Exploring Adolescent Pregnancy Expectations in Continuity of Midwifery Care: A Qualitative Study in Indonesia

Introduction: Adolescent pregnancy presents a significant challenge to global reproductive health, including in Indonesia. The unique obstacles that young pregnant women encounter when seeking appropriate and supportive healthcare services call for a deeper understanding to improve maternal care. Purpose: This study aims to explore the expectations of young pregnant women regarding continuous midwifery care in Indonesia. Method: This research employed an exploratory qualitative approach, conducting 13 face-to-face interviews between January and June 2022. Participants included midwives, young mothers, a coordinating midwife, and Mother and Child Health (MCH) program holders. Interviews, lasting 1-1.5 hours, were conducted, and the interview data were rigorously analyzed thematically by the research team, strengthening data reliability through triangulation. Results: Continuity management emphasizes friendly service, privacy, clear communication, and comprehensive health assessments. Informational continuity involves comprehensive information, direct communication, attractive aids, and health education evaluation. Relational continuity highlights comprehensive maternal care, family tradition approval, reminders, and efficient care. The study underscores the importance of tailored, holistic, and culturally sensitive midwifery care for young pregnant women's overall well-being. Conclusion: This study highlights adolescent pregnant women's unique needs, focusing on continuity management, informational continuity, and relational continuity. Proposed strategies include tailored health services, comprehensive maternal education, cultural sensitivity training for healthcare providers, policy integration, and diverse research. Successfully implementing these measures can significantly enhance maternal care outcomes for Indonesian adolescents.


INTRODUCTION
Adolescent pregnancy is a serious public health issue in low-and middleincome countries.Approximately 21 million girls aged 15 to 19 and 2 million girls under the age of 15 experience pregnancy each year in developing countries (Manhica et al., 2021;Musinguzi et al., 2022;WHO, 2017).The maternal mortality rate is estimated to be three times higher for ages 15-19 compared to women aged 20-24 (Akseer et al., 2022;Sewpaul, Crutzen, Dukhi, Sekgala, & Reddy, 2021).Adolescent pregnancy increases the risk of obstetric complications, gestational diabetes, anemia, hypertension disorders during pregnancy, and concurrent diseases compared to adult women (Govender, Taylor, & Naidoo, 2020).It is also associated with the risk of premature birth, low birth weight, infant mortality, and respiratory problems (Kemenkes RI, 2022).
In the context of Indonesia, the prevalence of adolescent pregnancy raises serious concerns.Many adolescent pregnancies resort to unsafe abortion methods, leading to complications such as pregnancy-related hypertension, endometriosis, and eclampsia, making unsafe abortion a primary cause of death among adolescent pregnancy (Akseer et al., 2022;Jahdi et al., 2019).Research indicates that infants born to mothers under 20 years old face a high risk of premature birth, low birth weight, congenital abnormalities, fatal neonatal issues requiring intensive care, and a high likelihood of death within the first seven days of life (Hackett et al., 2019).Within the Association of South East Asian Nations (ASEAN) region, Indonesia consistently holds the second-highest rate of adolescent pregnancies (Karaçam, Kizilca Çakaloz, & Demir, 2021).In Indonesia, 45.10% of first-time pregnant women are under 20 years old, with the percentage being 33.7% in West Sumatra.Moreover, the highest percentage of women under 20 receiving pregnancy care support is in Padang City, reaching 23.06%, followed by Padang Panjang City (20.45%),Bukittinggi City (19.28%), and Pariaman City (15.37%) (Kemenkes RI, 2022).
In addition to health risks, adolescent pregnancy faces social stigma and societal barriers.The social stigma surrounding adolescent pregnancy results in feelings of isolation, decreased self-esteem, and difficulties in seeking the necessary support and healthcare services (A.W Astuti, 2018;Jittitaworn, Fox, Catling, & Homer, 2020;Sewpaul et al., 2021).The current healthcare landscape remains insufficient in addressing the unique needs of adolescent pregnancy.The absence of an approach tailored to the nuances of adolescence, coupled with a lack of emotional support and adequate information, poses challenges in midwifery services (Cibralic et al., 2023;Rayment-Jones, Silverio, Harris, Harden, & Sandall, 2020).
This research aims to explore the expectations held by adolescent pregnancy regarding the continuity of midwifery care.This focus is significantly important as it enables a better understanding and proactive addressing of the obstacles they encounter (UNICEF & UNFPA, 2023).Through an in-depth comprehension of the perspectives and aspirations of these young women, healthcare providers, policymakers, and researchers can collaborate to shape services that are not only supportive and informative but also tailored to the unique needs of pregnant young women.The collective aim is to have a positive impact on the holistic well-being of both pregnant young women and unborn children while simultaneously working to eliminate the stigma associated with adolescent pregnancy.

METHODS
This research adopts an exploratory qualitative approach guided by the theoretical concept of the Midwifery Care Continuity pyramid proposed by Sandall, (2017), which encompasses continuity in management, information, and relationships.The chosen design aims to delve into the expectations of young pregnant women regarding continuous midwifery care, utilizing in-depth interviews as the data collection method.The study was conducted in Padang City in June 2022, involving 4 independent practicing midwives, 5 young mothers, 1 coordinating midwife, and 3 individuals responsible for the Mother and Child Health (MCH) program at the local health center as participants.The primary instrument for qualitative research was the researcher herself, and the facilitating researchers were midwives with a Master's degree in Midwifery.
Qualitative data collection involved in-depth interviews using tools such as a voice recorder, camera, and writing instruments.The lead researcher, a midwife with a Master's degree in Midwifery, acted as the facilitator.The interviews followed a prepared guide to ensure comprehensive coverage of the topics.Sample selection utilized purposive sampling, choosing participants based on characteristics and experiences relevant to the research topic.The sample included 4 independent practicing midwives, 5 young mothers, 1 coordinating midwife, and 3 MCH program holders.While purposive sampling provides rich and in-depth information, it introduces the potential for selection bias.
Participants were intentionally recruited based on their relevance to the research topic.Inclusion criteria ensured their direct involvement or experience with midwifery care for teenage pregnancies.However, it is acknowledged that this method may introduce bias as participants were not randomly selected.The determination of the sample size was based on achieving saturation, where no new information or themes emerged from the data.A total of 13 face-to-face in-depth interviews were conducted, involving midwives, young mothers, coordinating midwives, and MCH program holders.
In-depth interviews, conducted between January and June 2022, lasted approximately 1-1.5 hours per session.The interview guide comprised open-ended questions exploring participants' experiences, expectations, and challenges related to the continuity of midwifery care for teenage pregnancies.Interviews were conducted at participants' homes, in both the Indonesian and local languages, to ensure clarity and depth.To enhance the validity and reliability of the data, a rigorous data analysis process was employed.Thematic analysis was collectively conducted by the research team, involving the re-reading of transcripts and the development of analytical categories.This triangulation approach ensured the reliability of the qualitative data.

RESULT
The characteristics of the informants in this study are as follows in Table no 1.Through the voices of the informants, this qualitative study illuminates the multifaceted expectations of young pregnant women regarding continuous midwifery care.The research delved into three essential dimensions: continuity management, informational continuity, and relational continuity.These dimensions were explored through the direct expressions of the participants, offering intricate insights into their experiences and expectations.Health Assessment: A common theme emerged around the desire for comprehensive yet sensitive health assessments.As one informant articulated, "Only check the important things so that we are not embarrassed or uncomfortable (Informant 04b)."This aspiration reflects a quest for thorough examinations that also prioritize emotional well-being.Communication of Health Issues/Diagnosis/Conditions: Clarity in communication and comprehensive understanding of health-related matters surfaced in the words of an informant, "More in-depth counseling about what the complaint is and an explanation of the examination results (Informant 01b)."

Dimension of Continuity Management
Appropriateness of Care Plans: The significance of well-suited care plans was highlighted by an informant's words, "Getting the best service, which makes you comfortable.The young pregnant woman wants her complaints to be heard by the midwife, she is very happy when we pay attention to her, so we hope that we will pay more attention (Informant 02c)."Implementation and Evaluation: Emphasis on ongoing monitoring and evaluation of care came through, as one informant stated, "Ask for complaints again on the previous visit, hoping that the complaints will go away if they are still felt a solution will be given to overcome them (Informant 01a)."Information Needs: Young pregnant women sought a deeper understanding across various aspects of maternal health.An informant expressed, "Pregnant women hope to enjoy their pregnancy by getting education on patterns of sexual relations, the need for rest, knowledge about amniotic fluid, nutritional information, danger signs of pregnancy, preparation for delivery, and use of family planning (Informant 04b)."HealthEducation Method: The importance of interactive and engaging health education methods was stressed by an informant, "Information during pregnancy, overcoming labor pain, baby health (Informant 01a)." Preferred Health Education Media: The desire for diverse educational resources beyond traditional tools was captured in the words, "We need other book media that can help add to the lack of information in the MCH handbook (Informant 02b)."Evaluation of Health Education: The call for post-education assessments was echoed, "We need media or tools other than the MCH handbook that can answer all the complaints of pregnant women (Informant 01a)."Comprehensive Care: An informant conveyed the importance of holistic care that aligns with young pregnant women's needs, stating, "Perfect match (Informant 04c)."Cultural Understanding: The need for culturally sensitive care that respects individual beliefs and practices was emphasized, "Appreciated, understood, and we approve.Of course, their expectations are influenced by the culture and knowledge of their parents (Informant 01c)." Involvement and Continuity: The desire for continuous engagement and support from midwives was evident, "It is hoped that the midwife's control will be further improved, starting from pregnancy to delivery and also the family planning plan (Informant 04e)."Effective and Efficient Care: Effective communication and timely provision of relevant information were seen as crucial, "Complete data information in the MCH handbook or on the pregnant woman's status sheet, as well as the information provided according to the mother's needs (Informant 03a)." Privacy and Safety: Balancing privacy, confidentiality, and quality care emerged as a concern, "Mother, I hope the secret will be kept secret, our door will be closed during the examination, Mother will tell you personally if you want (Informant 01a)."Through the informants' narratives, this study weaves a tapestry of expectations, underscoring the importance of tailored, holistic, and culturally sensitive midwifery care.This approach is essential for addressing the needs and aspirations of young pregnant women, ultimately contributing to their overall well-being and positive maternal experiences.

DISCUSSION
The findings of this research offer profound insights into the expectations and needs of adolescent pregnancies regarding continuous midwifery care in Indonesia.

Management Continuity
The emphasis on sensitive and high-quality health assessments for adolescent pregnancies indicates the need for improvements in adolescent-friendly healthcare services (Erasmus, Knight, & Dutton, 2020;Hackett et al., 2019).Adolescent-friendly health services have demonstrated a positive impact on increasing the involvement of adolescent pregnancies in maternal healthcare.This underscores the necessity of adjusting healthcare approaches to meet the specific needs of adolescents, taking into account the local social and cultural context in Indonesia.

Informational Continuity
The importance of informational continuity emerges as a critical factor in the care of adolescent pregnancies (Shatilwe, Hlongwana, & Mashamba-Thompson, 2022).The urgent need to provide accurate and relevant information suggests the necessity for improvements in communication strategies.It is recommended that information be delivered in a specific and targeted manner, addressing issues such as gender equality, domestic violence, childbirth readiness, and other relevant aspects (Sandall, 2017).This targeted approach is expected to enhance the understanding and engagement of adolescent pregnancies in their care.

Relational Continuity
The significance of a continuous relationship between adolescent pregnancies and healthcare providers is highlighted as a key factor (Astuti, Hirst, & Bharj, 2020).Effective communication and the establishment of positive trust are identified as crucial elements that can have a positive impact on the overall quality of maternal care.Therefore, it is essential to emphasize the importance of building strong relationships between healthcare providers and adolescent pregnancies to ensure effective and continuous care.
In the context of international comparisons, these findings align with the study by D. Govender et al. (2020) in South Africa, which emphasizes the need for responsiveness to the cultural and social values of adolescent pregnancies in maternal care (Govender, Naidoo, & Taylor, 2020;Govender, Taylor, et al., 2020).The implications drawn from these findings are that in developing effective maternal care, healthcare providers in Indonesia need to consider the cultural and social diversity of adolescent pregnancies.In the context of adolescents' expectations regarding culture, the results of this study can serve as a foundation to better understand how cultural norms influence the expectations and needs of adolescent pregnancies.Early marriages and pregnancies, conflicting with injunctive and descriptive cultural norms, may reflect a shift in adolescent values related to marriage and pregnancy.Therefore, it is essential to consider how cultural influences can be integrated into more effective maternal care strategies (Maly et al., 2017).
In a policy context, this research suggests the need for specific and targeted models of continuous midwifery care for adolescent pregnancies, developing maternal care strategies focused on the specific needs of adolescent pregnancies rather than generalized maternal care (Erika, 2019).The integration of adolescent-friendly healthcare services, the provision of more specific information tailored to their needs, and increased training for healthcare providers could enhance the quality of care and engagement of adolescent pregnancies (Susanti et al., 2022).
Despite offering valuable insights, it is important to acknowledge several limitations.The limited sample coverage in a specific region may restrict the generalization of these findings to the entire population of adolescent pregnancies in Indonesia.Therefore, further research with a more representative sample across different regions of Indonesia is needed to validate and expand these findings.For future research, it is recommended to explore the potential impact of the proposed care strategies and measure their effectiveness in improving maternal health outcomes among adolescent pregnancies in Indonesia.Comparative research that compares these findings with existing literature can provide a deeper understanding of the local context and global variations in maternal care.

CONCLUSION AND RECOMMENDATION
In conclusion, this study provides profound insights into the expectations of adolescent pregnant women regarding continuous midwifery care in Indonesia.The three identified dimensions-continuity management, informational continuity, and relational continuity-underscore the critical aspects that need attention to cater to the unique needs of this demographic.The emphasis on sensitive health assessments highlights the importance of prioritizing emotional well-being and personalized care plans for adolescent pregnant women.Continuous evaluations and monitoring throughout the maternal journey are crucial to address the evolving needs of this specific group.The significance of informational continuity brings attention to the demand for diverse maternal health information, interactive education, and culturally sensitive care.Tailoring health services to meet these specific needs is imperative for ensuring the well-being of adolescent pregnant women.The importance of relational continuity stresses the need for trustworthy relationships between healthcare providers and adolescent pregnant women.Culturally attuned support, effective communication, and mutual trust are identified as key elements for ensuring a positive impact on the overall quality of maternal care.
The recommendation from this study; Healthcare systems should prioritize the development of tailored health services that address the unique needs of adolescent pregnant women.This includes implementing sensitive health assessments, continuous monitoring, and personalized care plans.There is a need for comprehensive maternal health education that is interactive, culturally sensitive, and addresses the diverse informational needs of adolescent pregnant women.Educational resources should cover a range of topics, including gender equality, domestic violence, childbirth preparedness, and other relevant aspects.Healthcare providers should undergo cultural sensitivity training to ensure that they can offer culturally attuned support to adolescent pregnant women.This training should emphasize effective communication and the building of trustful relationships.Policymakers should integrate the identified dimensions of continuity management, informational continuity, and relational continuity into maternal care policies.This integration will contribute to creating a healthcare environment that meets the expectations and needs of adolescent pregnant women.
Future research should involve a more diverse participant pool to ensure a comprehensive understanding of the expectations and needs of adolescent pregnant women.This will contribute to the development of more targeted and effective maternal care services.By implementing these recommendations, healthcare systems and policymakers can work towards redefining continuous midwifery care to better suit the expectations of adolescent pregnant women in Indonesia, ultimately improving maternal care outcomes for this specific demographic.

Table 1 .
The characteristics of the informants

Table 2 .
Triangulation Matrix of Expectations of Young Pregnant Women Regarding Continuous Midwifery Care in the Dimension of Continuity Management

Table 3 .
Dimension of Informational Continuity

Table 4 .
Dimension of Relational Continuity