A total of 89 youth and providers participated in the study, with greater numbers of Mexican youth participating compared to the California sample. A slightly larger number of providers were interviewed in California (Table 1). Most youth participants in Guanajuato, Mexico, received prenatal care from governmental neighborhood clinics and delivered in the district maternity hospital. In contrast, the participants in Fresno, California, received prenatal care from a variety of clinics and delivered in various local hospitals.
Table 1
Focus group and interview participants, by location
|
California
|
Mexico
|
Total
|
Number of focus groups
|
5
|
6
|
11
|
Focus groups total participants
|
20
|
39
|
59
|
In-depth interviews with youth
|
5
|
10
|
15
|
In-depth interviews with health providers
|
9
|
6
|
15
|
Total youth and provider participants
|
34
|
55
|
89
|
Although youth participants in both settings were of similar age (17 years) and all were either pregnant or new parents, the populations differed in other aspects (Table 2). In California, 88% of youth participants were parenting, while in Mexico, 55% of participants were parenting at the time of their focus group or interview. In Mexico, only 10% of youth participants were enrolled in school at the time of the study compared to 80% in California. Among parenting youth, nearly 50% in Mexico report delivering via cesarean section (C-section) compared to 14% in California.
Table 2
Demographics of youth focus group and interview participants by site
|
California (n = 25)
|
Mexico (n = 49)
|
Age (average)
|
17.5 years
|
17.2 years
|
Relationship status
|
|
|
Single
|
9 (36%)
|
3 (6%)
|
In a relationship, but not living together
|
6 (24%)
|
8 (16%)
|
Married/living with partner
|
10 (38%)
|
38 (78%)
|
Current pregnancy status
|
|
|
Pregnant
|
3 (12%)
|
22 (45%)
|
Parenting
|
22 (88%)
|
27 (55%)
|
Ever previously pregnant
|
|
|
Yes
|
4 (16%)
|
7 (14%)
|
No
|
21 (84%)
|
41(84%)
|
Currently in school
|
20 (80%)
|
5 (10%)
|
Delivery method of parenting participants
|
California (n = 22)
|
Mexico (n = 27)
|
Vaginal delivery
|
13 (59%)
|
9 (33%)
|
C-section
|
3 (14%)
|
13 (48%)
|
Missing information
|
6 (27%)
|
5 (19%)
|
Youth And Provider Perspectives On Maternity Care
Four cross-cutting themes in both locations emerged from interviews and focus groups with youth and providers regarding patient-provider interactions: communication and explanations, respectful or judgmental providers, engagement in decision-making, and a focus on the age of the patient and their partners. Perspectives and concerns regarding maternity care experiences varied widely between the youth and providers, regardless of location. While youth generally focused on the positive and negative characteristics of their providers, the providers were more likely to focus on structural challenges. Although similar preferences and concerns emerged from youth in both locations, negative experiences were more common and often more severe for youth in Mexico.
Patient-provider Communication And The Need For Clear Explanations
Youth Perspectives
Youth in both locations described the importance of clear communication and explanations from providers, although more youth in Mexico emphasized the importance of receiving clear explanations of clinical information than in California. Many youth in both California and Mexico described interactions with providers where they were not given clear explanations of what was happening and what clinical decisions were being made. Youth also described feeling frustrated about asking their health providers questions and not receiving sufficient answers and explanations. One participant said:
“I had asked them what's the infection that [my baby] has, I wanted them to explain it better to me…. they made me feel really frustrated that they weren't really explaining it to me...I tried asking the nurse that was in the NICU and they didn't know how to explain it to me…I do remember asking them and asking them.” (Youth, California)
In California, a few youth mentioned feeling fearful of asking questions of their providers because the provider made them uncomfortable. Many youth in Mexico indicated fear around the delivery of their babies, in particular because they did not know what to expect since providers and clinic staff did not always explain things to them.
P1: “The truth is, that I was scared as well. I went there without having pains, without anything, but when they put me with the other patients, and I saw how they were feeling, I started to feel nervous.
P2: I was scared, too. I was thinking about what they were going to do to me.” (Youth focus group, Mexico)
Many youth, but only in Mexico, recounted negative experiences of providers deliberately ignoring them and asking to speak with their parents instead of directly interacting with the youth. One participant explained how she learned that she would need a C- section:
“They explained it to my mom first and then my mom came to tell me that they had to do a C-section [and] to not be scared. But it was my mom who explained it to me.”(Youth, Mexico)
One participant with a positive experience said:
“They explained everything to me. When I had the baby, they also explained it all again to me.” (Youth, Mexico)
Provider Perspectives
Providers in both locations identified several challenges in communicating effectively with their adolescent patients, including personal opinions and structural issues. A few providers in both locations expressed a desire to stress the risks involved in adolescent pregnancy, with one provider stating:
“I give them an overview of the possible complications of an adolescent pregnancy, so that they can take into account what can happen and see that the decision they made is serious. Sometimes I tell them, it may sound unpleasant, but I tell them—look, there is preeclampsia, diabetes, premature birth and because of your age, it is very common that it can happen…We agree that although this is not the age to get pregnant, that we will do everything possible to detect any problem early and that they know the signs and or symptoms that might emerge.” (Provider, Mexico)
One medical assistant in California discussed how they facilitate communication between doctors and the young women as many adolescents feel uncomfortable speaking directly with their provider:
“Sometimes they don’t open up to the doctor but they will open up to us. Sometimes we’ll have to let the doctor know if there’s, you know, something that comes up or there’s something that they need to address.” (Provider, California)
In California, many providers described the presence of language barriers when communicating with immigrant youth and their families, particularly when needing to convey difficult information. Providers also discussed the need for language services other than Spanish since many recent migrants from Mexico only speak indigenous languages. As one provider said:
“There’s even some [patients] that speak only Mixteco… those are the ones that need the most care, the most help… It’s a very guarded community. So, what stays within their community, happens between their community and hush, hush, don’t say anything. So, it’s very hard if they bring an interpreter to get things out of them, because they’re not going to tell us. If not, you know, it’s kind of hard to be translated when the parent or a brother or a sister is present because they’re very guarded on what they say.” (Provider, California)
Several providers in California also mentioned that concerns about insurance and immigration status limited interactions with patients.
“I think especially the ones that have come here undocumented, or illegally, you know the fear of accessing care…. A lot of them will fly very low, under the radar and don’t take services. You know they might tap into MediCal for the baby once the baby is born but will take very minimal services out of fear of having to disclose their immigration status.” (Provider, California)
Respectful Or Judgmental Providers
Youth Perspectives
Youth most frequently mentioned the personal characteristics of their provider when reflecting on their maternity care experiences. Several youth in both locations appreciated feeling supported by their providers and receiving “normal” treatment. As one youth in Mexico stated:
“They treated me well…since the start of my pregnancy until I recovered. Yes, they treated me well, really. And they were very careful to think about everything.” (Youth, Mexico)
A few youth in California described feeling comfortable when providers and staff were non-judgmental, respectful, and kind. Conversely, only one youth in Mexico mentioned feeling comfortable with their provider. One participant said:
“They're really nice. They talk to you, they mostly focus on you and the baby… I felt very supported and not judged because I was...a teen mom.” (Youth, California)
One youth in California appreciated when providers treated them in an approachable manner and used their names. As this youth described:
“I would walk in and they would already know my name so that’s why I like going there. Some doctors they just see you as a patient and others they would actually know my name when I walk in.” (Youth, California)
A few youth in both California and Mexico described providers who were rude and judgmental in their interactions with them. One participant said:
“The doctor didn’t want to look after me, and even threw my papers at me; he was very rude. He threw the papers at me and demanded that my mother be called because I was overreacting.” (Youth, Mexico)
Often, youth in Mexico felt they could not express their pain because providers would get angry and pay less attention to them if they communicated their discomfort during delivery. Concerns about or experiences of pain, particularly around delivery, were the most common negative issue among youth in Mexico. In contrast, only a few youth in California mentioned pain. As one youth stated:
“If you are dramatic and loud, they hardly pay attention to you. There was a girl who had a one-year-old and she was pregnant again, but she was screaming [during delivery] as if someone were killing her, so they didn’t really pay attention to her, because she was overreacting.” (Youth, Mexico)
Many youth in Mexico, but only one participant in California, acknowledged the variation of experience within the same hospital or clinic depending on the assigned provider. One participant described the different providers at one hospital:
“The truth is there are doctors that are mean, but the doctor who delivered my baby was very good to me. It depends on which shift you are on…because the night shift, truthfully, they are all very careless. I did not like the night shift because they made fun of the girls.” (Youth, Mexico)
While some youth in California discussed having negative experiences with their initial providers, all of them felt like they could switch providers. Indeed, many youth in California described switching to a provider they liked better. One youth described her experience:
“I switched [doctors]. My [new] doctor was really nice. He told me everything. He explained everything to me, what I could give [my baby to eat], after I had my baby and stuff like that. I really liked my doctor, he was nice. It was just that one doctor [who was bad].” (Youth, Fresno)
Many youth in California also mentioned preferring female providers and would change doctors if they were assigned a male provider.
Provider Perspectives
Although mentioned less often, a few providers were aware of the criticisms from patients around lack of respectful, patient-centered care. Providers most often attributed their inability to provide patient-centered care to structural constraints, though some also recognized their own negative opinions regarding adolescent pregnancy and their patients’ life choices.
Providers in both countries expressed concern about patient caseload and the resulting limits on how much time they could spend per patient. In Mexico, one provider discussed their heavy patient caseload and the need for more providers. In particular, this provider discussed how having too many patients limits the time they can spend with individual patients:
“We have to provide care to everyone, and if we cannot provide specialized care to a patient, then we just get stuck, the truth is that we do not have much time to be focused on an actual medical appointment, and evaluate the entire situation around a particular patient.” (Provider, Mexico)
Providers in both locations also acknowledged their own underlying concerns about adolescent pregnancy and its consequences. Many providers in California and a couple of providers in Mexico focused on the tension they felt about what they perceived as being for the patient’s “own good.” Providers discussed how personally difficult it is for them when they strongly disagree with the life decisions made by their pregnant and parenting adolescent patients. For example, one clinical provider in California discussed the issue of staying in school:
“So I think the difficult thing for me as a provider and the clash that I have sometimes is that with teens, I want them to remain in school, and I sometimes get pushback, you know, because here I am, this educated white person coming in telling her how to raise her child. You know this is not what goes well, so you have to be really careful with that.” (Provider, California)
Similarly, one health educator in Mexico said:
“Sometimes I tell people, ‘we are sorry, it’s just that we sometimes worry.’… We can’t avoid it because they worry us. That is, sometimes it does cause anger, how you put your life at risk, when we are offering you, we are offering everything to plan your family and you don’t take advantage of it…[Then] I remember that it isn’t my responsibility, that my responsibility is to just offer [options] and information, that I can’t force them to make decisions, even for their own good.” (Provider, Mexico)
Shared Decision-making
Youth Perspectives
In general, youth in California expressed more agency around decision-making, especially around their delivery and clinical care, compared to youth in Mexico. When asked whether their provider had discussed delivery options with them, one youth in California explained:
“I talked about it and I had made up my mind...I had barely got transferred to [the hospital] when they asked... so they could write it down and keep the information so when delivery day. I had said I wanted normal [delivery] and when I went in, I was already asking for a C-section. I'm like ‘I can't!’ And they're all like, ‘oh you can. You're ready to open...’ oh okay! I was sad…but yeah they do give you, they ask you about it.” (Youth, California)
In contrast, youth in Mexico were rarely asked their opinion about their clinical care and most felt they could not disagree or question provider decisions regarding their care. For example, many youth described having never discussed the different delivery methods and their care plan with their providers. As one youth described:
“I hadn’t thought about…I’d never considered…well, how I wanted it to happen, normal [delivery] or C-section.” (Youth, Mexico)
A common experience for youth in Mexico was arriving at the maternity hospital and being turned away by providers who thought it was too early in the labor process. Many youth in Mexico described feeling frustrated about being sent home after going into labor, stating that providers ignored their requests and refused to admit them into the hospital. One youth ultimately gave birth outside the hospital because they would not admit her:
“I started to feel bad on a Friday. I went to the Maternity Hospital on that Saturday and they told me I was not ready yet, I was 1 cm dilated. On that Sunday, I could not take the pain any longer, and they told me that I still had one week left. The doctor told me to stop bothering him… that I still had one week left… I was assisted by a midwife when I was delivering, because in the Maternity Hospital, they did not want to take care of me.” (Youth, Mexico)
Provider Perspectives
While some youth expressed frustration about being ignored or having their concerns dismissed, particularly in Mexico, only a few providers mentioned the lack of youth engagement in decisions related to their care. Some providers in California, but none in Mexico, discussed the power imbalance that exists between providers and adolescent patients. They noted that many youth do not feel empowered to make their choices known, especially around the time of delivery, or that the youth’s opinions are blatantly disregarded by medical staff. As one health educator recounted:
“I think what we hear from their experience during delivery especially, that it’s sort of like happening outside of them, there’s not a lot of, ‘well what do you want and what do you need?’…And some are like really into this birth plan and ‘I’m going to do this!’ And they would go and the nurses would be like, ‘Uhhh!’ Just not even respectful of the fact that they had made this birth plan and they wanted these certain things… It’s just ‘you don’t know,’ ‘we’re doing this for you’. I hear a lot of, ‘nobody explained to me anything. They just did their things their way’. And they just feel like they weren’t in the loop.” (Provider, California)
These interactions may make youth feel more disempowered within the healthcare system. Many youth don’t know that they can question or have an opinion on the care that they receive. As two health educators explained:
P1: “Most of them do not [feel empowered], they are going to do whatever you tell them to.
P2: Yeah…they just said that’s what the doctor told them to do.” (Providers, California)
Another challenge related to decision-making is that medical staff may have preconceived ideas about youth, which can affect the services they deliver. One provider in California explained:
“Their [youth] experience at the birthing center with nurses, they get this feeling of impatience with the nurses because [the nurses] assume they know nothing. It’s been a big complaint or they have been upset that [the nurses] immediately give the baby a bottle of formula and didn’t give her the opportunity to nurse the baby first.” (Provider, California)
Focus On Age Of Adolescent And Partner
Youth Perspectives
Many youth in California and a couple of youth in Mexico stated that clinic staff and providers focused too much on their age or the age of their partners. During one focus group, two participants shared:
P 1: “My doctor told me I was too young and I was like, ‘okay.’”
P 2: “Mine too. He didn't tell me, he just looked at me and was like, ‘you're 15!?’” (Youth focus group, California)
Similarly, one participant in Mexico said:
“Well, the first time [the doctors] saw me they said ‘how come you will be turning 14 and will already have your first child?’ At the beginning, they told me that I was going to be playing with baby dolls, but that now I had to feed them for real.” (Youth, Mexico)
In California, some youth mentioned appreciating when providers did not make comments regarding their age during clinical encounters and instead treated them like “normal” patients. One participant explained that clinic staff:
“…didn’t ask me anything [about my age]. They just checked me and… she was asking me normal questions.” (Youth, California)
Many youth in California, but none in Mexico, described uncomfortable situations when providers asked questions regarding the father of the child. One participant said:
“When my doctor seen my age, he kept asking me a lot of questions and he was rude and he kept asking for who was the dad and I was like, ‘well I don't know,’ because I wasn't sure what to say. ‘Well how old is he?’ I was like, ‘I don't know’. I didn't want to reply. He was like, ‘is he 13, 60, 30? Do you not know how old?’ I don't know. So he made me feel so uncomfortable.” (Youth, California)
One youth in California discussed being wary of the questions asked by providers because of the potential impact requiring reporting of their partner’s age:
“They ask a lot of questions...a lot. My sister-in-law when she was pregnant, the same clinic called the cops on her. So, my brother had to go to court and everything…She was 13 and my brother was 15…and he ended up still getting locked up for that.” (Youth, California)
Provider Perspectives
Similar to the youth respondents’ concern, providers in California described the negative influence of mandated reporting. This legal requirement to report sex by an adult with a minor restrained patient-provider communication. Health providers acknowledged that pregnant and parenting adolescents are unlikely to be fully forthcoming given their status as mandated reporters. One provider described feeling conflicted about their role as a mandated reporter and that the decision to report is not always as clear-cut as it might seem:
“We didn’t ask about those things, even though we’re mandated reporters… like, I have a 23-year old dad here, who really loves this 16-year old girl, and they’re a family and he is a good guy and he’s providing for them and that would separate that family… There were some times that it was very morally conflicting because, on one hand, you know and so you’re trying to constantly get information, but not too much information. But, then also you know you do identify those times where you’re like this is a total predatory relationship. And then you do make reports.” (Provider, California)
Similarly, another provider discussed a particular patient who was reported to Child Protective Services (CPS):
“She was about second trimester when she came in…she was Mixteco and she was married, but she’s still a minor so CPS got involved and took her and gave her a foster mom. That was the hardest because she got taken from her husband [and] from everything that she knew.” (Provider, California)
While some Mexican providers discussed the age difference between their adolescent patients and partners, mandated reporting laws differ in Mexico and therefore, did not emerge as a theme.