Characterizing the cascades of care experienced by pregnant adolescents in three African countries; 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 of care and adverse delivery outcomes (mistreatment and obstetric complications) among pregnant adolescents in Ethiopia, Kenya, and South Africa using data from the MNH eCohort longitudinal survey. This study followed 3,051 pregnant women from their first antenatal care (ANC) visit to postpartum period. We used descriptive analysis to compare outcomes between adolescents (<20) and adults (20+), and logistic regression to identify factors associated with mistreatment and adverse delivery outcomes among adolescents. A total of 380 adolescents (mean age 18) and 2,671 adults (mean age 28) were included in the analysis. Adolescents were more likely to be unmarried (63%), particularly in Kenya (53%) and South Africa (99%), while most in Ethiopia were married (95%). Education level varied, with many Ethiopian adolescents lacking formal education. Only 23% of adolescents attended their first ANC visit in the first trimester compared to 30% of adults (p=0.003), with lower follow-up testing and adherence to iron and folic acid supplementation. The mean ANC visits was 3.8, with higher levels among adults in Ethiopia and Kenya. Over 95% of women delivered in health facilities, but consent for vaginal examinations was low (46%). Mistreatment was reported by 20% of women, with higher rates among adolescents (27% vs. 19%, p=0.003). A higher risk of obstetric complications was associated with rural residence (OR: 2.25, 95% CI: 1.09-4.63) and antenatal depression (OR: 2.43, 95% CI: 1.19-5.00). Mistreatment was associated with rural residence, public facility visits, and experiencing intimate partner violence. Kenyan adolescents, privacy during delivery, and high quality of care rating care were protective factors for mistreatment. Adolescents face critical gaps in maternal healthcare, requiring strengthened adolescent-friendly services, rural healthcare investments, and respectful maternity care policies to improve outcomes.