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

The capacity of health systems to provide quality care for pregnant adolescents remains underexplored. This study examined the quality, continuity, and experiences of maternal healthcare among pregnant adolescents (<20 years) compared with adult women (20 + years) in Ethiopia, Kenya, and South Africa. It also explored factors associated with mistreatment and obstetric complications among adolescents using data from the Maternal and Newborn Health eCohort study. We followed 3,051 pregnant women from their first antenatal care (ANC) visit until six weeks postpartum. We used descriptive analyses to compare care quality and outcomes and logistic regression to identify factors among adolescents. The study included 380 adolescents and 2,671 adults. Adolescents had lower first-trimester ANC attendance (22% vs. 30%, p = 0.003), fewer follow-up ANC visits (mean 3.1 vs. 3.8, p < 0.001), and lower adherence to iron-folic acid supplementation (59.0% vs. 69.4%, p < 0.001). Continuity of care was also lower (53% vs. 59%, p < 0.001). Adolescents experienced more mistreatment during delivery (26.9% vs. 18.6%, p = 0.003). Obstetric complications occurred in 31% of adolescents compared with 25.9% of adults. Mistreatment was associated with rural residence (adjusted odds ratio (aOR): 2.61, 95% CI: 1.11–6.13, p = 0.028), public facility use (aOR: 4.33, 95% CI: 1.44–13.1, p = 0.009) and intimate partner violence (IPV) (aOR: 3.31, 95% CI: 1.16–9.39, p = 0.025). Protective factors included being in Kenya (aOR: 0.19, 95% CI: 0.05–0.75, p = 0.018), privacy during delivery (aOR: 0.44, 95% CI: 0.21–0.92, p = 0.030) and high perceptions of quality of care (aOR: 0.37, 95% CI: 0.18–0.76, p = 0.007). Obstetric complications were associated with rural residence (OR: 2.25, 95% CI: 1.09–4.63; p = 0.028) and antenatal depression (OR: 2.43, 95% CI: 1.19–5.00, p = 0.015). These findings highlight gaps in adolescent maternal healthcare. Strengthening adolescent-responsive and respectful care within primary healthcare, alongside integrated mental health and IPV support, may improve adolescents’ maternal healthcare experiences and outcomes.