Teenage Mothers Care Practices

Case studies from Western Area, Koinadugu and

Pujehun DistrictsSierra Leone

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Non-responsibility clause
The present document aims to provide access to main information resulting from the study Teenage mother care practices. A
case study of Western Area, Koinadugu and Pujehun DistrictsSierra Leone conducted by Krystle Lai and Catriona Towriss in
2014 for Action Contre la Faim (ACF), Concern Worldwide, Save the Children and the Ministry of Health and Sanitation of Sierra Leone represented by the Directorate of Food and Nutrition.

Acknowledgment
This publication is the result of the collaboration between ACF, Save the Children, and Concern; and is based on the publication developed by Krystel Lai and Catriona Towriss in 2014.
The photos in the publications are: Sandra Calligaro for ACF Sierra Leone

In Collaboration with

Content
Copyright and Acknowledgment

Humanitarian Context

Programme Overview and Results

Conclusions and Recommendations

Endnotes

ii

Humanitarian Background
Background
The reduction of infant and child
deaths received incredible support by
the international community through
its inclusion as one of the Millennium
Development Goals (MDGs). Sierra
Leone displays poor child and infant
health indicators and in 2013 ranked

Children from poor households and

pregnancy6), yet increasing secondary

children of mothers who are not well

education of girls by just 1% could re-

educated, struggle to reach a normal

sult in an annual income increase of

nutritional status. Evidence also sug-

0.3% per capita7.

gests that teenage mothers are more

likely to have poor care practices, particularly with regards to feeding practices.

Teenage Pregnancy during the Ebola

outbreak
Prior to the Ebola epidemic declared in
Sierra Leone on May 26th 2014, teenage

Sierra Leone and Teenage Pregnancy

pregnancy accounted for 34% of all

182/1000 per live births . Evidence has

Adolescent pregnancy has received

pregnancies in Sierra Leone, but the

shown that one of the most effective

significant attention in Sierra Leone,

rate is expected to have been exacer-

ways to reduce infant and young child

particularly following the adoption, in

bated as result of the outbreak.

mortality is to improve child nutrition.

2013, of the National Strategy for the

Along with other nutrition factors,

Reduction of Teenage Pregnancy and

stunting, wasting and micronutrient

the consequent establishment of the

deficiencies account for about 35% of

National Secretariat. According to the

child deaths2.

Sierra Leone Demographic Health Sur-

Considering the health risks early child

vey 2013 (DHS), 28% of teenagers be-

pregnancy can lead to for both moth-

tween the age 15 and 19 have begun

ers and children, and the limited acces-

are wasted3. Under nutrition results

childbearing.

sibility to basic health services exacer-

from a combination of immediate caus-

Teenage pregnancies may have long

es of poor health and nutrition, such as

term consequences on the health sta-

the lack of available nutritious food or

tus of the mother and the child, as well

the presence of illness/disease, and

as broader impacts on their social and

underlying factors that influence those

economic status. It is estimated that

immediate causes. Such underlying

40% of maternal deaths occur as a re-

factors can include; family income,

sult of teenage pregnancy (MICS 2010).

highest for under-five mortality of

1

In Sierra Leone, 12.9% of children are

underweight, 28.8% stunted and 4.7%

parental educational status and cultural

factors that might impact on resource
distribution within the household.

In particular the closure of the schools

has left adolescent girls vulnerable in
their communities.

bated by the Ebola outbreak, it is likely

that the situation of adolescent mothers and children had worsened, and
that the burden of morbidity and mortality in this already vulnerable group
could increase.

The cost of adolescent pregnancy, as a

share of Gross Domestic Product (GDP)
could be as high as 30%5. Early preg-

Care practices4 also play a key role in

nancy often results in school dropout

determining a childs nutritional status.

(71% girls have done so as a result of

1

Study Overview and Results

Sandra Calligaro

From May July 2014 Action contre la

sources into childs survival, growth

the preparation, cooking, processing

Faim (ACF), Concern Worldwide, and

and development.

and storage of food.

1. Care for women: This refers to the

5. Hygiene practices: Outlines house-

care that family and community should

hold and personal hygiene practices

provide to women. This includes care

that affect the cleanliness of the envi-

for the woman during pregnancy and

ronment and the number of infectious

lactation, care for a womans repro-

agents that a child might ingest,

ductive health prior to pregnancy, care

through contaminated food or water

for her physical health and mental

or by placing contaminated items in

wellbeing and care for her socioeco-

their mouths.

nomic wellbeing within the home and

6. Home health practices: Refers to the

community.

care practices that help prevent illness,

2. Breastfeeding and feeding practices:

through the protection of the child

This describes the breastfeeding and

within the home, the management of

complimentary feeding practices that

health within the home and the timely

should be adopted by mothers and

utilization of health services for both

caregivers.

preventative and curative purposes

Save the Children alongside the Ministry of Health and Sanitation (MoHS)
conducted a study on teenage mothers
care practices. Several pieces of research have been conducted in Sierra
Leone and in other countries exploring
the relationship between maternal age
and child health asserting a direct relationship between the two elements.
However little is known about the care
practices of teenage mothers and the
influence this has on child health, particularly on nutritional status. This relationship was identified as important to
explore in light of the analysis of nutrition programme data, which revealed

(UNICEF, 1997).

that children repeatedly admitted in

3. Psychosocial care: Refers to the re-

the nutrition programme (outpatient

sponsiveness of the caregiver to the

The study was conducted in three dis-

and inpatient) were of adolescent

childs behaviour. It also refers to the

tricts of Sierra Leone Western Area,

mothers.

involvement, attention and affection

Koinadugu and Pujehun and included

given to the child, as well as the care-

45 adolescent mothers of children be-

givers encouragement of the childs

tween six to twenty-four months. The

learning, exploration and autonomy.

targeting ensued from the analysis of

This study refers to care practices defined by UNICEF (1997) as the practices at the household level of those who
give care to children, translating the

4. Food preparation: This aspect de-

available food and health care re-

scribes the care processed needed for

the

Outpatient

Therapeutic

Pro-

gramme (OTP) nutrition data that

showed that children between six to
2

twenty-four months comprise 85% of

having dropped out from school due to

the right nutritious food. Despite the

the total admissions. Therefore teen-

pregnancy.

efforts, Sierra Leones rates of early

age mothers, who were caring for children between 6 and 24 months old
were purposefully selected from health
centres in each of the geographical
areas. Individual interviews as well as
focus group discussions were conducted among the selected participants.

Many respondents (82%, 95% CI 71%94%) have received some support

throughout the pregnancy and the
delivery although many of the adolescents reported that health workers
treated them badly because they were

initiation and exclusive breastfeeding

remain quite low, with 54% of newborns breastfed within one hour and
only 32% of children are exclusively
breastfed until six months (SL DHS
2013)8.

young, which is a concerning finding.

This study reveals similar figures with

The mean age of the interviewed

The type of support mothers refer to

64% (95% CI 50%-78%) of mothers

mothers and their children were 17.9

was the possibility of asking questions

reporting having breastfed within one

years and 12.4 months respectively:

on pregnancy and delivery, receiving

hour after delivery. Giving water or

22% had already received treatment

some help during the last months of

breast milk substitutes (mixed feeding)

for undernutrition.

the pregnancy and having someone

is common however is not advised as it

Pregnancy and Delivery

accompanying them at birth.

can increase the risk of diarrhoea or

According to the study, teenage preg-

the nurses all left me when

nancy appears to be particularly stress-

I was in pain to go and

ful as result of feelings of isolation and

watch their movie. They

rejection by the childs father, the fam-

told me it was not them

ily and the community at large coupled

that made me pregnant so I

with low income. Due to rejection and

should bear the pain

challenges at home, over half of teenage mothers reported experiencing a

change in living circumstances between pregnancy and after giving birth.

child with water or other food as the

child asked for additional food than
breast milk and that, in some cases,
they believed that, due to their poor
nutritional status, their milk was not
sufficiently nutritious to respond to the

received support from a female rela-

childs needs.

tive (mother, auntie, etc.), and 89%

(95% CI 79%-98%) report to have delivered in a health facility.

ment when I found out I

The study also revealed that 36% of

was pregnant. I was scared.

teenagers surveyed experienced com-

My brother beat me. My

plications during delivery. This may be

mother drove me out of the

due to the body not being fully devel-

house

oped. Yet, teenagers disclose they had

In the short term, a lack of sustained

a poor knowledge on the delivery

and sufficient sources of income reduc-

phase and that this has contributed to

es access to recommended nutritious

increased stress, sometimes worsened

food and drugs needed during the

by the health staffs poor attitude to-

pregnancy/delivery phase. In the long-

wards pregnant teenagers.

term, this results in reduced decision-

Feeding Practices

tices for the child.

ers reported that they provided their

The majority of mothers interviewed

I was scared at that mo-

making power regarding feeding prac-

other infections. The majority of moth-

after one month, I had to

give warm water because I
didnt have enough food so
he wasnt satisfied
The study revealed that the actual
and/or perceived poor knowledge
about child nutrition is one of the factors limiting the ability of mothers to
adequately address their childs nutrition. Another reason appears to be
that often mothers are not the ones
providing the food therefore their engagement in the dietary choice is limited. Knowledge around the timing for

Good feeding practices are key to en-

introduction of complementary foods

suring the growth and development of

was also particularly poor.

In addition, this study confirms a corre-

a child. The MoHS, in collaboration

lation between teenage pregnancy and

with UNICEF and other partners, have

dropout rates from schools with 89%

developed the Infant and Young Child

(95% CI 76%-100%) of participants

Feeding Practices Guidelines to sup-

I think it is one year, but

my baby now, even when
its still small, if you dont

port mothers in providing children with

3

watch him, he will take the

have money. When you go

Play and discipline are essential con-

food for himself

to the hospital, most times,

tributors to the childs development:

they do not have the right

encouragingly 84% (95% CI, 73%-94%)

drugs, so they just write a

of mothers interviewed report playing

paper [prescription] and tell

with their child the day before the in-

you to go to the pharmacy

terview; and 75% (95% CI, 62%-88%)

anyway. And worse than

report feeling that it is important to

that, when you go there,

discipline the child. Most of the moth-

they just shout abuse at

ers report that their discipline consists

you

of explaining to the child when some-

As a result most of the children were

not receiving a balanced diet at the
time of the interview. Indeed the consumption of protein, fruit and vegetables was quite low associated with a
prolonged breastfeeding period.
Health Seeking Behaviour
Appropriate and consistent health
seeking behaviour is key in reducing
under five child morbidity and mortality. In this regard the study has looked
into postnatal care (PNC) and recognition of child illness. According to Sierra
Leones Reproductive, New-born and
Child Health Strategy (2011), a mother
should receive PNC on day 1, 2 and7
and 6 weeks postpartum. The study
reveals that despite 84% (95% CI 73%95%) of the interviewed mothers confirmed they attended PNC visits, over
26% were unable to provide the exact
number of PNC visits; and only 13%
(95% CI 2%-24%) reported to have
attended 4 or 5 visits.

Hygiene

thing wrong is done, however more

violent modalities are also used includ-

Access to clean water, sanitation and

ing corporal punishment. Teenage

hygiene (WASH) facilities, and practice

mothers interviewed expressed an

of hygiene behaviours are necessary to

understanding of what the major dan-

avoid childhood illness including diar-

gers for a child are, and what needs to

rhoea, particularly in a country where

be done to prevent injuries to occur.

20% of the deaths in children under 5

Yet, contrary to older women that tend

are related to this, and other similar

to leave the children with young family

diseases. The study, found that many

members, 42% (95% CI, 28%-56%) of

mothers (38%, 95% CI 25%-51%) re-

the respondents say they leave the

ported using packet water and 67%

child with an adult member of the fam-

(95% CI 57%-86%) of them reported

ily reducing the risk to the child.

treating the water prior providing it to

the child, irrespective of the source.

Maternal Experience

Whilst hand washing is largely accept-

This study aimed to explore the feeling

ed to be one of the most important

adolescent mothers have with regards

hygiene behaviours it was concerning

to the experience of being a mother at

As for child illness, the ability of the

to find that almost half of respondents

such an early age. The results reveal

mother to recognize it is paramount

(45%, 95% CI 30%-60%) were only able

the mothers frustration when the

for early access to health services. The

to list two of the five critical hand

child doesnt eat or sleep, and behave

study shows that many interviewed

washing times.

badly as they perceived it as the result

teenagers could list symptoms however only 9% (95% CI 1%-17%) of them

were able to provide more than four

Sleeping, Play and Discipline, Child Protection

of their inexperience and young age.

Furthermore, several of the mothers
who showed little, or incorrect under-

danger signs with the majority only

Another important component con-

standing of pregnancy and childbirth

able to list two. Furthermore, only 39%

tributing to a childs health and wellbe-

believe this is due to their age. Anoth-

(95% CI 26%-52%) took the child to the

ing is sleep. Most mothers could iden-

er source of negative feeling is the

health facility in case of fever. Indeed,

tify signs of tiredness in their child and

experienced lack of support from the

the majority (45%, 95% CI 31%-59%)

encouraged naps during the day alt-

childs father. Some interviewed moth-

report going directly to the pharmacy

hough the length of day sleeping was

ers reported experiencing difficulty in

as, due to drug shortages at health

not found to be associated with the

finding time for breastfeeding, instead

facilities, they are referred to the phar-

age of the child. Most concerning was

allocating as much time as possible

macy anyway by the nurse.

the high proportion of children who

earning income as they needed to earn

did not sleep under a net, 44% (95% CI

on their own to the detriment of the

30% - 60%) with this percentage found

childs nutritional status.

before the hospital, I rather go to the pharmacy, if I

to be higher in urban areas.

4

Conclusion and
Recommendations
Sandra Calligaro

Conclusion

our findings suggest that more support

lighted the important role that social

is needed during pregnancy and neo-

attitudes play in determining the

The study provides information sup-

natal

on

health seeking and feeding practices of

porting the need for a multisectoral

breastfeeding and Infant and Young

adolescent mothers, in particular the

response to provide more efficient and

Child Feeding (IYCF) is key to making a

attitudes of healthcare workers, fa-

appropriate support to teenage moth-

mother feel more confident in her abil-

thers, and the community. More must

ers. This support should be provided at

ities, and ultimately, to increase nutri-

be done to reduce stigma of teenage

each phase of motherhood, although

tion for infants. The study also high-

parenthood, only by doing so teenag-

periods.

Counselling

ers themselves will seek the support

they

deem

necessary.

3.

Reduce stigma among healthcare

7.

Shelter and associated services:

Education,

workers (HCW): Training on how

given the large proportion of

health, social services, must all be fully

to minimise social stigma of teen-

women who reported being forci-

engaged to provide teenage mothers

age mothers should be provided

bly excluded from home, emer-

with the holistic support they need to

to HCWs to enable adolescent

gency shelters could provide short

raise healthy, productive children. In

centred services. Such training

term accommodation for pregnant

Sierra Leone, 27% of female adoles-

could be on the job training, and

teenagers who have no alterna-

cents are mothers. Investment in both

ideally would involve teenage

tive. Shelters could also serve as

mother and child is absolutely neces-

mothers themselves, and the use

an important vehicle for health

sary to reduce morbidity and mortality,

of participatory methods.

and nutrition education, to ensure

and to foster better health, education

4.

and social outcomes for a new genera-

Establish peer support mecha-

better outcomes.

nisms: the mother-to-mother peer

tion.

groups model is well established in

Recommendations

Sierra Leone, and is used widely by

NGOs for behaviour change out-

1.

Harness the potential of ANC: ANC

comes.

is a well established service

groups for teenage mothers would

amongst teenage mothers in Sier-

be beneficial in creating a safe

ra Leone. Given that ANC is often

space for mothers to learn about

the first point in the continuum of

parenting skills, but could also

care, the opportunity should be

serve as an informal emotional

harnessed

quality

support mechanism for mothers

health education on having a

who are having difficulties in deal-

healthy

Mothers

ing with stress levels. Breastfeed-

should also be educated on the

ing counselling and IYCF education

delivery so that they know how to

should be included as part of the

prepare themselves mentally and

curriculum for these groups.

to

provide

pregnancy.

physically. This may minimise unnecessary stress caused by a lack

of knowledge on basic physiology.
2.

5.

Establishing

specific

Conduct further research on potential income generating activities: Access to financial resources

Augment PNC attendance: Inte-

is key to enabling teenage moth-

grate family planning into PNC

ers to establish a sense of control

services, and augment percentage

over their own and the childs

of teenage mothers who are ac-

health.

cessing these services at the recommended

times.

Nutrition

should be integrated into all service delivery packages (as outlined

in RMNCH strategy). Breastfeeding
counselling and counselling for
appropriate IYCF could be further
researched to ensure adequate
care and support is given to lactating mothers.

6. Establish programmes to enable

teenage mothers to re-enter the
education

system:

programmes

that provide low cost or free childcare that enable mothers to go

back to school were seen to be
effective in Koinadugu. Scaling up
similar projects could serve well to
increase education rates among
teenage mothers.

Endnotes
1

UNICEF, Every Child Counts, 2013

The Lancet Series, Maternal and Child Undernutrition: global and regional exposures and health consequences, 2008

Government of Sierra Leone, National SMART Survey, 2014

Care practices include care for women, breastfeeding and feeding practices, psycho-social care, food preparation, hygiene

practices and home health practices. UNICEF 1997

5

Chaaban and Cunningham (2011), The World Bank; Measuring the Economic Gain of Investing in Girls: 30% - Uganda; Nigeria

27%; Malawi - 26%

6

UNICEF Sierra Leone (2010). A glimpse into the world of teenage pregnancy in Sierra Leone.

Dollar D. & Gatti R. (1999). Gender Inequality, Income, and Growth: Are Good Times Good for Women? World Bank Policy

Research Report on Gender and Development, Working Paper Series 1. Washington, D.C: World Bank.
8

The National SMART Survey conducted in June 2014 revealed an improvement in the data on early initiation to breastfeeding

and exclusively breastfeeding, respectively 54.9% and 58.8%.