Participants’ characteristics
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FGD (description and
number)
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Total number of participants
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20
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Age range
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15- 23 years
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Marital status
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married (2)
unmarried (18)
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Educational status
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completed primary level (17)
no education (3)
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Place of delivery
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health facility (5)
traditional birth attendant (15)
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Contact with health facility
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only during pregnancy (6)
only post pregnancy (11)
both during and after pregnancy (3)
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Personal loss due to Ebola
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loss of relative or baby (6)
no loss (14)
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The data were grouped under categories within the three delays framework. The main themes reflect a combination of ‘The Three Delay Model’ and the key subjects that were discussed in relation to each delay. The first theme underlines how fear on a community and individual level influenced participant’s decision to not seek care. The second theme highlights how an enforced measure such as quarantine and fear of certain transportation became an additional barrier to health care access during the outbreak. The third theme describes the different encounters participants had with health care workers at the health facility and how this negatively affected their behaviour towards health-seeking. Illustrative quotes, aimed at representing the main findings of the theme are presented in italics.
FIRST DELAY: FEAR OF EBOLA
Fear in the community
Some participants had stopped seeking health care at hospitals and clinics after giving birth, due to fear. The adolescent mothers discussed how the fear of Ebola in the community was a major challenge, which caused a general sense of discouragement toward health-seeking. According to the adolescent mothers, the reactions to the outbreak, the circulating rumors and misconceptions about Ebola were most prominent at the beginning of the outbreak, but speculations reduced as the number of Ebola victims started declining. Participants were confronted daily with news of the outbreak and unfortunate experiences of loss in their communities. Some participants had been skeptical of the EVD describing how the fast spread in their communities awoke superstition and conspiracy theories, which shaped their perceptions toward health care facilities. When participants were asked what community, members said that discouraged them from health-seeking, they supported each other’s comments by saying:
FGD3, P3:“They encouraged us to give birth at home. Because if you go to the hospital you won’t come out alive.”
FGD3, P1:“They will leave you there (in the hospital) until you die.”
FGD3, P4:“If they come and take you with the ambulance and you don’t return then they (members in the community) will believe it is an Ebola case.”
FGD3, P5:“Some areas always had bad rumors, if you go to the hospital for two or three days the community will say Ebola took you away.”
The fear of contracting Ebola led to many of the participants preferring home-births by traditional birth attendants (TBA), in spite of many TBAs refusing to provide care during the epidemic, due to the lack of protective equipment and fear of contracting Ebola. Home delivery was said to be encouraged by people in the community, due to preconceived notions and ignorance about the transmission of the EVD. The decision to seek health care or deliver at home was described as a terrifying dilemma many participants faced during their pregnancy. Death was viewed as the ultimate outcome which evoked feelings of distress and hopelessness.
Some of the mothers who had a home-delivery said they had not sought care after their delivery because they were scared, while others participants had avoided going to the hospital for a whole year, due to the fear of contracting Ebola.
FGD3, P3:“People were scared, even if they don’t get the sickness but they will die of fear because they refuse to go to the hospital. If you feel pain you’ll be scared that if you go to the hospital you will die. You will end up being so scared you deliver at home and then you over bleed, you die.”
When personal loss leads to fear
The experience of personal loss was another barrier to seeking health care. The loss of friends, close and distant relatives was described as discouraging, scary and traumatizing experiences, that not only led participants to grief but also increased the fear of losing their own lives. Some participants explained how they were separated from relatives due to loss, while others moved in with extended family outside affected areas out of fear of contamination.
FGD2, P3: “Like me, my sister she had the same problem. When we went to the hospital with her they would not give her treatment and then she lost her life, so we were all scared of going to the hospital because she lost her life. Anyone who went there to visit her they would send them away. She was so sick that God took her life. So we were so scared of going to the hospital, this sickness that came scared us all (…)”
Participants explained how their experience of personal loss made them live in fear. Witnessing the sudden death of a family member up close was justification for participants’ mistrust of the health system. The adolescent mothers described how it made them feel unsafe in their community, especially after witnessing Ebola ambulance entering their neighborhood and spraying chlorine and unknown liquids.
SECOND DELAY: REACHING FACILITY
The financial burden
The lockdown had dire consequences for people with low socio-economic status who were already struggling to survive as indicated in the quote below:
FGD4, P4: “The reason why I was suffering more was because of the lockdown, at that time my husband was a driver and cars were not allowed to go anywhere, and if he cannot get customers how should we get by.”
During the three-day lockdown participants were said to have lost their income because they were cut off from earning a living and subsequently unable to access health care, food and water. Local and weekly markets were also banned, affecting participants with local businesses. The government also shut down small facilities, converting hospitals and clinics into Ebola treatment centres, furthering the distance to health facilities, subsequently worsening the conditions for pregnant women, who already faced limited access to adequate health care.
For some participants, transportation played a significant role in the perceived spread of the EVD. Therefore, the continuous and rapid spread of the EVD was of great concern for many of the adolescent mothers both during and after their pregnancy. As a result, some participants preferred walking or taking a motorbike instead of the local boda boda (mini-bus), which on one hand was considered to be a more affordable option, but on the other hand were usually more crowded. Local drivers also refused to take passengers from certain areas in Waterloo with increased spread of EVD or high death rates, which became a major constraint for some participants, forcing them to walk for miles before being able to access transportation.
THIRD DELAY: EXPERIENCE AT HEALTH CARE FACILITIES
Health care workers’ behavior towards adolescent mothers
One of the main challenges participants identified was the unfriendly attitude among health care workers. Adolescent mothers were often met with unwelcoming and negative attitudes among health care workers. This behaviour discouraged the adolescent mothers from utilising health facilities, which led to them seeking aid from traditional birth attendance and private facilities or just staying at home when ill, as described in the quotes below:
FGD2, P3:“Because we saw the type of treatment people received so even if you go for treatment you will be discouraged and go back, go sit at home, because you will see how they treat the next person.”
FGD1, P5:“When you go to the hospital the nurses, when you want to sit down they will yell at you, they will yell at you as if you are a mad person. When we go to the hospital they treat us badly during Ebola.”
Moreover, a few participants suggested that health care workers’ behaviour had worsen during Ebola, due to their fear of contamination. The young women were frustrated with no longer being examined properly. Nurses no longer touched pregnant women without gloves or examined or auscultated the fetal heart in order to identify the fetus positioning or gestational age. It was reported that fear among nurses and midwives were strong, because not all facilities had received training, and some did not have access to protective equipment such as gloves and masks at the beginning of the epidemic:
FGD1, P5:“So when I went there they said that right now they do not touch people, so I should go and sit down for a while, so I decided to return home. When I came home, I did not go to the hospital again, because I have tried not once but twice and they do not want to touch me, so I do not want to go”
All the FGDs had reports of health care workers verbally insulting and stigmatising the adolescent mothers because of their age. The participants, nurses’ viewed adolescent pregnancy as an intentional act that the girls chose instead of completing their education. It was indicated that this behaviour and perception existed before the outbreak, but it exacerbated due to the increased level of adolescent pregnancy.
FGD2, P5:“(….) The first thing she said (referring to the nurse),“you children now a days when the put you to school what do you come with, what is the profit you bring to your parents, only pregnancy” (…)”
Financial barriers to health
Participants were aware of the Free Health care initiative the government had implemented for children under five years of age and lactating mothers, but according to some of the adolescent mothers, the initiative was affected by the reallocation of health care funds, prioritising health services for the EVD. Therefore, health care workers were still charging patients for health care expenses. Due to their low socioeconomic background participants were unable to pay for the unexpected charges, which became a common reason for not seeking care during this time. One participant mentioned how health workers would try to sell drugs to them for their financial gain and many times the only alternative they had was to buy traditional medicine.
FGD2, P2:“Then they prescribe drugs for you to go and buy and as soon as you leave the hospital they call you back “come we have drugs for sale, come we will sell it to you ”(...) They deal with money at the hospital right now.”(…) “they do not give you any drug that is the thing, we have to take the children to the pharmacy to provide drugs for them the country way (traditional medicine) wash the child with country medicine.”
Socio-economic inequalities were also discussed and several participants described how they were left largely unattended because they failed to pay the required fee and how partiality was shown to those who had the means to provide the charged fee. Paying out-of-pocket costs for medical expenses was reported as a common phenomenon, especially during Ebola. At some health facilities nurses required patients to pay a fee whenever they visited, demanding that they “greet the table”, which was an expression commonly used when asking patients to pay user fees before being attended to;
FGD2, P1:“When you go to the hospital they will tell you to greet the table (...) They say “if you do not greet the table we won’t attend to your child”. So if you don’t have that money it does not matter how long you sit there they won’t attend to you. You just have to return home in peace. So that is why if you do not have money you don’t go to the hospital, you will sit at home.”
Participants described how health care workers were hesitant to expose themselves to potentially infectious bodily fluids and therefore they were more kind to patients if they could document a negative Ebola test before receiving treatment. At the beginning of the epidemic the test only cost 17,000 Leones equivalent to 2.35 dollars, which was considered very expensive for those living below the poverty line. The cost for the Ebola screening gradually increased during the outbreak and some participants ended up paying 70,000 Leones, equivalent to 10 dollars.
FGD3, P2:“If you do the test (Ebola test) and you have done everything they will speak to you nicely. As long as you have done the test and you can show documentation saying you have done the test. But the test is very expensive to take, sometimes they will say 70,000 Leones, and not all pregnant women have that kind of money.”
FGD3, P3:“If you have or if you don’t have money, and even if you say you don’t have money, they will tell you to go and find money “ go to the man who got you pregnant so he can pay the 17,000 Leones so you can do the test”. Some people cry because of the condition.”
Women who did use the service before Ebola acknowledged that the general care they received was of better quality, because the queuing system was in order before with a “first go, first served” policy and one was almost guaranteed to be seen and cared for by health professionals. As expressed by participants, nurses and midwives were considered less compassionate as they feared for their own lives and irrespective of how sick the women were when arriving at the facility, they were not attended to unless they paid for service charges or could provide some evidence of their Ebola status.