PREGNANCY DISCLOSURE AND TIMING OF ANTENATAL CARE AMONG ADOLESCENT WOMEN IN KISOZI SUB COUNTY
.1 Background to the study
Maternal death has declined substantially worldwide except in Sub-Saharan Africa. Of the 21 countries with the highest maternal mortality 15 are in sub-Saharan Africa (Hogan et al., 2010). In 2010, pregnancy and childbirth-related complications led to an estimated 454 maternal deaths per 100’000 live births in Tanzania (NBS, 2010). Most of these complications occur unpredictably during labour, delivery and the immediate postpartum period (Ronsmans, 2006). Deaths could be averted with prompt and adequate diagnosis and care (Campbell, 2006). However, 49% of all women in developing countries still deliver at home without any skilled attendant.
Moreover, according to the definition of the World Health Organisation (WHO) (WHO, 2006), a quarter of all women in developing countries begin childbearing as adolescents before reaching the age of 20 years. An estimated 70’000 adolescent mothers die each year worldwide because their bodies are not yet physically ready for motherhood and due to social disadvantages (Bearinger, 2007). Pregnancy and childbirth thus constitutes the number one killer among 15-19 year old girls worldwide (WHO, 2006).
Several studies have shown that women who started antenatal care (ANC) attendance early and attended frequently were more likely to be assisted during delivery by a skilled attendant compared to those who initiated ANC late and attended only few visits [8–11]. Although ANC might not have the potential to predict and avert obstetric emergencies during pregnancy and childbirth, it exposes women to health education on risk factors and encourages them to deliver with a skilled attendant or in a health facility. Recent studies have suggested that women who knew about risk factors were more likely to utilize health facilities for delivery than those without knowledge [10, 12]. Moreover, ANC provides the opportunity to detect and treat anomalies of pregnancy and to deliver preventive health services such as immunization against tetanus, prophylactic treatment of malaria and worms, and HIV testing and counselling (leading to Preventing Mother to Child Transmission of HIV, PMTCT) [13]. To fully benefit from these interventions, it is important that women start ANC early on in their pregnancy. The revised Focused Antenatal Care (FANC) model of WHO [13] as well as the Tanzanian FANC guidelines [14] recommend at least four ANC visits for uncomplicated pregnancies with the first visit starting before 16 weeks of gestation [13]. However, an analysis of Demographic and Health Surveys (DHS) from 45 developing countries showed that women in sub-Saharan Africa start antenatal care considerably later than women from other regions [8]. Similarly, other studies reported late ANC enrolment after more than five months of gestation in sub-Saharan African countries [15–18], including Tanzania [2, 10, 19, 20]. A comparative analysis of the use of maternal health services in sub-Saharan Africa showed that adolescent mothers initiated ANC attendance even later and had poorer maternal health care than adult mothers [21].
Quantitative studies on timing of ANC attendance from developing countries have been able to shed light on the influence of socio-demographic factors. Although there is mixed evidence, late booking of antenatal care has repeatedly been associated with young age [21–24], premarital status [21, 23] unwanted pregnancies [16, 23, 25], high parity [16, 21, 23, 26, 27], lack of formal education [21–23, 27], low socio-economic status (SES) [16, 23] and ethnicity [16, 27]. Less is known about the influence of social and cultural determinants on prenatal care use among adult and adolescent pregnant women [28]. Qualitative as well as quantitative studies have stressed the influence of social support from family members [24, 29–31]. A study from Nepal for example reported the important role of mothers-in-law in deciding about ANC use of their pregnant daughters-in-law [30]. Studies from Uganda showed that adolescents were more likely to experience violence from parents, to be rejected by their partner, expelled from school, and to be stigmatized [29, 32], and therefore to hide their pregnancy [32]. Late recognition of and uncertainty about the pregnancy [33–35], as well as cultural beliefs and practices around pregnancy [34–38], have been reported to influence women’s timing of ANC attendance. Ethnographic studies from Mozambique and southern Tanzania illustrated for example that women at an early stage of pregnancy delayed ANC initiation purposely in order to protect the unborn from witchcraft and sorcery attacks of jealous neighbours and kin [36, 37]. Other studies showed that women’s ANC attendance is mediated by their experiences and the quality of care at earlier ANC visits [39, 40]. These studies clearly indicate that beyond demographic and socio-economic factors, social and cultural factors as well as individual perception of pregnancy and care impact women’s timing of ANC enrolment. Unfortunately, data are often not disaggregated by age, thus hiding particular vulnerabilities and issues [6].
Exploratory studies carried out in the study area in 2007 as a preparation for this study confirmed several of the factors stressed in the literature. In semi-structured interviews [41], health workers reported that women, and in particular women from the ethnic group of the Sukuma – semi-nomadic pastoralists who started to migrate into the region in the 1980s [42] – initiated ANC attendance late and underutilized ANC due to lack of education and living in distant settlements. Data collected between 2007 and 2009 from the Health Management Information System (HMIS) of the health facilities within the study area [41] indicated that the proportion of pregnant women who initiated ANC attendance after the fifth month of gestation rose from 53% to 56% between 2006 and 2008. Over this period, 18% of all ANC attendees were 19 years old or less. In an in-depth study with a small sample of recent adult and adolescent mothers (Gross 2007, unpublished data), adolescent women were found to visit the ANC clinic later and less frequently than adult women. Moreover, adolescent mothers differed from adult mothers in several ways: most of them were in their first pregnancy which was unplanned and prior to marriage, they still lived at their parents’ home and they did not get any social or economic support from their partner or the child’s father.
Based on the insights from the literature review and the exploratory studies, three main research questions arose that are addressed in this paper: First, do pregnant women – and in particular adolescent pregnant women – start ANC attendance late? Second, what factors are associated with early or late ANC attendance? And finally, do adolescent pregnant women differ from adult pregnant women in terms of social and economic support?
1.2 Statement of the problem
Early and frequent antenatal care attendance during pregnancy is important to identify and mitigate risk factors in pregnancy and to encourage women to have a skilled attendant at childbirth. However, many pregnant women in sub-Saharan Africa start antenatal care attendance late, particularly adolescent pregnant women. Therefore they do not fully benefit from its preventive and curative services. This study assesses the timing of adolescent pregnant women’s first antenatal care visit and identifies factors influencing early and late attendance in Kisozi Sub County.
1.3 Purpose of the Study
The purpose of the study was to find out the causes of child abuse in Kisozi Sub County.
1.4 Research objectives
The objectives of the study included;
- To find out the causes of child abuse.
- To find out effects of child abuse on the education of children
- To identify possible solutions that can be put in place to overcome child abuse.
1.5 Research Questions
The research questions also included;
- What are the causes of child abuse?
- How does abuse affect the educational needs of children in terms of their physical, mental and social development?
- What are the possible solutions that can be put in place to overcome child abuse?
1.6 Scope of the study
1.6.1 Content scope
The research study will focus on the causes of child abuse and it will target mostly the children, their parents and other key informants with experience about children related issues.
1.6.2 Geographical scope
The study will be conducted in Kisozi Sub County located in Wakiso District. This is because it is one of the areas with the highest child abuse cases.
1.6.3 Time scope
The study was carried out for a period from June to October, 2017 and considering 2007-2016 as the period of body of knowledge to review literature.
1.7 Significance of the study
- The study findings shall be of a great significance to the community as a way of creating awareness on the existence of child abuse so as to come up with solution on how to overcome it.
- It shall also be of a great significance to the government of Uganda in general and other stakeholders such as NGOs, civil societies, religious leaders for future interventions and also strengthen the strategies put in place so as to solve the problem of child abuse.
- The research study shall also act as a future reference for students in various schools and institutions who will want to undertake a study in the same area of study or in a different study related to this topic in future.
1.8 Conceptual framework
This section proposes a conceptual framework within which the concept, childa buse is treated in this work. It is arrived at basing on the System’s theory Input-Output model advanced by Ludwig Von Bertalanffy in 1956. The selection of the model is based on the belief that, the quality of input invariably affects quality of output in this case violence. (Acato 2006)
Figure 1. Showing the conceptual framework for this study
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Independent variable Dependent variable
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Extraneous variables
Source: Adopted from Koontz and Weihrich (1988:12).
CHAPTER TWO
LITERATURE REVIEW
2.0 Introduction
This chapter reviews literature related to the study according to stipulated objectives. It was organized under three subtopics in relation to the incidence of child abuse by different scholars from the general perspective about the causes, forms and effects of child abuse on the educational development of children especially on the physical, social and moral development from different sources.
2.1 Overview of child abase
Different jurisdictions have developed their own definitions of what constitutes child abuse for the purpose of removing a child from him or her family and persecuting a criminal charge. The mental health journal states that child abuse is “any out or failure to cut on the part of a parent or caretaker which results into death, serious physical or emotional harm” thus affecting the physical, moral and social development of children.
According to Mehr Khan, UNICEF region Director, East Asia and pacific region. Trafficking is one of the starkest symptoms of child abuse. While some girls and boys are being trafficked, ending up as bonded labour or beggars, the vast majority of victims are women and girls who are being sold into prostitution, domestic work and forced into early marriage. Thus abuse and exploitation are both contributing factors to the phenomenon as well as consequences resulting in the violation of many, if not all fundamental human rights thus affecting the children education.
According to the convention on the rights of the child (CR€), Uganda, through Article 19, has made a commitment to ensure that children live in a good state and health environment tree or abuse. The constitution does not specifically mention the protection of children for sexual and physical abuse while in the care of parent or legal guarding but protects the child in Article 34(1) by demanding that the best interests of the child should be the main consideration.
The lack of alternative care for children has often led them back to the hands of their abusers which affect the development and education of children. As Deo Iga states the major problem we have encountered is that we have to compromise in most cases, although the children are abused. They have to stay with the abusers because they have no where to go as the crisis centers cannot keep these children for along time.
There is also lack of alternative care for the children development because the crisis centers do not have the resources. For example ‘in cases where a child is defiled by a member of the family, you find that although we usually counsel them. They have to go back to the family in which they have been defiled from thus affecting the physical, moral and social development as well as education due to fear and anxiety they can not pay attention in classes and are unable to do their assignments given to them as home work due to limited concentration due to the environment they are stay in.
2.2 Causes of child abuse
Murphy et al (1991) have argued that child abuse is a complex problem which has multiple causes. Understanding the cause of abuse is crucial to addressing the problem of child abuse. Alcohol or drug abuse is one of those causes, many substance users abuse their children, those who do usually continue or even intensity psychological abuse if they give up the substance abuse for their behavior before, they are likely to change to using the stress or staying away from the substance of the excuse. (Bancroft. 2002).
Another study found that over two thirds of cases of child maltreatment involve parents with substance abuse problems. This study specifically found relationship between alcohol and physical abuse and cocaine and sexual abuse. Cultural norms about what constitutes abuse vary widely among professionals as well as the wider public people do not agree on what behaviors constitute abuse. Some human service professionals claim that cultural norms that sanction physical punishment are one on the causes or child abuse and have undertaken campaigns to redefine such norms. (Murph et al, 1991).
Parents who physically abuse their spouses are more likely to physically abuse their children (Ross, 1996). However, it is difficult to know whether marital strife is a cause of child abuse, or if both the marital strife and abuse are caused by tendencies in the abuser. Substance abuse is a major contributing factor t child abuse. One study found that parents with documented substance abuse, most commonly alcohol, cocaine and heroin are much more likely to mistreat their children and also much more likely to reject court-ordered services and treatments.
As a state of child loosing either a parent or both to death was identified as one of the factors of child abuse as backed by the following information. According to Elizabeth and pal Jareg in their book titled “Reaching children through dialogue” (1994 p.51) deserved that orphan children are liable to all kinds of treatment that may cause harm to their lives. One of the orphans was examined and said ‘When we are living with our relatives, their children get food first, they say they must have the food before us”.
When we cannot go to school like other children in the family! And when out relatives are angry, “we do not get food and we begin to cry and get pain in our heads”. Children in difficult circumstances, unit 3 under the ministry of Gender and community development of child care and protection (1998, Pg 38} reveals that most orphans in many times are left with no shelter at all when their parents die simply because their family has been living in a rented house by force, thereby leaving children (orphans) without home resorting to streets, early marriage., sex worker in order to get money and take care of their siblings.
According to the ministry of education white paper (1993), loss of parents and lack of support from the local extended families reduces the opportunities for orphaned children to growth and development and girl child in particular to continue with education.
According to the 1991 school census Ministry of Education and Sports, 9.5% of the children in primary schools dropped out of school because of loss of parents, hence agreeing to the statement that orphan hood is one of the causes of child abuse given information.
Poverty as looked at in terms of income type of housing and lack of certain basic necessities is identified as one of the cause of child abuse in most communities. According to the UNICEF Report (2005 Pg.19) fundamentally, poverty is a denial of choices and opportunities, a violation of human dignity .^It means lack of basic capacity to participate effectively in society, It means not having enough to feed and not housing a school or clinic to got to when sick. Having no land on which to grow one’s food or job to earn a living not having access to credit means insecurity, powerlessness or exclusion of individuals, households and communities means susceptibility to violence and it often implies living in a marginal or fragile environment, without access to clean water or sanitation, United Nations economic and social council report (1998).
Lindon (1998) discussed ways in which poverty leads to a child’s underdevelopment, he went a head by saying that poverty is the most cause of child abuse in families, he added that it affects families and increase chances of children bad environment to more chaotic form with stress and fewer sources or income hence abusing children. Due to this kind of life children are always driven to practice prostitution and slavery in order to gain financial or material payments to the parents. Thus poverty is cause of child abuse.
According to the UNICEF Report (2005. Pgl29) women guardian of an orphan in Busia is quoted “when the parents have HIV/AIDS, tension is created among relatives and neighbors due to long periods or sickness and beliefs that the cause of sickness is witchcraft. Because there is almost no property left to inherit at the time of death, the relatives who would be guardians to provide support are distancing themselves”. The report continues by saying the vulnerability caused by HIV/AIDS is often a gradual process involving the progressive loss of capacity (income, parenting capacity) by parents as they fall sick before actual death where children themselves become primary caregivers of themselves and to the parents and when the parents dies since relatives fear to association with the children they will end up being heads of the families themselves which leads to school dropout, early marriage and other associated problems. Also children with HIV/AIDS are isolated and often abused by their family members or community and yet parents with HIV/AIDS have always been so harsh and rude to the children due to the harsh pains they experience and so realize revenging on their children.
Abusers may blame the victim’s actions for causing them to lose control of their temper, it is often apparent however that they do not behave in the way with other people when abusers smash up property in apparently random acts it often turns out that they avoid damaging their own belongings, and if law officers called by alarmed neighbors. Arrive the “uncontrollable rage” will be instantly switched offer. At this point the abuser, who is calm, will often pass the blame to the victim. Who is likely to be visibly disturbed. (Bancroft, 2002)
Abusers are found in all walks of life and many of them are successful and confident, they include heads of corporations, high ranking police officers and judges. Boosting abusers May increase their sense of entitlement and read to worse abuse. (Bancroft, 2002).
Famularo et al (1992), said that in the United States, the National Association of social workers has issued statements that even the mildest forms of physical punishment, such as moderate spanking, lowered children’s self-esteem, constitute outs of violence, and teach children that physical force is an acceptable way to resolve conflicts.
Against this letter argument, the philosopher prof. David Benatar points out that one might as well say that during people teaches that forcing others to give up some of their property is an acceptable way to respond to those who act in away that one does not like.
“It beatings send a message, why don’t detentions, imprisonments, fines, and a multitude of other punishments convey equally undesirable message?” He adds that ” there is all the difference in the world between legitimate authorities, the judiciary, parents, or teachers using punitive powers responsibly to punish wrongdoing and children or private citizens going around beating each other, looking each other up and extracting financial tributes (such as lunch money).
There is a vast moral difference here and there is no reason why children should not learn about it Punishing children when they do wrong seems to be one important way of doing this”. In the United Kingdom, sociology professor Frank Furred suggests that many advocates of a total ban on physical punishment are actually against all forms of punishing children. He sees the underlying agenda as an anti-parent crusade, and argues that the much acted Murray straws research is far less clear – cut than the claims made on its behalf by what he calls “anti-smoking Zealots.
2.3 Effects of child abuse on the education of children
According to main M. and Hesse, E. (1990), Children with a history of neglect or physical abuses are at risk of developing psychiatric or a disorganized attachment style that influences their physical, mental and social development.
This is associated with a number of developmental problems including dissociative symptoms as well as anxiety, depressive and acting – out symptoms. A study by Dante Cichetti found that 80% of abused and maltreated infants exhibited symptoms or disorganized attachment.
Child survivors of abuse and neglect tend to avoid intimacy in their relationships because the feeling of closeness increases their feelings of vulnerability and lack of control (James, 1994). Intimacy is not desired because it represents a threat rather than nurturance and love. To avoid intimacy, children may exhibit withdrawal, lack of eye contact, hyperactivity, aggression, and other inappropriate behaviors at school that hinders attention.
Victims of childhood abuse also suffer from different types of physical health problems that influence their development in later life some reportedly suffer from some type of chronic head, abdominal, pelvic or muscular pain with no identifiable reason. Even though the majority of childhood abuse victims know or believe that their abuse victims know or believe different health problems in their adult life, for the great majority their abuse was not directly associated with those problems indicating that sufferers were most likely diagnosed with other possible causes for their health problems. Instead of their childhood abuse. (Hamnasu Takele, MBA, Amberton University).
If maltreated children are unable to experience relief through numbing, they may exhibit more provocative behaviors in order to initiate the numbing process that can quiet their fears of more maltreatment. Some of the provocative behaviors include aggression and inflicting harm to others, inflicting harm to themselves such as mutilation and suicide, and behaving in antisocial ways that result in harsh punishments. The underlying purpose behind these provocative and emotional acts is to produce the numbing responses that can lessen their extreme fears.
The effects of child abuse vary depending on its type. A 2006 study found that childhood emotional and sexual abuse is strongly related to adult depressive symptoms, while exposure to verbal abuse and witnessing of domestic violence had a moderate one. For depression, experiencing more than two kinds of abuse exerted synergistically stronger symptoms. Sexual abuse was particularly deleterious in is in familiar form, for symptoms of depression, anxiety, dissociation and limbic irritability.
Childhood verbal abuse had a stronger association with anger- hostility than any other type of abuse studied, and was second only to emotional abuse in its relationship with dissociative symptoms that influence the physical, mental and social development of children. Child abuse creates significant correlations between repeated illness and family traumas encountered by the child before the age of 18years. These relationships show that inequality in terms of illness and suffering is not only social.
It has also its origins in the family where it is associated with the degree of lasting effective problems (lack of affection parental discord. The prolonged absence of a parent, or a serious illness affecting either the mother or father) that individuals report having experienced in child-hood. (Hammasu Takele, NBA, Amberton University)
2.4 Solutions that can be put in place to overcome child abuse
According to Ms. Mehr Khan, UNICEF Regional Director East Asia and Pacific Region the road map for the combat against trafficking and commercial sexual exploitation of children should include a wide range of activities and interventions targeting different levels of the protective environment. Full implementation or regional commitments and Action Plans should be a priority as agreements have been made based on regionally specific concerns. Among the various frameworks and action plans there should be are some key common
Actions identified.
Uganda is a signatory to the UN Convention on the Rights of the Child (CRC), which was ratified in1990. Uganda is also party to the African Charter on the Rights and Welfare of the Child, which states that Member States recognize the rights, freedoms and duties enshrined in this Charter and shall undertake the necessary steps, in accordance with their Constitutional processes and with the provisions of the present Charter, to adopt such legislative or other measures as may be necessary to give effect to the provisions of the Charter. Article 16: Protection Against Child Abuse and Torture, States Parties to the Charter are reminded to take specific legislative, administrative, social and educational measures to protect the child from ail forms of torture, inhuman or degrading treatment and especially physical or mental injury or abuse, neglect or maltreatment including sexual abuse, while in the care of the child. In addition, Uganda ratified ILO convention 182 on Worst Forms of Child Labour, which protects children against sexual exploitation.
Speedy ratification of the key legal instruments, this is an important step towards promoting solidarity among countries and common frame works. The key instruments should include the optional protocol to the CRC on the sale of children. Child prostitution and child pornography, the ILO convention 182 on the worst forms of child labour, and the protocol to the UN convention Against Transnational organized crime to prevent, suppress and punish Trafficking in person, especially women and children
Early and regular child and family screening and treatment. Donnelly, (1997), stresses that because abusive behavior is often cyclic, many health and developmental problems in early childhood can lead to behavioral, educational, and psycho-emotional problems in later adolescence and adulthood, which could lead to the recurrence of abusive behavior. Also, many abused children at first appear acquiescent, cooperative, shy, affectionate, and abnormal, but this apparent serenity may mask multiple psychological problems. For this reason, detecting and treating health and developmental problems early in life is important. Early childhood screening and treatment programs should be seen as a continuation of the preschool screening services, such as those offered by a home visitor.
The purpose of such programs is to detect problems children may be having, including abuse and neglect, and to ensure that these children receive the necessary health, mental health, and other services that will best protect them from becoming abusive parents. Programs also remain sensitive to the possibility that a child may be inappropriately labeled, with long-term negative consequences.
The purpose of child care or day care programs is to furnish parents with regular or occasional out-of-home care for their children. While child care is a necessity in households in which all adults are employed, such services also are beneficial responsibilities very stressful. Child care programs also provide opportunities for children to learn basic social skills. Head Start programs in particular provide a rich mix of child care and child development services.
2.5 Programs for abused children
It has been argued that prevention of abuse is in part tied to providing therapeutic treatment to children or young people who have been abused or neglected. To minimize the long-term effects of abuse, age-appropriate treatment services should be available to all maltreated children. Treatment programs for abused children include therapeutic day school programs as well as day hospital programs, residential programs, and home and clinic setting treatment. These programs most often concentrate on improving the cognitive and developmental skills of younger children and psychodynamic treatment for children in older age groups. This needs to be the area of high priority. Efforts required should include training and sensitization of law enforcers, the development of a child and victim friendly investigative and court procedures and witness protection schemes. Harmonization of national laws with international child rights standards is also an important measure.
In order to break and address the problem of child abuse, the government should collaborate with other organizations development partners should enact and enforce policies through collaboration and protect children against exploitation and other abuses. Policies concerning human rights, Natural Justice (fair and treatment) among others as outlined under the children statute children Act and in the Article 21 and 42 of the constitution of the republic of Uganda as amended in 1995.1 support that should be emphasized and implemented.
Besides, the government and other partners should ensure establishment of more orphanages, child care centers and other related services providing institutions to cater for those children abused due to lack of parental care and support because the research findings in this book will show that the biggest percentage of abused children are those with who are neglected by their parents. Physically abused and sexually abused thus support the issue of establishment of more care centers.
