Adolescent pregnancy and the sexual and reproductive health care for young women in Maluku, Indonesia: a mixed-methods investigation

Abstract

Background

Adolescent pregnancy remains a significant issue for 15-19-year-old girls globally, affecting their health, their educational prospects, and their socioeconomic status. In many LMICs, it remains challenging for young women to obtain appropriate and equitable healthcare, particularly regarding their sexual and reproductive health care (SRH) needs. This can be exacerbated by restrictive laws, combined with traditional and entrenched socio-cultural values that perpetuate gender inequality. Indonesia is a geographically vast country with variation in access to education, in rurality, in socio-economic status and in the socio-cultural milieu and dominant religion. Research from several regions in Indonesia highlights existing barriers to good SRH for adolescents, but there are only few existing studies in Maluku, which is one of the poorest regions in the country and has one of the highest rates of adolescent pregnancy.

Aims

This body of research aimed to investigate the characteristics and outcomes of adolescent pregnancy and the influential factors shaping the experience of SRH care for young women in Maluku, Indonesia. The research had four specific aims: 1) to investigate an association between regions and adolescent pregnancy in Indonesia, taking into consideration measures of inequality, 2) to examine the difference in characteristics and pregnancy outcomes between adolescent and adult pregnant women presenting to a hospital in Maluku for pregnancy care and childbirth, 3) to explore factors influencing SRH care seeking behaviour among young women in Maluku, and 4) to explore young women and healthcare workers perspectives and experiences when engaging in SRH care in Maluku.

Methods

This research used a mixed-methods approach, combining both quantitative and qualitative methods. For the quantitative research, I analysed data obtained from the 2017 Indonesian Demographic Health Survey (IDHS) on 7501 adolescent women in Indonesia and 2433 medical records of adolescents and adults presenting for pregnancy and childbirth care to either of two hospitals within the Maluku province. The qualitative data were obtained from in-depth interviews with 36 young women aged between 18 – 24 years old and 17 healthcare workers which were conducted in Ambon, the main city and capital of Maluku.

Results

The quantitative study using IDHS data found that adolescents living in the Maluku islands region were 1.45 times more likely to experience an early pregnancy than those living in Java-Bali, which is the most developed region of Indonesia. No significant effect was observed for adolescents living in other regions. Furthermore, the strongest predictors of adolescent pregnancy in Indonesia were found to be: 1) either no education or only primary education compared to secondary or higher, 2) living in a rural area compared to an urban area, and 3) being in the lowest socioeconomic quintile compared to the highest. The hospital-based data study found that adolescent patients presenting to a hospital in Maluku for pregnancy and childbirth care were more likely than the adults to have never been married and to be unemployed. Adolescents were less likely to report ever using any family planning method in the past. On admission to hospital, adolescents were more likely to be admitted for inpatient care without a referral and into a third-class hospital ward. Babies born to adolescents were at greater risk of low birth weight, small for gestational age, and birth asphyxia.

The first qualitative study findings provided rich information regarding factors influencing women to delay seeking initial pregnancy care. Being unmarried led women to present later for pregnancy care, regardless of the woman's age or the presenting health problem. However, where there was a perceived urgency for treatment, such as when seeking care for HIV, marital status became less important. Findings also show that access to SRH services can be expedited by healthcare workers providing community outreach services. The second qualitative study focused on the reported experiences of young women who were pregnant and presented for antenatal care, and the experiences of healthcare workers providing this care. The study revealed that young women's initial engagement in care, including their expectations of treatment, is shaped by a discriminatory social context. However, other factors, such as family and personal connections in the health system, influence their positive experiences of care. While retention in care is precarious, continued engagement was facilitated by healthcare workers' emphasis on respectful treatment. The findings from both qualitative studies reveal that despite healthcare workers ability to positively impact the access to, and the experience of, health care services for adolescents, restrictive national laws that prohibit access to family planning for unmarried people limit the extent of their ability to improve SRH for many.

Conclusions

This study highlights the significance of early pregnancy risk among adolescents living in Maluku. High socio-economic disadvantage and lack of education predisposes to adolescent pregnancy and may then further compromise a young women’s ability to continue education or to start employment. Adolescent pregnant women in Maluku experience a range of adverse perinatal outcomes that align with studies from other settings. Unmarried young women's negative perceptions about being stigmatised for certain SRH issues persist and influence their access to and utilisation of SRH services. Respectful SRH services are often provided but may be inadequate when discriminatory policies and practices exclude young unmarried women’s access to preventive health care measures such as family planning. A reform of national and local policies and practices is vital to reduce adolescent pregnancy in Indonesia and to provide opportunities for young women to continue their education or start employment prior to marriage and family.