An Evaluation of the Effectiveness of a Maternal, Neonatal and Child Health Component for the Matasa Matan Arewa and Smart Start Interventions Targeting Married Adolescent Girls in Nigeria and Ethiopia

Pregnancy and childbirth are a leading cause of morbidity and mortality among adolescent girls. In 2021, maternal conditions were the fourth leading cause of disability-adjusted life years and the second leading cause of mortality among adolescent girls 15-19. The negative health consequences of teen pregnancies include pregnancy complications (pre-eclampsia, unsafe abortion, anaemia, maternal depression), birth complications (pre-term birth, obstructed labour, obstetric fistula), post-partum complications (post-partum haemorrhage, puerperal sepsis, neonatal death, low birth weight neonates and postpartum depression) and death. Further, pregnancy at adolescence is associated with multiple socio-economic outcomes such as discrimination, rejection, social isolation, school discontinuation and economic deprivation. Despite the need to careful monitoring and care needed during pregnancy, most pregnant girls receive poor health care. Fewer pregnant girls, compared to their older counterparts, initiate ANC, attend the recommended number of ANC visits, receive high quality ANC care, are supervised during birth by a skilled health worker or receive postpartum care. There is growing global attention for health systems to make strategic investments to avert teen pregnancies and to deliver high quality, user-friendly and timely interventions for the adolescent girls who conceive.

Motherhood is a key aspiration for most women including those in adolescence. In patriarchal societies, where early marriage is common, girls are expected to begin childbearing immediately after their marriage to prove their fertility. At this age, married adolescent girls lack comprehensive knowledge about pregnancy and childbirth, and have limited agency and decision-making power to determine what is the best care for them. Delivering high quality and timely antenatal care is a crucial intervention that could avert most of the risks associated with adolescent pregnancy. Initiating ANC in early pregnancy provides health workers an opportunity to perform health promotion and education, conduct risk assessment and action, and monitoring and timely management of pregnancy complications. Yet ANC outcomes for pregnant adolescents are wanting. Studies have documented various reasons why ANC attendance is poor for adolescent girls which include health system factors such as the tense relationships with providers, the poor service quality, and long distances to health facilities; social factors such as level of support from the male partner and community norms; and individual factors such as age, level of education, autonomy, knowledge of the importance of ANC, place of residence, financial factors, pregnancy disclosure, parity and marital status. Holistically addressing the factors influencing the timing, consistency and completeness of ANC attendance and improving the quality and user-centredness of ANC for adolescent girls using a socio-ecological model could improve the pregnancy outcomes among pregnant teens and reduce the avoidable complications.

Several interventions have been trialed to increase demand for, utilization and completion of ANC among adolescent girls who are pregnant. These include group ANC and home visits by community health workers. Findings from these studies has shown a promising outlook on the interventions' ability to increase ANC adherence, reduce the gestational age at first ANC attendance, improve the satisfaction with ANC services and skilled attendance at birth. Yet not all expected outcomes from these interventions were attained and only two of the five studies in a systematic review of interventions to increase ANC adherence showed positive results. Group ANC has shown good results at increasing the awareness of at least three pregnancy danger signs among pregnant adolescent girls. In a separate study conducted in Kenya, nutritional and health knowledge relevant to pregnant women were not substantially different between ANC and non-ANC attendees. In a similar study in Tanzania, only 40.2% of women were knowledgeable on the danger signs of pregnancy. A study in Indonesia demonstrated good results of a trial to increasing knowledge across the pregnancy continuum.

Although intervening to increase demand and timeliness of initiating ANC, doing so in the pre-conceptual period, when girls and their partners are considering conceiving offers the most opportune window to create awareness of what things they need to do to attain a healthy pregnancy. This would include what health issues can affect fertility, the desired nutritional behaviors and the signs and symptoms of pregnancy. This would also alert the couple on what things are expected in early pregnancy including access to early ANC. Intervening prior to conception is important, because it provides health workers an opportunity to screen health risks that could prevent conception, but also those which could negatively affect pregnancy outcomes. Despite the recognition of the value of pre-conceptual interventions, there is huge gap of evidence on what interventions would work for adolescent girls at risk of pregnancy to increase demand of and relevance of ANC. First, interventions in this period are less prioritized by health systems and providers. Second, when such interventions exist, they vary widely between geographies with very few of these in developing countries and interventions not being tailored to the needs of adolescent girls. This was affirmed by a scoping review conducted in 2017 which demonstrated that only 6 of the 27 studies on preconceptual interventions were conducted outside of the United States, only one in Lebanon. Although, most of the interventions demonstrated improvement in preconceptual knowledge, change in dietary habits and use of folic acid, none of the studies tracked the impact of the interventions on ANC outcomes, when pregnancy occurred.

The lack of adolescent-specific evidence and the recognition of the number of teen pregnancies in sub-Saharan Africa, does present a valid opportunity for programmers to design, implement and evaluate pre-conceptual and early pregnancy interventions to document their impact on ANC, maternal and neonatal and post-partum outcomes. Since 2016, Population Services International (PSI) and its consortium partners employed human centred design (HCD) techniques to design a user-centered intervention MNCH component targeting married adolescent girls in northern Nigeria and Ethiopia under the Adolescents 360 (A360) project. This component is layered on two signature aspirational sexual and reproductive health interventions, Smart Start for Ethiopia and Matasa Matan Arewa (MMA) for northern Nigeria. The interventions increase demand for and uptake for voluntary modern methods of contraception and counselling services in primary care outlets among married adolescent girls. The MNCH component targets adolescent girls and young women (AGYW) at risk of pregnancy, those actively trying to conceive and those in early pregnancy. The MNCH component for northern Nigeria is called MMA Plus and that in Ethiopia is called Smart Pathways. MMA plus is implemented through Society for Family Health and is implemented through primary care centres (PHCs) in Kaduna and Jigawa states. At the PHCs girls receive services directly through a trained youth-friendly provider and participate in life, family and health (LFH) classes. LFH consists of four guided mentorship sessions conducted over a four-week duration convened by trained mentors. During these sessions girls receive information including nutrition, child spacing, interpersonal communication, financial management and gains life and vocational skills). The MNCH component is built on the LFH classes. Girls who are at risk of pregnancy and who don't want to use a method of contraception or who suspect that they are pregnant are mobilized by female mentors or through their husbands to attend LFH sessions at PHCs. Those who walk in to receive services are offered the services directly and introduced to the LFH classes. The sessions take two hours, are moderated by trained female mentors and attended by ANC experts (trained providers) who offer information and counselling on attaining health pregnancies. Girls who test positive for pregnancy undergo routine ANC, enhanced with gestational age-specific messages about the expectations of ANC, birth preparedness, nutrition during pregnancy, danger signs and how to avoid them and postpartum family planning (PPFP).