ABSTRACT

Objective:

To identify barriers to and facilitators of access to perinatal mental health services among pregnant adolescents and young mothers in Belize.

Methods:

This was an exploratory descriptive qualitative study using focus group discussions conducted in August 2023. The study sample was selected through purposeful sampling. Participants included pregnant adolescents, adolescent mothers and young mothers from rural and urban areas in three regions of the country (Southern, Northern, and Western). The data were analyzed using thematic analysis and the results were organized into themes.

Results:

The barriers and facilitators identified fell into four themes. The first theme was individual factors and showed that respondents had good knowledge about mental health problems and a desire to seek mental health services. However, awareness about their availability was limited. The second theme was health systems and highlighted a lack of trust and confidence in health care providers, as well as limited access to mental health services due to insufficient human resources, long waiting times, and transportation costs. The third theme was stigma about teenage pregnancy and mental health issues. The fourth theme was social support, with both family and peer group support identified as facilitators for help-seeking among the respondents.

Conclusion:

This study highlights important barriers to using mental health services for pregnant adolescents and young mothers in Belize. These include stigma, lack of awareness of mental health services, and limited access to them. Implementing targeted strategies to address the barriers are recommended to improve provision and uptake of mental health services among the study population.

Keywords:
Pregnancy in adolescence; adolescent mothers; mental health; mental health services; Belize

RESUMEN

Objetivo.

Determinar los factores que obstaculizan o facilitan el acceso a los servicios de salud mental perinatal en las adolescentes embarazadas y las madres jóvenes en Belice.

Método.

Se realizó un estudio cualitativo descriptivo y exploratorio mediante grupos de opinión que tuvieron lugar en agosto del 2023. La población del estudio se seleccionó mediante muestreo intencional. Participaron adolescentes embarazadas, madres adolescentes y madres jóvenes de zonas rurales y urbanas de tres regiones del país (sur, norte y oeste). Se realizó un análisis temático de los datos y se organizaron los resultados en temas.

Resultados.

Los obstáculos y los factores facilitadores señalados se organizaron en torno a cuatro temas. El primer tema fueron los factores individuales y mostró que las participantes tenían buenos conocimientos sobre los problemas de salud mental y deseaban buscar servicios de salud mental. Sin embargo, lo que sabían sobre los servicios disponibles era limitado. El segundo tema fueron los sistemas de salud y puso de relieve la falta de confianza en los prestadores de atención de salud, así como el acceso limitado a los servicios de salud mental debido a los recursos humanos insuficientes, los largos tiempos de espera y los costos de transporte. El tercer tema fue la estigmatización en torno al embarazo adolescente y los problemas de salud mental. El cuarto tema fue el apoyo social, y las participantes señalaron que tanto el apoyo de la familia como el del grupo de pares facilitaban la búsqueda de ayuda.

Conclusiones.

Este estudio pone de relieve los obstáculos importantes que dificultan el uso de los servicios de salud mental para las adolescentes embarazadas y las madres jóvenes en Belice. Entre ellos se encuentran la estigmatización, la falta de conocimiento sobre los servicios de salud mental y el acceso limitado a ellos. Se recomienda aplicar estrategias específicas para abordar los obstáculos a fin de mejorar la prestación y la aceptación de los servicios de salud mental en la población de estudio.

Palabras clave:
Embarazo en adolescencia; madres adolescentes; salud mental; servicios de salud mental; Belice

RESUMO

Objetivo.

Identificar barreiras e facilitadores de acesso a serviços de saúde mental perinatal entre adolescentes grávidas e mães jovens em Belize.

Métodos:

Estudo qualitativo descritivo exploratório conduzido por meio de discussões em grupos focais realizadas em agosto de 2023. A amostra do estudo foi selecionada por meio de amostragem intencional. As participantes incluíram adolescentes grávidas, mães adolescentes e mães jovens de áreas rurais e urbanas de três regiões do país (sul, norte e oeste). Os dados foram analisados por meio de análise temática, e os resultados foram organizados em temas.

Resultados:

As barreiras e os facilitadores identificados foram divididos em quatro temas. O primeiro tema abordado foram fatores individuais; determinou-se que as entrevistadas tinham bom conhecimento sobre problemas de saúde mental e expressavam o desejo de buscar serviços de saúde mental; no entanto, o conhecimento sobre sua disponibilidade era limitado. O segundo tema referia-se aos sistemas de saúde e revelou a falta de confiança nos prestadores de serviços de saúde, bem como o acesso limitado aos serviços de saúde mental devido à escassez de recursos humanos, aos longos tempos de espera e aos custos de transporte. O terceiro tema foi o estigma associado à gravidez na adolescência e aos problemas de saúde mental. O quarto tema foi apoio social; tanto o apoio da família quanto o de um grupo de apoio entre pares foram identificados como facilitadores da busca de ajuda entre as entrevistadas.

Conclusão:

Este estudo destaca importantes barreiras ao uso de serviços de saúde mental por adolescentes grávidas e mães jovens em Belize. Entre essas barreiras estão o estigma, a falta de conhecimento sobre os serviços de saúde mental e o acesso limitado a esses serviços. Recomenda-se a implementação de estratégias específicas para abordar as barreiras a fim de melhorar a oferta e a aceitação dos serviços de saúde mental na população do estudo.

Palavras-chave
Gravidez na adolescência; mães adolescentes; saúde mental; serviços de saúde mental; Belize

Adolescent pregnancy, defined as pregnancy in 10–19-year-old females, is a public health concern with well documented causes and serious health, social, and economic consequences (¹1. World Health Organization Adolescents pregnancy [internet]. Geneva: WHO; 2024 [cited 2024 Jun 4]. Available from: https://www.who.int/news-room/fact-sheets/detail/adolescent-pregnancy
https://www.who.int/news-room/fact-sheet... ). Although the global adolescent birth rate has decreased, from 64.5 births per 1 000 females aged 15–19 years in 2000 to 41.3 births in 2023, the rate of change has been uneven across regions. Substantial variations exist in the adolescent birth rate both between and within countries with the Latin American and the Caribbean and sub-Saharan African regions experiencing slower declines. In 2023, sub-Saharan Africa, and Latin America and the Caribbean continued to have the highest adolescent birth rates globally at 97.9 and 51.4 births per 1 000 females aged 10–19 years, respectively (¹1. World Health Organization Adolescents pregnancy [internet]. Geneva: WHO; 2024 [cited 2024 Jun 4]. Available from: https://www.who.int/news-room/fact-sheets/detail/adolescent-pregnancy
https://www.who.int/news-room/fact-sheet... ).

Globally, factors associated with adolescent pregnancy include early union and child marriage, child sexual abuse, limited knowledge, and lack of access to sexual and reproductive health services (²2. Sully EA, Biddlecom A, Daroch J, Riley T, Ashford L, Lince-Deroche N, et al. Adding it up: investing in sexual and reproductive health 2019. New York, NY: Guttmacher Institute; 2020.). Adolescent parenthood is associated with adverse outcomes for young mothers, such as mental health problems including depression, anxiety, self-harm, substance abuse, and post-traumatic stress disorder (³3. Fisher J, Cabral de Mello M, Patel V, Rahman A, Tran T, Holton S, et al. Prevalence and determinants of common perinatal mental disorders in women in low- and lower-middle-income countries: a systematic review. Bull World Health Organ. 2012:90(2):139–49. https://doi.org/10.2471/BLT.11.091850
https://doi.org/10.2471/BLT.11.091850... ). Perinatal mental health problems are significant contributors to maternal morbidity and mortality, and are associated with poor maternal and neonatal outcomes (e.g., pre-eclampsia, hemorrhage, premature delivery, and stillbirth), and suicide (⁴4. Howard LM, Khalifeh H. Perinatal mental health: a review of progress and challenges. World Psychiatry. 2020;19(3):313–27. https://doi.org/10.1002/wps.20769
https://doi.org/10.1002/wps.20769... ). Mental health services for mothers are not just about addressing problems; they also nurture an environment where mothers can thrive, ensuring they have the emotional strength to foster the same in their children (³3. Fisher J, Cabral de Mello M, Patel V, Rahman A, Tran T, Holton S, et al. Prevalence and determinants of common perinatal mental disorders in women in low- and lower-middle-income countries: a systematic review. Bull World Health Organ. 2012:90(2):139–49. https://doi.org/10.2471/BLT.11.091850
https://doi.org/10.2471/BLT.11.091850... ).

Depression in pregnancy has been linked with adverse birth outcomes such as preterm birth and low birth weight, while postpartum depression is associated with poor cognitive outcome and psychiatric morbidity in childhood and adolescence (⁴4. Howard LM, Khalifeh H. Perinatal mental health: a review of progress and challenges. World Psychiatry. 2020;19(3):313–27. https://doi.org/10.1002/wps.20769
https://doi.org/10.1002/wps.20769... ). The prevalence of depression among adolescent mothers is higher than among adult mothers and non-pregnant adolescents, with rates estimated between 16% and 44% compared with 5% and 20% among adult pregnant mothers and non-pregnant adolescents (⁴4. Howard LM, Khalifeh H. Perinatal mental health: a review of progress and challenges. World Psychiatry. 2020;19(3):313–27. https://doi.org/10.1002/wps.20769
https://doi.org/10.1002/wps.20769... ). In the Latin American and Caribbean region, the prevalence of psychological distress and suicidal behaviors among pregnant adolescent ranges between 13% and 67% (⁵5. Wilson-Mitchell K. Factors associated with adolescent pregnancy, psychological distress, and suicidal behavior in Jamaica: an exploratory study. J Midwifery Womens Health. 2014;59(5):552. https://doi.org/10.1111/jmwh.12248
https://doi.org/10.1111/jmwh.12248... ).

In Belize, the adolescent birth rate was 44.0 per 1 000 females aged 15–19 years in 2023 compared with the Latin American and Caribbean regional average of 51.4 per 1 000 female aged 15–19 years (⁶6. World Bank Group. Adolescent fertility rate (births per 1,000 women ages 15–19) [internet]. Washington, DC: Worlds Bank; 2024 [cited 2024 Jun 5]. Available from: https://genderdata.worldbank.org/en/indicator/sp-ado-tfrt
https://genderdata.worldbank.org/en/indi... ). Data on adolescent mental health in Belize are limited; however, the three primary mental health-related causes for admission to hospital in adolescents are substances use, attempted suicide and disorders due to anxiety and stress (⁷7. Government of Belize, UNFPA, PAHO, UNICEF. Belize adolescent health national strategic plan 2019–2030. Belize City: UNICEF Belize; 2022 [cited 2024 Dec 2]. Available from: https://www.unicef.org/belize/media/2486/file/Adolescent%20Health%20National%20Strategic%20Plan%202019-2030.pdf
https://www.unicef.org/belize/media/2486... ). The suicide rate among adolescents aged 15–19 years has increased significantly from 5 per 100 000 in 2013 to 10 per 100 00 in 2017, accounting for 36% of suicides across all age groups in the country (⁷7. Government of Belize, UNFPA, PAHO, UNICEF. Belize adolescent health national strategic plan 2019–2030. Belize City: UNICEF Belize; 2022 [cited 2024 Dec 2]. Available from: https://www.unicef.org/belize/media/2486/file/Adolescent%20Health%20National%20Strategic%20Plan%202019-2030.pdf
https://www.unicef.org/belize/media/2486... ).

Despite the high prevalence of mental health disorders among adolescent and young mothers and the need for mental health care, studies report many barriers to accessing and using mental health services (⁴4. Howard LM, Khalifeh H. Perinatal mental health: a review of progress and challenges. World Psychiatry. 2020;19(3):313–27. https://doi.org/10.1002/wps.20769
https://doi.org/10.1002/wps.20769... ).

This study aimed to identify barriers to and facilitators of access to perinatal mental health services among pregnant adolescents and young mothers in Belize. It is part of the larger study: Situational analysis of maternal mental health services for adolescents and young mothers in Belize.

METHODS

Study population and setting

Belize, with a population of about 400 000, is divided into four administrative regions and six health districts. Each district has a hospital which supports between three and five primary health care centers. This study was conducted in urban and rural areas of three of the four regions in Belize with large populations of adolescents: the Southern Region (Bella Vista and Dangriga communities); the Northern Region (Orange walk and San Narciso communities), and the Western Region (City of Belmopan and Valley of Peace).

The mental health program in Belize is community-based with most services delivered in mental health clinics located within urban primary health care facilities and community hospitals. However, no figures are available on the prevalence of mental health disorders in Belize since no epidemiological study has been conducted. In order to address the shortage of mental health practitioners in the country, training of psychiatric nurse practitioners was introduced in 1991. Later, the World Health Organization’s mental health Gap Action Programme (mhGAP) was rolled out which aimed at integrating mental health into primary health care. There are eight primary health care centers with mental health clinics, one in each of the six districts and two in Belize City. The clinics operate from Mondays to Fridays, 08:00 to 17:00. Each clinic is staffed with two or three psychiatric nurse practitioners supervised by three psychiatrists who also conduct mobile services and specialist outreach services to health facilities within their respective districts (⁸8. Ministry of Health and Wellness. Belize national mental health policy 2023–2028. Belmopan: Ministry of Health and Wellness; 2023 [cited 2024 Dec 2]. Available from: https://www.health.gov.bz/wp-content/uploads/2023/11/NMH-Policy-Final-Signed.pdf
https://www.health.gov.bz/wp-content/upl... ).

Study design and sampling

This was an exploratory descriptive qualitative study that used focus group discussion to gather data. A purposive sampling method was used to select pregnant adolescents (10–19 years) and young mothers (≤ 24 years) from rural and urban areas in the three regions included in the study.

Data collection and analysis

Data were collected using an interview guide with structured, open-ended questions and guided prompts. The guide was developed based on the existing literature to identify the barriers to and facilitators of use of perinatal mental health service.

Six focus group discussions were held: three with pregnant adolescents (between 10 and 12 adolescents in each group); two with adolescent mothers (between 10 and 12 in each group) in urban and rural areas; and one with young mothers (eight individuals) in rural areas. The respondents were aged 16–24 years. The discussions took place within a designated noise-free area of the health facilities to ensure individual privacy and confidentiality.

The inclusion criteria were: pregnant adolescents who had attended an antenatal care clinic at least once; and adolescent or young mothers who had made at least two antenatal care visits and had made at least one postnatal clinic visit. The exclusion criteria were: pregnant adolescents who had not attended any antenatal care clinic; and young mothers or adolescent mothers who had not attended any clinic either for antenatal care or postnatal care.

Focus group discussions were conducted between 7 and 15 August 2023 and each lasted about 60 minutes. Interviews were audio-recorded to ensure accurate capture of the participants’ responses, transcribed verbatim, and checked against the audiotapes. Data were analyzed using thematic analysis and the result organized into themes.

Ethical approval

Ethical approval was obtained from the Institutional Review Board in the Human Research Protection Program of Yale University, United States of America (ID: 2000035843). Informed signed consent was obtained from all participants enrolled in the study. They were informed that their participation was voluntary and that they were free to leave at any time without giving a reason. Confidentiality of the data was assured and the participants were not asked to provide any details that could be used to identify them.

RESULTS

The barriers and facilitators identified are organized into four themes: factors related to the individual; health system factors; stigma; and social support factors.

Theme 1: factors related to the individual

This theme is divided into two subthemes: 1.1 desire to seek help; and 1.2 awareness of the availability of mental health services.

1.1 Desire to seek help. Many respondents were aware of mental health problems during pregnancy and postpartum, and some were able to communicate how they had felt. They expressed the desire for mental health support, highlighting the need to talk with someone, particularly professionals, who could address their emotional concerns.

1.2 Awareness of the availability of mental health services. Many respondents showed a lack of awareness about the mental health services available at health care facilities. Most of them reported they had no idea where to seek mental health support, despite a desire for help. This issue is compounded by the fact that not all health clinics provide mental health services, contributing to the confusion and lack of awareness among participants.

Theme 2: health system factors

This theme also divided into two subthemes: 2.1 trust and confidence in health care providers; and 2.2 access to mental health services.

2.1 Trust and confidence in health care providers. Although some respondents wanted to access mental health services, many were hesitant to discuss their emotional well-being or worries with health care providers due to distrust, lack of confidence and fear of judgement. Many reported experiencing negative attitudes from health workers during antenatal and postnatal visits related to the stigma associated with teenage pregnancy. Additionally, respondents felt that health workers often did not provide them with enough attention or time to be able to express their feelings and concerns.

2.2 Access to mental health services. Limited access to mental health services was a significant barrier identified by the respondents. Many mentioned non-availability of mental health practitioners in the clinics they attended, especially among respondents in the rural areas. Some complained about the substantial time and transportation cost required to reach facilities where mental health nurses were available. Others expressed concerns about long waiting times at clinics and the inconvenient timing of visits of the mental health nurse, which often conflicted with their other responsibilities.

Theme 3: stigma

Stigma was identified as a key barrier to accessing mental health services. Many respondents indicated that considerable stigma exists around both teenage pregnancy and mental health issues in their communities. Participants reported feeling judged for being young and pregnant by community members and health workers. They expressed concerns that they would be blamed for their mental health problems if seen going to the mental health clinic, as their pregnancies were often viewed as a result of their perceived immaturity.

Theme 4: social support

Participants underscored the importance of social support from family members, particularly their mothers, in managing their emotional concerns. They expressed trust in their mothers and family members, which played a crucial role in helping them make informed decisions, including seeking professional help.

Some respondents also mentioned being motivated by others with similar experiences who successful navigated the challenges and moved forward with their lives in terms of education and careers. They suggested that having peer support group meetings would be a useful platform for seeking help and sharing experiences.

DISCUSSION

The study provides insight into the perspectives of pregnant adolescents and young mothers on barriers to and facilitators of utilization of mental health services. The key factors identified were individual, health system, stigma, and social support factors.

Individual factors

Most of the respondents expressed the desire to seek mental health support and the need to talk to someone, particularly professionals. This may stem from good knowledge and awareness about mental health problems during pregnancy and the postpartum period. Similar findings were reported in a study on pregnant and postpartum Mexican American adolescents who were knowledgeable about the symptoms of mental health problems, particularly perinatal depression (⁹9. Recto P, Dimmitt Champion J. “We don’t want to be judged”: perceptions about professional help and attitudes towards help-seeking among pregnant and postpartum Mexican-American adolescents. J Pediatr Nurs. 2018:42:111–7. https://doi.org/10.1016/j.pedn.2018.04.010
https://doi.org/10.1016/j.pedn.2018.04.0... ). However studies in Jamaica and Uganda in pregnant mothers found significant gaps in knowledge about mental problems during pregnancy and the postpartum period, which hindered the use of perinatal mental health services (¹⁰10. Elmore S. Postpartum depression in Jamaica: exploring the lived experiences [Dissertation]. Louisville, KY: University of Louisville; 2023. https://doi.org/10.18297/etd/4107
https://doi.org/10.18297/etd/4107... , ¹¹11. Nakku J, Okello E, Kizza D, Honikman S, Ssebunnya J, Ndyanabangi S, et al. Perinatal mental health care in a rural African district, Uganda: a qualitative study of barriers, facilitators and needs. BMC Health Serv Res. 2016;16:295. https://doi.org/10.1186/s12913-016-1547-7
https://doi.org/10.1186/s12913-016-1547-... ).

Mental health literacy, defined as “the knowledge and beliefs about mental disorders,” has been found to be associated with appropriate help-seeking behaviors (⁴4. Howard LM, Khalifeh H. Perinatal mental health: a review of progress and challenges. World Psychiatry. 2020;19(3):313–27. https://doi.org/10.1002/wps.20769
https://doi.org/10.1002/wps.20769... ). Even when perinatal health services are available, women in the perinatal period seek less help compared with women in other periods of life (¹²12. Osok J, Kigamwa P, Huang KY, Grote N, Kumar M. Adversities and mental health needs of pregnant adolescents in Kenya: identifying interpersonal, practical, and cultural barriers to care. BMC Womens Health. 2018;18(1);96. https://doi.org/10.1186/s12905-018-0581-5
https://doi.org/10.1186/s12905-018-0581-... ). Studies in Malawi and South Africa and a systematic review on barriers to and facilitators of mental health help-seeking behaviors during the perinatal period indicated that poor mental health literacy and difficulties in recognizing symptoms were barriers to adolescents accessing mental health services, especially pregnant adolescents and young mothers (¹³13. Mhango W, Michelson D, Gaysina D. “I felt I needed help, but I did not get any”: a multiple stakeholder qualitative study of risk and protective factors, and barriers to addressing common mental health problems among perinatal adolescents in Malawi. Glob Ment Health (Camb). 2023;10:e73. https://doi.org/10.1017/gmh.2023
https://doi.org/10.1017/gmh.2023... , ¹⁴14. Spedding MF, Stein DJ, Naledi T, Sorsdahl K. Pregnant women’s mental health literacy and perceptions of perinatal mental disorders in the Western Cape, South Africa. Mental Health Prevent. 2018;11:16–23. https://doi.org/10.1016/j.mhp.2018.05.002
https://doi.org/10.1016/j.mhp.2018.05.00... ). Enhancing education and training within communities on mental health problems faced during pregnancy and postpartum, and targeting adolescents, health care providers, and community members through multiple channels are recommended. These measures may include delivery through health and education systems, as well as social and traditional media platforms (¹³13. Mhango W, Michelson D, Gaysina D. “I felt I needed help, but I did not get any”: a multiple stakeholder qualitative study of risk and protective factors, and barriers to addressing common mental health problems among perinatal adolescents in Malawi. Glob Ment Health (Camb). 2023;10:e73. https://doi.org/10.1017/gmh.2023
https://doi.org/10.1017/gmh.2023... , ¹⁴14. Spedding MF, Stein DJ, Naledi T, Sorsdahl K. Pregnant women’s mental health literacy and perceptions of perinatal mental disorders in the Western Cape, South Africa. Mental Health Prevent. 2018;11:16–23. https://doi.org/10.1016/j.mhp.2018.05.002
https://doi.org/10.1016/j.mhp.2018.05.00... ).

Health system factors

Despite the desire to seek professional help, most respondents were unaware of available mental health services in their communities. This is similar to findings in a study in Mexico and a systematic reviews, all of which which reported that lack of knowledge about where to go for mental health services was a significant barrier to adolescents seeking help, including pregnant adolescents and young mothers (¹⁵15. Gulliver A, Griffiths KM, Christensen H. Perceived barriers and facilitators to mental health help-seeking in young people: a systematic review. BMC Psychiatry. 2010;10(113). https://doi.org/10.1186/1471-244X-10-113
https://doi.org/10.1186/1471-244X-10-113... , ¹⁶16. Lara MA, Navarrete L, Nieto L, Berenzon S. Acceptability and barriers to treatment for perinatal depression. An exploratory study in Mexican women. Salud Ment. 2014;37(4):293–301). A study in Brazil highlighted that mental health issues were not discussed or addressed during regular perinatal care (¹⁷17. Baldisserotto ML, Theme MM, Gomez LY, Reis TB. Barriers to seeking and accepting treatment for perinatal depression: a qualitative study in Rio de Janeiro, Brazil. Community Ment Health J. 2020;56(1):99–106. https://doi.org/10.1007/s10597-019-00450-4
https://doi.org/10.1007/s10597-019-00450... ).

Raising awareness about available mental health services through platforms that already engage adolescents is important. This approach could include: education sessions in health facilities while adolescents were waiting for services; school health campaigns; education in adolescent and youth clubs; support from community health workers and social workers; community outreach; and perinatal and child health campaigns (¹⁸18. Naslund J, Aschbrenner K, Araya R, Marsch L, Unützer J. Digital technology for treating and preventing mental disorders in low-income and middle-income countries: a narrative review of the literature. Lancet Psychiatry. 2017;4(6):486–500. https://doi.org/10.1016/S2215-0366(17)30096-2
https://doi.org/10.1016/S2215-0366(17)30... ). The use of digital technology has also been found to be a feasible and culturally acceptable method for mental health promotion and prevention, including help lines, especially among young women (¹⁹19. Mutahi J, Larsen A, Cuijpers P, Peterson SS, Unutzer J, McKay M, et al. Mental health problems and service gaps experienced by pregnant adolescents and young women in sub-Saharan Africa: a systematic review. EClinical Medicine. 2022;44:101289. https://doi.org/10.1016/j.eclinm.2022.101289
https://doi.org/10.1016/j.eclinm.2022.10... ).

Lack of confidence and trust in health care providers was another barrier due to fear of judgement, uncompassionate attitudes of and stigmatization by health workers. Similar barriers were identified in studies in Mexico, South Africa, Uganda, and the United States among pregnant adolescents and young mothers (⁹9. Recto P, Dimmitt Champion J. “We don’t want to be judged”: perceptions about professional help and attitudes towards help-seeking among pregnant and postpartum Mexican-American adolescents. J Pediatr Nurs. 2018:42:111–7. https://doi.org/10.1016/j.pedn.2018.04.010
https://doi.org/10.1016/j.pedn.2018.04.0... , ¹¹11. Nakku J, Okello E, Kizza D, Honikman S, Ssebunnya J, Ndyanabangi S, et al. Perinatal mental health care in a rural African district, Uganda: a qualitative study of barriers, facilitators and needs. BMC Health Serv Res. 2016;16:295. https://doi.org/10.1186/s12913-016-1547-7
https://doi.org/10.1186/s12913-016-1547-... , ¹⁴14. Spedding MF, Stein DJ, Naledi T, Sorsdahl K. Pregnant women’s mental health literacy and perceptions of perinatal mental disorders in the Western Cape, South Africa. Mental Health Prevent. 2018;11:16–23. https://doi.org/10.1016/j.mhp.2018.05.002
https://doi.org/10.1016/j.mhp.2018.05.00... , ¹⁶16. Lara MA, Navarrete L, Nieto L, Berenzon S. Acceptability and barriers to treatment for perinatal depression. An exploratory study in Mexican women. Salud Ment. 2014;37(4):293–301). The quality of client–provider relationship significantly influences intentions and actions to seek mental health support (⁹9. Recto P, Dimmitt Champion J. “We don’t want to be judged”: perceptions about professional help and attitudes towards help-seeking among pregnant and postpartum Mexican-American adolescents. J Pediatr Nurs. 2018:42:111–7. https://doi.org/10.1016/j.pedn.2018.04.010
https://doi.org/10.1016/j.pedn.2018.04.0... , ¹⁹19. Mutahi J, Larsen A, Cuijpers P, Peterson SS, Unutzer J, McKay M, et al. Mental health problems and service gaps experienced by pregnant adolescents and young women in sub-Saharan Africa: a systematic review. EClinical Medicine. 2022;44:101289. https://doi.org/10.1016/j.eclinm.2022.101289
https://doi.org/10.1016/j.eclinm.2022.10... ). Adolescents, especially pregnant adolescents, and young mothers are more likely to seek help from health care providers who are sensitive, respectful, non-judgemental, compassionate, and good listener (²⁰20. Jack SM, Duku E, Whitty H, Van Lieshout RJ, Niccols A, Georgiades K, et al. Young mothers’ use of and experiences with mental health care services in Ontario, Canada: a qualitative descriptive study. BMC Women’s Health. 2022;22(1): 214. https://doi.org/10.1186/s12905-022-01804-z
https://doi.org/10.1186/s12905-022-01804... ).

A study among adolescent mothers in Jamaica that compared quality of care in a teen pregnancy clinic and standard antenatal clinic found adolescents who received care at the teen pregnancy clinic reported positively on the specific interventions tailored to their needs. The study suggested the need for adolescent-focused maternity care (⁵5. Wilson-Mitchell K. Factors associated with adolescent pregnancy, psychological distress, and suicidal behavior in Jamaica: an exploratory study. J Midwifery Womens Health. 2014;59(5):552. https://doi.org/10.1111/jmwh.12248
https://doi.org/10.1111/jmwh.12248... ).

Confidentiality is a significant enabler of any therapeutic relationship. Thus, regular training and orientation of health care providers is needed on adolescent-friendly services and respectful, non-judgemental care to increase the trust of adolescents. Strengthening the capacity of these workers through continuous supportive supervision will ensure that they are well equipped to address the unique mental health needs of pregnant adolescents and young mothers.

Non-availability of mental health practitioners in most of the primary health clinics was another barrier to help-seeking, especially in rural areas. Long waiting times and inconvenient scheduling of clinic appointments further impeded access to services. Similar barriers were reported in studies in Jamaica, Uganda, and the United States, highlighting the need to integrate mental health services into maternal and child health services and train primary care providers (⁵5. Wilson-Mitchell K. Factors associated with adolescent pregnancy, psychological distress, and suicidal behavior in Jamaica: an exploratory study. J Midwifery Womens Health. 2014;59(5):552. https://doi.org/10.1111/jmwh.12248
https://doi.org/10.1111/jmwh.12248... , ⁹9. Recto P, Dimmitt Champion J. “We don’t want to be judged”: perceptions about professional help and attitudes towards help-seeking among pregnant and postpartum Mexican-American adolescents. J Pediatr Nurs. 2018:42:111–7. https://doi.org/10.1016/j.pedn.2018.04.010
https://doi.org/10.1016/j.pedn.2018.04.0... , ¹¹11. Nakku J, Okello E, Kizza D, Honikman S, Ssebunnya J, Ndyanabangi S, et al. Perinatal mental health care in a rural African district, Uganda: a qualitative study of barriers, facilitators and needs. BMC Health Serv Res. 2016;16:295. https://doi.org/10.1186/s12913-016-1547-7
https://doi.org/10.1186/s12913-016-1547-... ).

Similar barriers to accessing mental health services reported in other studies included limited resources for transportation especially those in the rural area, unavailability of child care, and lack of time to balance the competing demands of self-care with parenting (¹⁵15. Gulliver A, Griffiths KM, Christensen H. Perceived barriers and facilitators to mental health help-seeking in young people: a systematic review. BMC Psychiatry. 2010;10(113). https://doi.org/10.1186/1471-244X-10-113
https://doi.org/10.1186/1471-244X-10-113... , ¹⁶16. Lara MA, Navarrete L, Nieto L, Berenzon S. Acceptability and barriers to treatment for perinatal depression. An exploratory study in Mexican women. Salud Ment. 2014;37(4):293–301, ²¹21. Kumar M, Huang K, Othieno C, Wamalwa D, Madeghe B, Osok J, et al. Adolescent pregnancy and challenges in Kenyan context: perspectives from multiple community stakeholders. Glob Soc Welf. 2018;5(1):11–27. https://doi.org/10.1007/s40609-017-0102-8
https://doi.org/10.1007/s40609-017-0102-... ).

Adolescent-friendly service delivery models tailored to the unique needs of adolescents and young mothers have been recommended to increase uptake of mental health services for these young people (²¹21. Kumar M, Huang K, Othieno C, Wamalwa D, Madeghe B, Osok J, et al. Adolescent pregnancy and challenges in Kenyan context: perspectives from multiple community stakeholders. Glob Soc Welf. 2018;5(1):11–27. https://doi.org/10.1007/s40609-017-0102-8
https://doi.org/10.1007/s40609-017-0102-... , ²²22. Broom M, Ladley A, Rhyne E, Halloran D. Feasibility and perception of using text messages as an adjunct therapy for low-income, minority mothers with postpartum depression. JMIR Ment Health. 2015;2(1):e4. https://doi.org/10.2196/mental.4074
https://doi.org/10.2196/mental.4074... ). This includes flexible options of scheduling and booking appointments at a convenient time and walk-in clinics. In addition, the use of text messages to schedule appointments and provide tailored mental health messages have been reported as a potential strategy to provide needed mental health support to adolescents and young mothers (²³23. Nicholas J, Bell IH, Thompson A, Valentine L, Simsir P, Sheppard H, et al. Implementation lessons from the transition to telehealth during COVID-19: a survey of clinicians and young people from youth mental health services. Psychiatry Res. 2021;299:113848. https://doi.org/10.1016/j.psychres.2021.113848
https://doi.org/10.1016/j.psychres.2021.... , ²⁴24. Oladeji O, Simmons J, Baitwabusa AE. Pattern of presentation and treatment outcomes among patients attending psychotherapy services in a primary health care centre in Belize. J Adv Med Med Res. 2024;36(6):118–32. https://doi.org/10.9734/jammr/2024/v36i65457
https://doi.org/10.9734/jammr/2024/v36i6... ).

Stigma

Stigma was a barrier to accessing services, with respondents indicating stigma about both teenage pregnancy and mental health issues in their communities, which was exacerbated by the attitudes of some health workers. Other studies have also reported stigmatizing attitudes from community members and health workers (¹⁶16. Lara MA, Navarrete L, Nieto L, Berenzon S. Acceptability and barriers to treatment for perinatal depression. An exploratory study in Mexican women. Salud Ment. 2014;37(4):293–301, ²²22. Broom M, Ladley A, Rhyne E, Halloran D. Feasibility and perception of using text messages as an adjunct therapy for low-income, minority mothers with postpartum depression. JMIR Ment Health. 2015;2(1):e4. https://doi.org/10.2196/mental.4074
https://doi.org/10.2196/mental.4074... ). Stigma related to adolescent pregnancy and mental health care is reported to make adolescents reticent to seek medical care at the heath facilities (¹⁶16. Lara MA, Navarrete L, Nieto L, Berenzon S. Acceptability and barriers to treatment for perinatal depression. An exploratory study in Mexican women. Salud Ment. 2014;37(4):293–301). Stigma has been found to contribute to underutilization of mental health services in previous studies in South and Central America and the Caribbean (²⁵25. Mascayano F, Tapia T, Schilling S, Alvarado R, Tapia E, Lips W, et al. Stigma toward mental illness in Latin America and the Caribbean: a systematic review. Braz J Psychiatry. 2016;38(1):73–85., ²⁶26. Gallimore JB, Gonzalez Diaz K, Gunasinghe C, Thornicroft G, Taylor Salisbury T, Granholm P. Impact of mental health stigma on help-seeking in the Caribbean: systematic review. PLoS One. 2023;18(9):e0291307. https://doi.org/10.1371/journal.pone.0291307
https://doi.org/10.1371/journal.pone.029... ). In the Caribbean, mental health and expressing emotions has been culturally and socially stigmatized, and associated with shame, personal weakness, and a lack of commitment to God (²⁶26. Gallimore JB, Gonzalez Diaz K, Gunasinghe C, Thornicroft G, Taylor Salisbury T, Granholm P. Impact of mental health stigma on help-seeking in the Caribbean: systematic review. PLoS One. 2023;18(9):e0291307. https://doi.org/10.1371/journal.pone.0291307
https://doi.org/10.1371/journal.pone.029... ). Community beliefs may also suggest that mothers with depression are unable to be good mothers (¹⁷17. Baldisserotto ML, Theme MM, Gomez LY, Reis TB. Barriers to seeking and accepting treatment for perinatal depression: a qualitative study in Rio de Janeiro, Brazil. Community Ment Health J. 2020;56(1):99–106. https://doi.org/10.1007/s10597-019-00450-4
https://doi.org/10.1007/s10597-019-00450... , ²⁷27. Hadfield H, Witkowski A. Women’s experiences of seeking and receiving psychological and psychosocial interventions for postpartum depression: a systematic review and thematic synthesis of the qualitative literature. J Midwifery Womens Health. 2017;62(6):723–36. https://doi.org/10.1111/jmwh.12669
https://doi.org/10.1111/jmwh.12669... ). These beliefs contribute to a fear of judgement and possible separation from their babies, resulting in hesitance to seek appropriate care (¹⁷17. Baldisserotto ML, Theme MM, Gomez LY, Reis TB. Barriers to seeking and accepting treatment for perinatal depression: a qualitative study in Rio de Janeiro, Brazil. Community Ment Health J. 2020;56(1):99–106. https://doi.org/10.1007/s10597-019-00450-4
https://doi.org/10.1007/s10597-019-00450... , ²⁷27. Hadfield H, Witkowski A. Women’s experiences of seeking and receiving psychological and psychosocial interventions for postpartum depression: a systematic review and thematic synthesis of the qualitative literature. J Midwifery Womens Health. 2017;62(6):723–36. https://doi.org/10.1111/jmwh.12669
https://doi.org/10.1111/jmwh.12669... ).

Addressing stigma requires adequate sensitization and education of community members and health workers on the mental health problems faced by pregnant adolescents and young mothers and the need for compassionate and non-judgemental support (¹⁶16. Lara MA, Navarrete L, Nieto L, Berenzon S. Acceptability and barriers to treatment for perinatal depression. An exploratory study in Mexican women. Salud Ment. 2014;37(4):293–301). Integrating preventative and promotive mental health messaging and interventions, including universal and routine mental health screening, for pregnant and postpartum mothers as part of antenatal and postnatal services is recommended as a strategy to increase access to mental health services and destigmatize mental health problems among adolescents and young mothers (¹⁶16. Lara MA, Navarrete L, Nieto L, Berenzon S. Acceptability and barriers to treatment for perinatal depression. An exploratory study in Mexican women. Salud Ment. 2014;37(4):293–301, ²⁸28. Blackmore R, Boyle JA, Gray KM, Willey S, Highet N, Gibson-Helm M. Introducing and integrating perinatal mental health screening: development of an equity-informed evidence-based approach. Health Expect. 2022;25(5):2287–98. https://doi.org/10.1111/hex.13526
https://doi.org/10.1111/hex.13526... ).

Social support

Respondents identified social support from family members as essential in managing their emotional problems and facilitating help-seeking. The role of peer support groups was also identified as important in promoting mental health and help-seeking behaviors.

Social support systems have a positive influence on maternal mental health outcomes (²⁹29. Mermer G, Bilge A, Yucel U, Ceber E. Evaluation of perceived social support levels in pregnancy and postpartum periods. J Psychiatr Nurs. 2010;1(2):71–6, ³⁰30. Backstrom C, Larsson T, Wahlgren E, Golsater M, Martensson LB, Thorstensson S. “It makes you feel like you are not alone”: expectant first-time mothers’ experiences of social support within the social network, when preparing for childbirth and parenting. Sex Reprod Healthc. 2017;12:51–7. https://doi.org/10.1016/j.srhc.2017.02.007
https://doi.org/10.1016/j.srhc.2017.02.0... ). These systems help reduce parenting stress, validate mothers’ experiences, and encourage young mothers to seek professional mental health care as needed (³¹31. Lucas G, Olander EK, Ayers S, Salmon D. No straight line—young women’s perceptions of their mental health and wellbeing during and after pregnancy: a systematic review and meta-ethnography. BMC Womens Health. 2019;19(1):152 https://doi.org/10.1186/s12905-019-0848-5
https://doi.org/10.1186/s12905-019-0848-... , ³²32. Yurdakul M. Perceived social support in pregnant adolescents in Mersin area in Turkey. Pak J Med Sci. 2018;34(1):115–20. https://doi.org/10.12669/pjms.341.14221
https://doi.org/10.12669/pjms.341.14221... ).

A study in Jamaica found that social support protected mothers from postpartum depression, while a study in Brazil found pregnant teenagers with high social support had a 67% lower prevalence of suicide than those with low social support (¹⁰10. Elmore S. Postpartum depression in Jamaica: exploring the lived experiences [Dissertation]. Louisville, KY: University of Louisville; 2023. https://doi.org/10.18297/etd/4107
https://doi.org/10.18297/etd/4107... , ³³33. Pinheiro RT, da Cunha Coelho FM, da Silva RA, de Ávila Quevedo L, de Mattos Souza LD, Castelli RD, et al. Suicidal behavior in pregnant teenagers in southern Brazil: social, obstetric and psychiatric correlates. J Affect Disord. 2011;136(3):520–5. https://doi.org/10.1016/j.jad.2011.10.03
https://doi.org/10.1016/j.jad.2011.10.03... ). Likewise, a study in the United States found perinatal women who had greater perceived social support had fewer clinical symptoms of depression at a later date (³⁴34. Kay TL, Moulson MC, Vigod SN, Schoueri-Mychasiw N, Singla DR. The role of social support in perinatal mental health and psychosocial stimulation. Yale J Biol Med. 2024;97(1):3–16. https://doi.org/10.59249/WMGE9032
https://doi.org/10.59249/WMGE9032... ).

Conversely, weak social support was significantly associated with the risk of mental health problems (depression, anxiety, and self-harm) during pregnancy (³⁵35. Bedaso A, Adams J, Peng W, Sibbritt D. The relationship between social support and mental health problems during pregnancy: a systematic review and meta-analysis. Reprod Health. 2021;18(1):162. https://doi.org/10.1186/s12978-021-01209
https://doi.org/10.1186/s12978-021-01209... ). Integrating community-based social support programs with maternal health services and ensuring discussions on social support during clinic visits are essential for promoting mental health among adolescent mothers (³⁵35. Bedaso A, Adams J, Peng W, Sibbritt D. The relationship between social support and mental health problems during pregnancy: a systematic review and meta-analysis. Reprod Health. 2021;18(1):162. https://doi.org/10.1186/s12978-021-01209
https://doi.org/10.1186/s12978-021-01209... ). Adopting adolescent-friendly service delivery models, coupled with community-based social support programs, will further increase the accessibility and effectiveness of perinatal mental health services.

Strengths and limitations

The use of a qualitative method provided a nuanced understanding of the barriers to and facilitators of access to mental health services among pregnant adolescents and young mothers. The participants were selected from both rural and urban areas of the country which provides a balanced view of challenges being faced in both settings.

A limitation of the study was that the participants were not recruited based on whether they were experiencing mental health problems or had a history of mental health problems during pregnancy or in the postpartum period, although a few did discuss their experiences. This may have limited their responses about mental health care. Despite this limitation, the findings are timely as Belize begins to strengthen perinatal mental health services. These insights will facilitate the development of an appropriate strategy for implementing adolescent-friendly perinatal mental health programs.

Conclusion

The study identified the key barriers to and facilitators of the use of mental health services by pregnant adolescents and young mothers, including individual, health system, stigma, and social support factors. Addressing the barriers is crucial for improving care for pregnant adolescents and increasing their use of mental health services.

Disclaimer.

The authors hold sole responsibility for the views expressed in the manuscript, which may not necessarily reflect the opinion or policy of the Revista Panamericana de Salud Pública / Pan American Journal of Public Health and/or those of the Pan American Health Organization and the World Health Organization.

REFERENCES

Publication Dates

History