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Antenatal Care Experience in Adolescent Pregnancy

Background: Adolescent pregnancy is a problem that needs to be considered for both clinical and social reasons. In Indonesia more than 2 million young women aged 15-19 years which is around 10% of total births. The birth rate per 1,000 women in those aged 15-19 years is 512 cases. Some pregnant teenagers are reluctant to carry out prenatal care in the early trimester. The initial initiation of antenatal care(ANC) service has benefits of being able to detect the risk factors of early pregnancy, preventing the risk of pregnancy and encouraging a healthy life quality. Method: This Systematic Literature Review is adjusted to the Systematic Literature Review steps, namely Identification of problems, Prioritizing problems and questions, Creating Frameworks,and Literature searching, on two databases (PubMed & Science Direct), Selecting relevant articles which use quantitative methods, Making critical appraisal, Extracting selected paper data, Collecting data and Making maps to answer the questions. Result: The data extracted from the systematic literature review article is arranged into several themes. The author then divides them into sub-sections, they are:(1) youth experience in antenatal care service, (2)barriers in accessing antenatal care service, and (3)expectations regarding the experience of antenatal care service provided by health workers. Conclution: The negative experience received during a health examination is the most memorable and hurtful experience. The negative experience comes from judgmental words and judgmental attitudes from health professionals. The barriers that occur in accessing health services include long travel time, financial problems, and the stigma surrounding communities about teenage pregnancy. The hopes of adolescents in order to improve the quality of ANC services include health workers who are expected to be able to interact with patients well so that patients feel comfortable.


I. I NTRODUCTION
Adolescents are residents who are in the age range of 10-19 years [1]. Based on the data from the Indonesian Health Profile 2017 the number of adolescents aged 10-19 years in Indonesia amounted to 22 million people spread across all provinces in Indonesia. The problem that often occurs in adolescents is teenage pregnancy. In Indonesia more than 2 million young women aged [15][16][17][18][19] years are estimated to have given birth between 2005 and 2010, which is around 10% of total births. The birth rate per 1,000 women aged [15][16][17][18][19] years is 512 cases [2]. Adolescent pregnancy is a problem that needs to be considered for both clinical and social reasons. Complications that can occur during adolescent pregnancy include the increasing risk of hypertension, anemia, gestational diabetes, and other complications during the process of pregnancy and childbirth. Adolescent pregnancy is associated with increased LBW babies, preterm birth, incidence of infant asfiction and also infant mortality [3], [4].
In an effort to carry out a safe pregnancy and childbirth, pregnant women need a follow-up care from families and health workers [1].
Antenatal Care (ANC) services include identifying risks of pregnancy, early detection of complications of pregnancy, health education and health promotion. Minimum ANC visit 4 times during pregnancy is divided into 3 periods. 1 time at less than 12 months of pregnancy, 1 time at 24-28 weeks gestation, and 2 times at 32 and 36 weeks' gestation [1].
Based on data from USAID [5], it shows that out of 28.3% of pregnant women in Indonesia, have their first ANC after 4 months or more. The factors that influence the delay in ANC visits include maternal age that is too young, marital status, unwanted pregnancy, high parity, low education level, and environmental factors [6].
Given the importance of ANC for pregnant women especially in teen adolescent pregnancy as an effort to detect early pregnancy complications and to obtain information about pregnancy, Systematic Literature Review explores the experiences of pregnant adolescents in receiving ANC services during pregnancy, adolescent barriers and expectations in ANC services in order to meet needs of security, trustworthy, and uplifting for teenagers in the process of pregnancy.

II. METHOD
The researcher screened 802 literatures studies from two databases (PubMed and ScienDirect) for review. This Literature Review used journals with qualitative research methods indexed Q1, Q2 and Q3. The population in this review was teenagers who had received ANC services during pregnancy to find out the experiences of pregnant adolescents in getting ANC services during pregnancy, their barriers and expectations in ANC services. of problems, 2) Prioritizing problems and questions, 3) Creating Frameworks, 4) Literature searching, 5) Selecting articles, 6) Making critical appraisal, 7) Extracting selected paper data, 8) Collecting data and making maps to answer questions.

A.
Problem Identification Based on the background, the identification of the problem that will be used as an article review was birth incidences in young mothers which occur a lot in developing countries and delayed antenatal care access on adolescent pregnancy.

B.
Research Question What are the experiences of adolescents during pregnancy in accessing ANC services and what are their expectations of health workers in effort to carry out ANC services?

C.
Framework The making of the framework uses the PEOS strategy namely Population, Exposure, Outcome, and Study design. . The process of selecting articles to be included in the systematic literature review was undertaken initially by the primary author and followed by the recommended Prisma flow diagram Based on Figure 1 the researchers identified 802 articles, and then after filtering the title, abstract, the research method, 115 articles were found to be taken and reviewed independently based on inclusion and exclusion criteria. Then further filtering of the article was done to find the right and complete reference regarding adolescent experiences in ANC services and to obtain articles for critical appraisal. Authors filtered the articles based on critical appraisal results and got 9 articles for the final review.

D.
Critical appraisal Critical appraisal is used to assess the quality of the articles to be used. The tool chosen to assess the quality of the articles is CASP. The filtered articles at the critical appraisal stage were 15 articles that were in accordance with the experiences, obstacles and expectations of adolescents in accessing antenatal care (ANC) services in both developed and developing countries and were qualitative research in accordance with predetermined inclusion and exclusion criteria. After this critical appraisal process 9 articles were obtained with good quality, indexed with standards Q1, Q2 and Q3by Scopus.

E.
Mapping The findings with systematic searches obtained articles published in 2008-2018, authors and sources of data taken came from Malawi (n = 2), Laos (n = 1), Belgium (n = 1), Australia (n = 1), Canada (n = 1), South Africa (n = 1), America (n = 1), United Kingdom (n = 1). So the results of the articles were grouped which consist of 5 articles in developed countries (Belgium, Australia, Canada, America, UK) and 4 articles in developing countries (2 articles from Malawi, 1 article from South Africa, and 1 article from Laos).
The data extracted from the systematic literature review were arranged into several themes. The themes included in the review of this article include:

2.
Barriers experienced by adolescents in accessing ANC services,

3.
Adolescents' expectations regarding the experience of ANC services provided by health workers.

A.
Adolescents' experience ANC during pregnancy Based on the findings of the article that provides an explanation of adolescents' experiences during an ANC examination, in the study "A qualitative examination of health care experiences of pregnant and parenting youth" [7] mentioned that adolescents had an unpleasant experience while undergoing an ANC pregnancy examination. They felt the negative interactions of health workers during antenatal care and they did not believe in health workers because they felt judged during the examination.
"When I checked myself for the first time, he (the health worker) really ignored me because I was too young, I understand that. But he really ignored me about that. "(Adolescent) In addition to experiences in technical issues, some adolescents related their experiences related to the counseling given during the ANC. Adolescent during ANC felt that the communication with health workers regarding the results of health examinations was inadequate so they could not remember specific details regarding the counseling provided and the counseling was repeated [8].
"After the examination, I did not communicate with health workers, there was no communication whatsoever. Health workers only record the check book, so I don't know whether my baby is in good condition or about how his growth is"(Adolescent) But there are findings which state that pregnancy information can be very adequate, especially the offending information about starting school again after giving birth because it absorbs their aspirations.

B. Barriers in accessing ANC services in adolescents
The findings indicate that one of the obstacles in accessing ANC services in adolescents is the distance traveled which is too far. A study about understanding barriers preventing pregnant women from starting antenatal clinic in the first trimester of pregnancy in Ntcheu District-Malawi revealed that long distances from home to health care facilities have an effect in determining when to check for pregnancy in adolescents. Some adolescents said that they couldn't do the initial ANC because the distance from the house is too far away and makes them worry about getting tired before delivery [9].
"When I think about the distance from home to a health facility which very far, I always feel discouraged to do the ANC" (Adolescent) There are articles about the obstacles to access the ANC in some teens in where it is a common obstacle for adolescents to access ANC services is the cost of services, drugs and transport as unexpected funds [10].
"Some people are worried about financial problems because they are afraid they don't have money and the doctor will leave her alone to death. Therefore she does not access ANC services. (Adolescent) The study suggested that participants were afraid of not having enough money to get their pregnancies checked [11]. "In the beginning of pregnancy, I was scared because I didn't have money. When I was 6 months pregnant, I still had nothing for my baby. (...) I stopped eating to save money and I had a problem with that ... "(Adolescent) The findings of the study by Haddrill (2014) suggest that some adolescents are afraid of the bad stigma of the consequences of adolescent pregnancy which leads them to hide the baby from social services, or respond to the father of her baby, family and close friends and negative stereotypes which popular about teen pregnancy. [12] "I know I should have gone for a health check, but I couldn't leave. Because I am still 17 years old, I find it hard to tell anyone, hard when people will see me ... I don't know, it looks like I'm not responsive ... I don't want to think about it. So I get rid of that thought. "(Adolescent) C.
Youth expectations regarding access to ANC services Expectations from adolescents in ANC services were revealed in a study conducted by Duggan that health workers should be able to make clients feel comfortable when checking their pregnancies. Health workers can give greetings and attention during consultations. In addition, health workers are expected to be able to give empathy and become close to clients [13]. "I should be treated well so that I feel comfortable so I will come to check the pregnancy again" "Health workers should speak as if they were their children. He shouldn't just check like an ordinary person. " In addition, in the same study, teenagers want a private place to make it comfortable during antenatal care. "You know this is a problem that teenagers have, you want someone to talk to, and you want something private" Other findings obtained from the research suggest that the sense of family and respect given by health workers is also a factor in returning to ANC. Teenagers are very happy if they were treated with attention by anyone who performs health checks. "I just want to be respected and respected during an ANC examination" [14].
Some women feel the option of giving counseling is important based on patient autonomy. Women believe that health workers should provide comprehensive, irrespective information based on personal views, ensuring women in making the right decisions [15].
"Everyone should have the right information ... having a child is a big decision. And choosing not to have children is a big decision too. I think that people should have the right information" A research found that adolescents showed practical needs during pregnancy, such as being given information about body shape changes, when to come to health workers, information and preparation about labor, etc. They added that the ongoing relationship between adolescents and health workers is the most important thing during pregnancy [11].

IV. D ISCUSSION
The results of the review conducted on ANC in adolescent pregnancies were obtained through findings on adolescent experiences regarding ANC services that were received during pregnancy, both less pleasant and pleasant treatments from health workers during the pregnancy checkup process. The results of the study suggest that some adolescents had unpleasant experiences where health workers were less friendly when giving ANC services to adolescents [8]. The negative experience received during a health examination

Advances in Health Sciences Research, volume 24
was the most memorable and hurtful experience. The negative experience they experienced came from judgmental words and judgmental attitudes from health professionals. Adolescents' perceptions of poor assessment by health workers resulted in distrust between adolescents and health workers and became a frightening feeling for adolescents to fund health services [7]. Bad actions from health workers can prevent some women from carrying out early ANC examinations. The lack of attention from health workers has been reported in several conditions and has a negative effect on the quality of health services [16].
The obstacles that arise in accessing ANC services according to adolescents include the long distance to the health services. The distance from the house to the place of health service has an effect on the implementation of early ANC [9]. Another study conducted by Were in 2013 reported that women postponed ANC examinations because they were waiting to get money as transport capital to health services. These findings indicate that socio-economic status is likely related to decision making to reach ANC service points, especially the time to access ANC services [16].
One obstacle that can affect prenatal care is the stigma from the public regarding teen pregnancy. Access to reaching ANC services in adolescents is influenced by the mother's readiness to accept her pregnancy and is also influenced by social aspects during pregnancy. Some women are afraid of judgment, community stigma, or other consequences in pregnancy such as the acceptance of babies. Women struggle to accept difficulties with those around them which then delay the access to health services [12]. Another study suggested that support of people around is an important factor for adolescents to access health services, and it is also important to increase adolescent knowledge about ANC services and maternal health [17].
The hopes of adolescents in ANC services as expressed in the study that health workers should be able to make clients feel comfortable during their health examination [13]. The results of this study are supported by a research which shows that adolescents want health workers to do ANC services to treat adolescents as good as they treat adults. Therefore, the habits and attitudes of health workers are expected to be more consistent in serving all ranges of patients' ages. A good relationship between health workers and patients shows the characteristics of the health services provided [18].
The high teenage pregnancy rate in Indonesia according to the 2012 IDHS, more than 2 million adolescent girls aged 15-19 years, is estimated to have given birth between 2005 and 2010, making it necessary to have special treatment from the government [19] [2]. The government program organized by BKKBN is in the form of the Youth Reproductive Health and Health Information Counseling Center (PIK-KRR) which aims to educate adolescents and reach teens to create a happy and prosperous small family (BKKBN). The hope expressed by pregnant adolescents is the provision of comprehensive counseling. As mentioned in the findings in the article that some pregnant teenagers feel that they need information about pregnancy, childbirth and motherhood skills, pregnant teenagers realize that they do not have any preparation in dealing with this pregnancy.
Becoming an attentive health worker for adolescent clients during pregnancy consultation is an action that can educate and help them to accept their pregnancy. Another study conducted from the point of view of health workers stated that health education and space specifically for adolescents were the key components for the friendly service towards pregnant adolescents [2] [20].

V. CONCLUSION
Antenatal care (ANC) is a treatment provided by skilled health workers for pregnant women and adolescents to ensure the health condition of the mother and fetus in the best condition. In fact, there are still unsatisfactory ANC services such as lack of sympathy from health workers and inadequate communication in the provision of counseling and injustice of services, especially for pregnant adolescents which can be the reason for delaying ANC examinations. Barriers that occur in accessing health services include the long travel time, financial problems, and the stigma surrounding communities about teenage pregnancy. The hopes of adolescents in order to improve the quality of ANC services include health workers who are expected to be able to interact with patients well so that patients feel comfortable. Another hope is the provision of comprehensive counseling from health workers so that the teenager knows the condition of her pregnancy and what to do during pregnancy

ACKNOWLEDGMENT
We would like to thank Aisyiyah university for making PPP1 program (professional practice project) for us and we would also like to show our gratitude to the our promotor promoter who provided insight.