive, insulting, harsh intimidating and judgmental towards adolescent mothers [25]. Evidence reports that the perception of adolescent pregnancy out of wedlock in most sub-Saharan African settings are negative [3, 23, 25]. Young single mothers are in most communities considered to be less respectable, a disgrace to their parents and they are deemed as idle and promiscuous, usually subjected to shame, gossip and rejection in their community [25]. These findings are aligned with a previous study from rural Sierra Leone, where adolescent mothers were more likely to be stigmatized and experience additional barriers [25].
The inability to correctly diagnose the Ebola virus especially during the beginning of the epidemic was also an interesting finding. The fear pregnancy symptoms being mistaken for Ebola symptoms caused participants to avoid seeking. Several African countries have suffered from infectious disease spreading rapidly and fatally, particularly during and after civil war. HIV/AIDS, malaria, and tuberculosis are already prevalent in Africa and also require constant monitoring. Previous research has suggested that improving a country’s health infrastructure post-conflict can increase government legitimacy and economic development [26]. The hidden fees and out-of-pocket payments participants encountered at the health facility was also a barrier to receiving quality healthcare. This barrier was also found in among the rural population in Sierra Leone during Ebola [25].
While some participants bribed their way through the system others sought to traditional medicine and other alternatives. Out-of-pocket expenses for unexpected charges raised concern among participants, causing confusing as to whether or not the Free Health Care Initiative was still available. In Liberia evidence revealed how pregnant women and women suffering from obstructive labour were also refused treatment from health care facilities during Ebola because they were unable to pay the required health charges. This eventually led to some women dying from maternal mortality [3].