Pregnant Teens Face More Mistreatment and Gaps in Maternal Care Across Three African Countries

Pregnant adolescents in Ethiopia, Kenya, and South Africa are receiving worse maternal healthcare than adult women at nearly every stage of pregnancy and childbirth, according to a new cohort study published in PLOS Global Public Health. The research, which followed more than 3,000 women from their first antenatal visit until six weeks after delivery, found that mothers under the age of 20 attended fewer check-ups, took fewer supplements, experienced more mistreatment by health workers, and suffered more obstetric complications than their adult counterparts. The findings offer one of the most detailed longitudinal pictures yet of how health systems in sub-Saharan Africa serve — and often fail — their youngest mothers.

The study drew on data from the Maternal and Newborn Health eCohort, a research platform designed to track the quality of care that women actually experience across the full continuum of pregnancy, delivery, and the postpartum period. Rather than relying on retrospective surveys conducted months or years after birth, the eCohort approach follows women in near real time, allowing researchers to capture continuity of care and the timing of interventions with far greater precision. In this analysis, the team led by Beatrice Amboko, Irene Mugenya, and Catherine Arsenault followed 3,051 pregnant women, of whom 380 were adolescents aged under 20 and 2,671 were adults aged 20 or older, across health facilities in the three countries.

The differences began before most adolescents had even established contact with the health system. Only 22 percent of adolescents attended antenatal care in their first trimester, compared with 30 percent of adult women, a statistically significant gap that matters because early initiation of antenatal care is one of the strongest predictors of detecting complications such as anemia, hypertensive disorders, and infections before they become dangerous. World Health Organization guidance recommends that a woman’s first contact occur within the first 12 weeks of pregnancy, and delays in adolescent initiation suggest that barriers such as stigma, fear of judgment from providers, lack of awareness, and difficulty navigating clinics are operating well before a teenager ever reaches a consultation room.

Once in care, adolescents continued to lag behind. They averaged 3.1 follow-up antenatal visits compared with 3.8 among adult women, and their adherence to iron-folic acid supplementation was markedly lower, at 59.0 percent versus 69.4 percent. Iron-folic acid supplementation is a cornerstone of antenatal prevention, reducing the risk of maternal anemia and contributing to healthier birth weights, so a ten-percentage-point shortfall across a large adolescent population translates into a meaningful burden of preventable risk. Continuity of care — the proportion of women who remained with the same provider or facility through the course of their pregnancy — was also lower among adolescents, at 53 percent compared with 59 percent among adults. Fragmented care of this kind disrupts the accumulation of clinical knowledge about a patient, increases the chance that risk factors are missed, and erodes the trust that keeps young women coming back.

The most striking findings emerged around the experience of childbirth itself. Nearly 27 percent of adolescents reported mistreatment during delivery, compared with 18.6 percent of adult women. Mistreatment in this context encompasses a range of disrespectful and abusive practices, including verbal abuse, physical abuse, neglect, and violations of privacy and dignity during labor. That one in four teenage mothers experienced such treatment is a sobering indicator of how health systems can compound, rather than alleviate, the vulnerability of their youngest patients. Adolescents also experienced obstetric complications at a higher rate, with complications occurring in 31 percent of adolescents compared with 25.9 percent of adults — a difference consistent with the biological immaturity of adolescent reproductive systems, which are associated with elevated risks of obstructed labor, preterm birth, and other adverse outcomes.

To understand what drives mistreatment among adolescents, the researchers used logistic regression, a statistical technique that estimates the independent effect of each factor while holding others constant. The analysis revealed that mistreatment was strongly associated with where and how adolescents gave birth. Those living in rural areas had 2.61 times higher odds of mistreatment than their urban counterparts, and those delivering in public facilities had 4.33 times higher odds than those in private facilities. These associations point to structural pressures: rural facilities are often understaffed and overcrowded, and public facilities in all three countries absorb the majority of deliveries under conditions of high patient volume, limited privacy, and strained provider morale. Adolescents who reported experiencing intimate partner violence had 3.31 times higher odds of mistreatment, suggesting that violence in the home and disrespect in the clinic are intertwined forms of harm that often travel together.

Just as important as the risk factors were the protective ones. Adolescents delivering in Kenya had 81 percent lower odds of mistreatment compared with those in the comparison setting, an adjusted odds ratio of 0.19 that hints at the influence of national policy environments, provider training programs, and facility-level norms. Privacy during delivery cut the odds of mistreatment nearly in half, with an adjusted odds ratio of 0.44, and adolescents who held high perceptions of the quality of their care had 0.37 times the odds of mistreatment. The protective effect of privacy is particularly actionable: simple measures such as curtains around delivery beds, single-room labor wards, and protocols that limit the number of people present during examinations are inexpensive interventions that directly safeguard dignity. The link between perceived quality and mistreatment also suggests a virtuous cycle in which respectful, competent care reinforces itself through trust and positive expectations.

The analysis of obstetric complications among adolescents identified a different set of drivers. Rural residence was associated with 2.25 times higher odds of complications, likely reflecting longer travel times to facilities, delayed access to emergency obstetric care, and lower socioeconomic conditions that affect nutrition and overall health. Antenatal depression more than doubled the odds of complications, with an odds ratio of 2.43. This finding adds to a growing body of evidence that maternal mental health is not a peripheral concern but a clinically significant determinant of physical outcomes. Depression during pregnancy can reduce attendance at antenatal visits, impair adherence to supplementation and other preventive measures, and alter physiological stress pathways that affect fetal development. Yet mental health screening remains rare in routine antenatal care across much of sub-Saharan Africa, and the study’s authors argue that integrating mental health support into primary healthcare could meaningfully improve outcomes for young mothers.

The study’s longitudinal design strengthens its conclusions in ways that cross-sectional surveys cannot. By following women from first antenatal contact through the postpartum period, the researchers could observe whether care was actually delivered and continued, rather than relying on women’s recall of events long past. The statistical adjustments for confounding factors — including country, residence, facility type, and experiences of violence — lend credibility to the specific associations identified, although the authors note that observational designs cannot fully rule out residual confounding, and the relatively small number of adolescents in the sample means some estimates carry wide confidence intervals.

The implications for policy are clear. The authors argue that health systems should strengthen adolescent-responsive and respectful care within primary healthcare, alongside integrated mental health and intimate partner violence support. In practice, this means training providers to treat teenage mothers without judgment, ensuring privacy in delivery rooms, expanding early antenatal contact through community outreach and school-linked services, screening for depression and violence at routine visits, and addressing the resource constraints that push public and rural facilities toward the conditions in which mistreatment flourishes. With adolescent pregnancy remaining common across much of sub-Saharan Africa, and with the youngest mothers bearing both biological and social vulnerability, the study makes the case that the quality of care a health system offers its teenage mothers is a sensitive measure of its overall commitment to respectful, equitable healthcare — and that, on this measure, Ethiopia, Kenya, and South Africa still have substantial work to do.

Subject of Research: Quality, continuity, and experiences of maternal healthcare for pregnant adolescents compared with adult women in Ethiopia, Kenya, and South Africa

Article Title: Maternal healthcare quality, continuity, and experiences among pregnant adolescents and adult women in Ethiopia, Kenya, and South Africa: A cohort study

Article References: Amboko, B., Mugenya, I., Odipo, E., Kosgei, R. J., Yang, W.-C., Sabwa, S., Wondim, G. M., Mfeka-Nkabinde, N. G., Mthethwa, L., Mzolo, N. C., Kruk, M. E., Arsenault, C., & Nzinga, J. (2026). Maternal healthcare quality, continuity, and experiences among pregnant adolescents and adult women in Ethiopia, Kenya, and South Africa: A cohort study. PLOS Global Public Health, 6(10), e0004729. https://doi.org/10.1371/journal.pgph.0004729

Image Credits: AI Generated

DOI: 10.1371/journal.pgph.0004729

Keywords: maternal health, adolescent pregnancy, antenatal care, mistreatment, obstetric complications, Ethiopia, Kenya, South Africa, intimate partner violence, antenatal depression, respectful care, PLOS Global Public Health