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Perceived Barriers to Accessing Pregnancy-Related Health Information Among Married Adolescent Women: A Qualitative Study in Iran
Original Study Perceived Barriers to Accessing Pregnancy-Related Health Information Among Married Adolescent Women: A Qualitative Study in Iran Ashraf Ghiasi MSc 1, Afsaneh Keramat PhD 2,*, Maryam Farjamfar MD 3, Katayon Vakilian PhD 4 1
Student Research Committee, School of Nursing and Midwifery, Shahroud University of Medical Sciences, Shahroud, Iran Reproductive Studies and Women's Health Research Center, Shahroud University of Medical Sciences, Shahroud, Iran Clinical Research Development Unit, Bahar Hospital, Shahroud University of Medical Sciences, Shahroud, Iran 4 Nursing and Midwifery Collage, Arak University of Medical Sciences, Arak, Iran 2 3
a b s t r a c t Study Objective: To date, no study has reported barriers to accessing pregnancy-related health information among married women younger than the age of 19 years. Indeed, the voice of the girls being married is absent in the literature. We sought to explore the barriers to accessing pregnancy-related health information from the perspective of Iranian married adolescent women. Design: Qualitative study. Setting: The research was conducted in Mashhad city (health care centers) and Shahrood County (a maternity teaching hospital, and urban/ rural health care centers) in Iran. Participants, Interventions, and Main Outcome Measures: Twenty-four married adolescent women aged 14-19 years were recruited through purposive sampling. Individual in-depth interviews were tape-recorded, transcribed verbatim, and analyzed using conventional content analysis. Prolonged engagement with participants, maximum-variation sampling, member checking, peer deferring, and external audit were used to enhance the rigor of the study. Results: The results showed 3 categories: “structural barriers,” “individual barriers,” and “sociocultural barriers.” The structural barriers category consisted of 2 subcategories, namely, poor quality of education and counseling in the health care centers, and transportation barriers. The 2 subcategories of the individual barriers category consisted of affective barriers and cognitive barriers. The sociocultural barriers category included the following 2 subcategories: husband's decision-making power and fear of being labeled infertile. Conclusion: The barriers identified in this study should be considered when designing educational interventions for married adolescent women. Moreover, further research is needed to enhance current knowledge on this topic. Key Words: Iran, Health information, Married adolescents, Pregnancy, Qualitative study
Introduction
Globally, approximately 16 million girls aged 15-19 years and approximately 2 million girls younger than the age of 15 years give birth each year, constituting 11% of all births.1 Complications during pregnancy and childbirth are the leading cause of death for girls aged 15-19 years.2 According to data from 38 countries, maternal mortality ratio for girls aged 15-19 years is 28% higher than for women aged 2024 years.3 A number of studies have suggested that access to accurate and timely health information before and during pregnancy can reduce complications and adverse outcomes associated with pregnancy.4 Providing pregnancy-related health information to women will enable them to engage in preventive health behaviors, recognize problems when they occur, communicate effectively with health care providers (HCPs), make informed health decisions, and improve self-care capabilities.5,6
The authors indicate no conflicts of interest. * Address correspondence to: Afsaneh Keramat, PhD, Hafte Tir Square, Shahroud, Iran; Phone 009823-32395054; fax: 023 32395009. E-mail address: [email protected] (A. Keramat).
Although several studies have investigated problems associated with adolescent pregnancy, few have focused on information needs and barriers to accessing pregnancyrelated health information from the perspective of adolescent mothers. In a qualitative study on the health information-seeking behaviors of pregnant adolescents, unavailability of teenager-friendly antenatal services, feeling ashamed to talk about pregnancy-related issues, negative attitudes of HCPs, and perceived social stigma associated with teenage pregnancy were key barriers that limit pregnant adolescents’ access to health information.7 In this study, most of the participants (27/28) were not married. In Iran, premarriage sex is not acceptable for adolescent girls, thus, most adolescent pregnancies in our country occur within marriage. The legal age of marriage in Iran is 13 years for girls. However, the Iranian civil code allows girls younger than the age of 13 years get married with the consent of their father or the permission of a court judge.8 As in many other countries in the world where child marriage is common, girls in poorer, more rural areas of Iran like Sistan va Baluchistan and Khorasan Razavi Provinces are more likely to marry in childhood.9,10 The United Nations Children's Fund estimates that 3% of Iranian girls are
1083-3188/$ - see front matter Ó 2019 North American Society for Pediatric and Adolescent Gynecology. Published by Elsevier Inc. https://doi.org/10.1016/j.jpag.2019.08.012
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married before their 15th birthday and 17% are married before their 18th birthday.8 The numbers could be even higher, because many rural marriages in Iran are often held in secret and are not officially recorded.11 Considering the social structure in which traditional gender roles persist and women get pregnant within the first few years of their marriage, child marriage in Iran is often accompanied by teenage pregnancy and early motherhood. In Iran, approximately 6.3% of all live births are to mothers aged younger than 20 years.12 To our knowledge, no study has reported barriers to accessing pregnancy-related health information among married adolescents in Iran or other countries. Indeed, the voice of the girls being married is absent in the literature. To address this gap, we conducted a qualitative study to explore barriers to accessing pregnancy-related health information from the perspective of Iranian married adolescent women.
Data Analyses
Data were analyzed using conventional qualitative content analysis (CA).13 CA is particularly useful when little is known about the phenomenon of interest. It is divided into 3 distinct approaches: conventional CA, directed CA, and summative CA. Conventional CA allows gathering data directly from research participants without imposing preconceived categories or previous theoretical perspectives.14 In this part of the research, the transcribed interviews were read several times to get a sense of the whole. The texts were divided into meaning units, which were then condensed, abstracted, and labeled with codes. The extracted codes were interpreted and compared on the basis of differences and similarities and grouped into subcategories and categories. MAXQDA software version 10 (VERBI GmbH) was used to facilitate data analysis. The first author was responsible for data analysis and the other coauthors, especially the corresponding author, checked this process. Disagreements were resolved through discussion.
Methods Study Design and Setting
The present qualitative study was part of an exploratory sequential mixed methods study that investigated the reproductive health needs of married adolescent women in Iran. The research was conducted in Mashhad city (health care centers) and Shahrood County (a maternity teaching hospital, and urban/rural health care centers). Mashhad is the second most populous city in Iran and the capital of Khorasan Razavi Province. This province ranks among the top provinces with highest number of registered child marriages. Shahrood County is a county in Semnan Province. Shahrood, the capital of the county, is the largest and the most populous city of Semnan Province. We chose urban/rural health care centers and a maternity teaching hospital to increase the chances of recruiting volunteers from different educational levels, social status, and place of residence.
Data Collection
Data were collected using semistructured, in-depth interviews from November 2017 to March 2018. A purposive sampling method was used to recruit nonpregnant and pregnant married adolescents for in-depth interviews. Interviews were conducted in a private room at the maternity teaching hospital or health care centers. All interviews were performed by the first author, who began collecting data with a general question (such as “What are the barriers faced by married adolescent women in accessing pregnancy-related health information?”). During the interviews, further probing questions (such as “Could you explain more?” “Could you provide an example?”) were asked to elicit deeper responses. Data saturation was achieved with 21 respondents; however, 3 additional interviews were done to ensure the accuracy of the data. All interviews, which lasted between 30 and 80 minutes, were digitally recorded and transcribed verbatim.
Rigor and Trustworthiness
The criteria of credibility, dependability, transferability, and confirmability were applied to enhance the rigor of the research.15 Credibility was established through field notes, prolonged engagement with participants, complete immersion in the data, checking findings with participants (member check), and 3 coauthors (peer debriefing). Confirmability and credibility of research findings was strengthened using maximum-variation sampling. The external audit was used to enhance confirmability and dependability of the data. During the external audit, the correctness of analysis was approved by 2 academic members who were familiar with the analysis of qualitative studies. To ensure the transferability of the data, findings were checked by 4 adolescent women who did not participate in the research. Ethical Approval
Ethical approval of the study was obtained from the Ethics Committee of Shahroud University of Medical Sciences before data collection (IR.SHMU.REC.1396.69). Moreover, the purpose of the research interview was clearly explained to the participants and written informed consent for participation in the study was obtained from them. Results
The participants were 24 married girls aged between 14 and 19 years. The characteristics of participants are reported in Table 1. The analysis of semistructured interviews identified 3 categories, 6 subcategories, and 10 main codes for barriers to accessing pregnancy-related health information from the perspective of married girls (Table 2). Structural Barriers
Two subcategories emerged within the “structural barriers” category; these were the poor quality of education
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3
Table 1 Characteristics of Participants ID
Age, Years
Location
P1 P2 P3 P4 P5 P6 P7 P8 P9 P10 P11 P12 P13 P14 P15 P16 P17 P18 P19 P20 P21 P22 P23 P24
17 18 17 18 18 17 18 18 18 18 17 16 18 17 17 15 17 16 19 17 14 17 18 17
Rural Urban Urban Rural Urban Urban Urban Rural Rural Urban Suburban Suburban Urban Urban Urban Rural Urban Rural Suburban Rural Rural Urban Suburban Rural
G/P 1/0 1/1 1/0 1/0 1/1 2/1 1/1 1/0 1/0 1/0 1/1 1/0 1/0 0/0 2/1 1/0 1/1 1/0 2/2 1/0 1/0 1/0 1/1 1/0
Pregnant
Duration of Marriage
Educational Level, Grade
Husband's Age, Years
Husband's Educational Level, Grade
Yes, 38th week No, 1 day after birth Yes, 34th week Yes, 18th week No, 5 days after birth Yes, 14th week No, 2 months after birth Yes, 38th week Yes, 37th week Yes, 8th week No, 3 months after birth Yes, 20th week No No Yes, 38th week Yes, 26th week No, 1 month after birth Yes, 39th week No, 1 day after birth Yes, 40th week Yes, 8th week Yes, 27th week No, 4 months after birth Yes, 37th week
10 Months 21 Months 1 Year 6 Month 13 Months 4 Years 15 Months 1 Year 13 Months 2 Years 3 Years 11 Months 15 Months 7 Months 4 Years 8 Months 2 Years 11 Months 4 Years 15 Months 4 Months 3 Years 15 Months 9 Months
8 9 12 12 8 8 0 8 11 13 7 10 12 12 7 8 8 8 5 5 6 9 8 8
26 20 26 31 30 24 25 28 24 26 25 27 23 24 22 21 28 21 25 25 19 32 24 19
6 7 9 10 12 8 1 8 6 8 7 11 11 16 8 11 8 8 5 3 5 11 11 8
G/P, gravidity/parity.
and counseling in the health care centers and transportation barriers. Poor Quality of Education and Counseling in the Health Care Centers
This subcategory includes the following 3 main codes. Inadequate or Inaccurate Provision of Information by HCPs. Some of
participants reported that they had received little or no information about pregnancy-related issues from their HCPs. As this adolescent woman stated: She (Behvarz) just takes my blood pressure, measures my weight, gives me a pill (supplement), and also listens to the baby's heartbeat on Wednesdays when the midwife comes to the health care center. They don't tell me anything. They didn't even inform me of childbirth preparation classes. When I came here (hospital), a lady told me that childbirth preparation classes are held in the hospital, while I didn't know it!dP9
In addition, some participants had received misinformation from their HCPs (midwives and/or obstetricians), but they were unaware that the information they had received was inaccurate, as shown here:
Midwife (HCP) told me if you have a toothache do not visit the dentist at all. You should not pull out your tooth during pregnancy. She also said: If you have a toothache, do not use any medicine, it is harmful.dP5 When I was pregnant, I was worried about having sex. So, I visit the doctor and asked her whether having sex is harmful during pregnancy, and she said: Yes, it's harmful. It's better not to have. So, we (I and my husband) decided not to have sex during pregnancy.dP7 Communication between HCPs and Clients. Most study participants spoke about the importance of clientprovider communication. Some of them indicated that poor or nonexistent communication made them less willing to talk about their sexual and reproductive health concerns with their HCP, for example, one participant said:
Ineffective
When I went the health center, if midwives (HCPs) were comfortable with me; I would be comfortable with them but when they were not comfortable with me, I couldn't ask them anything. So I didn't ask (them) anything.dP15
Table 2 Categories, Subcategories, and Main Codes that Emerged From the Data as Barriers to Accessing Pregnancy-Related Health Information Category Structural barriers
Subcategory
Main Codes
Poor quality of education and counseling in the health care centers
Inadequate or inaccurate provision of health information by HCPs Ineffective communication between HCPs and clients Lack of privacy for counseling Long distance to childbirth preparation classes Feeling ashamed or embarrassed to ask questions They didn't know what information they needed to know Perception of being at low risk for pregnancy-related complications Lack of permission from their husbands to talk about their SRH concerns with others Lack of permission from their husbands to use the Internet Lack of informational support from family
Individual barriers
Transportation barriers Affective barriers Cognitive barriers
Sociocultural barriers
Husband's decision-making power Fear of being labeled infertile
HCP, health care provider; SRH, sexual and reproductive health.
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Moreover, the statements generated by participants showed that the age differences between HCPs and adolescent women can make communication less effective, for example:
know what information they needed to know. Indeed, the limited knowledge about sexual and reproductive health matters acted as a barrier to information-seeking; among them, 1 participant said:
I think if there would be a midwife (HCP) of my own age in the health care center, then I may feel comfortable to ask my questions.dP13
When I was pregnant, I didn't even think to ask questions. It was my first pregnancy. I was young and inexperienced. Now I say to myself, if I knew what to ask, studied more, knew more about delivery, I wouldn't be so stressed during delivery.dP2
Lack of Privacy for Counseling. Some participants said that their
worries regarding the lack of privacy within the health care settings made it difficult for them to ask their health provider questions about pregnancy-related issues, as shown in the following example: Now I don't know how to prevent pregnancy after giving birth, because there are 2 ways, using pills that I don't like and using a condom that my husband doesn't want. The health center is crowded all the time and there are always some other people there, so I can't ask my questions comfortably.dP12 Transportation Barriers
This subcategory consists of 1 main code as described in the following section. Long Distance to Childbirth Preparation Classes as an Information Source. Some adolescent women reported that they were
aware of the existence of childbirth preparation classes; however, long distance, particularly for rural women, was the main reason they did not participate in this training course, as described by one participant: Although the childbirth preparation classes were free I couldn't go to the classes due to long distance. It would have been better if these classes were held in Bastam [a city in Shahrood County]. I could attend the classes when I went to the health center for antenatal care, but there were none.dP3 Individual Barriers
This category emerged from 2 subcategories, namely, affective barriers and cognitive barriers. Affective Barriers
This subcategory consists of the following main code. Feeling Ashamed or Embarrassed to Ask Questions. Most in-
terviewees stated that feeling ashamed to ask questions prevented them from seeking pregnancy-related information, not only from HCPs but also from their family members. As these 2 participants said: I like and expect that HCPs inform me about nutritional tips without asking. I myself am a very shy person and usually don't ask any question.dP16 I feel shy to ask some questions. For example, I wanted to know about baby's position in the uterus, but I felt shy. I thought it would be a bad question. If I asked this question, others might be laughing at me and say how these questions came to your mind?!dP1 Cognitive Barriers
This subcategory has the following 2 codes. They Didn't Know What Information They Needed to Know. Several
participants in the present study stated that they didn't
Perception of Being at Low Risk for Pregnancy-Related Complications. Interview data showed that adolescent women with
lower perceived risk of adverse pregnancy outcome are less likely to seek pregnancy-related health information than those who have a higher-risk perception, as shown here: In our city, it's customary to get married in young ages. Now 20 of my classmates are either pregnant or have already given birth to a child. They had some problems during their pregnancies. For instance, they suffered ectopic pregnancy, high blood pressure, diabetes, and one of them underwent abortion since her child had no heart. For this, I had a lot of stress. Now I am studying a lot not to suffer these kinds of problems.dP10 I had no question (during pregnancy), because I didn't have any problems in pregnancy.dP23
Sociocultural Barriers
This category is classified into 2 subcategories of husband's decision-making power and lack of social support from family. Husband's Decision-Making Power
The statements generated by participants revealed that a husband's decision-making power might act as a significant barrier to access pregnancy-related health information in an adolescent woman. This subcategory consists of 2 codes as described in the following sections. Lack of Permission From Their Husbands to Talk about Their Sexual and Reproductive Health Concerns with Others. Some of the in-
terviewees indicated that their husbands don't allow them to talk about their sexual and reproductive health concerns with others, for example, this participant said: During pregnancy, we (my husband and I) didn't have sex. We thought it may hurt the baby.. I didn't ask anyone about it, because my husband doesn't allow me to talk about such things with others or ask a question about sexual issues from others. He doesn't like it at all.dP11 Lack of Permission from Their Husbands to Use the Internet. In some
cases, opposition from their husbands was the main factor that made them fail to use the Internet as a source of health information, as shown here: Although I have a cell phone, due to some taboo contents on Telegram, my husband doesn't let me use the Internet. He uses the internet but doesn't let me use it.dP19 Fear of Being Labeled Infertile
This subcategory consists of the following main code.
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Lack of Informational Support from Family. Most of the partici-
pants said that they were under social pressure to prove their fertility soon after marriage. Some of them made efforts to hide their decision to become pregnant because of fear of being labeled infertile if they didn't get pregnant immediately. Therefore, concealing pregnancy decision (trying to get pregnant but don't want people to know) is a factor that prevents or delays adolescent women to ask their questions about pregnancy-related matters from their family members when they are trying to become pregnant, as shown here: They (my relatives) tell me: Are you sterile? Why don't you get pregnant?! For this reason, although I want to get pregnant, I haven't told them anything. I don't ask them any question. I want them to know about it later. I don't like to hear this question: Couldn't you still get pregnant!? dP14
Discussion
To our knowledge, this is the first study aimed at identifying barriers to accessing pregnancy-related health information from the perspective of married adolescent women. On the basis of this study's findings, insufficient or inaccurate information provided by HCPs is a major factor that hinders married adolescents' access to pregnancyrelated health information. This finding is consistent with some previous research in Iran and other societies that suggest that receiving inadequate or inaccurate information from health care professionals is a barrier to accessing health care services and information.16e19 We also found that ineffective communication between HCPs and adolescent women is a challenge that study participants face in obtaining pregnancy-related health information. This finding is consistent with previous research, which concluded that ineffective communication between HCPs and pregnant women during antenatal visits poses a serious hindrance to the health information exchange, and negatively affects the pregnant women's trust in providers.20,21 Furthermore, we found that the age differences between midwives and adolescent women can make communication less effective, which was confirmed by Chaibva et al.22 Another barrier that emerged in this study is lack of privacy for counseling within the health facilities. This result supported those of Mishra, who reported that lack of privacy in health facilities can act as a barrier to use reproductive and sexual health services in Muslim women.23 Although childbirth preparation classes, as a source of pregnancy-related health information, are free of charge in our country, long distance (or travel times) was a barrier that led to some participants’ inability or unwillingness to use this available service. This finding is similar to earlier studies that reported that women who have to travel long distances tend to use maternal health services less.24,25 In addition, this study has revealed that embarrassment and feeling shy to ask questions is an important reason why some married adolescents do not use HCPs or family
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members as a source of health information. This result is consistent with the findings of a previous study.7 Furthermore, in our study, some participants did not know what they did not know and thus they were less likely to seek their pregnancy-related information from their HCPs or other sources of information. This finding is in agreement with an Australian study.26 Our results also highlighted that perception of being at low risk for pregnancy-related complications is an obstacle that keeps adolescent women from seeking pregnancyrelated health information. This supports the results of Wilunda et al, who reported that women with higher perceived risk of adverse pregnancy outcome are more likely to attend antenatal care than those who have a lower risk perception.27 The present study showed that husband's opposition is another reason for not using formal and/or informal sources of health information among married adolescent women. A previous study indicated that women with higher autonomy in household decisions are more likely to seek and obtain maternal health care compared with those who did not have autonomy.28 In another study, it was shown that women's decision-making autonomy regarding their own health care is positively associated with their age.29 In Iranian culture, women are expected to become pregnant soon after marriage.30 Hence, it is not surprising that some adolescent women in our study were under pressure from family and relatives to prove their fertility immediately after marriage. Findings of our study showed that feeling such pressure acts as a factor that prevents or delays adolescent women to access informational support from their family members when they are trying to become pregnant. Evidence suggests that not having sufficient network support might act as a barrier to informationseeking among low-income pregnant women.31 Jat et al reported that social support from friends and family members and receiving information from them are related to the use of prenatal care services.32 Another study showed that informational support from friends and family members is a determinant that can lead to improved health outcomes during pregnancy.33 The study has some limitations that should be considered. Similar to all qualitative studies, the use of convenience sampling in this study could limit transferability of our findings. In this study we only explored perceived barriers to accessing pregnancy-related health information among married adolescent women, although they might not be aware of all potential barriers. Further, in this study the interviews were conducted in Persian and then translated into English, which might change the original meanings to some extent. Conclusion
The findings in this study indicate that structural, individual, and sociocultural barriers are perceived hindrances to accessing pregnancy-related health information among married adolescents in Iran. These results have implications for policy makers, planners, and health practitioners to design and develop health promotion programs and
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culturally sensitive health interventions for this group of women. Moreover, because of the limited number of studies in this area, further research is needed. Acknowledgments
This article is extracted from Ashraf Ghiasi PhD thesis in Reproductive Health, financially supported by Shahroud University of Medical Sciences, Iran (grant number 9664).We hereby acknowledge the research deputy for providing research facilities. The authors also give thanks to the married adolescent women who participated in the study. References 1. World Health Organization: Why Is Giving Special Attention to Adolescents Important for Achieving Millennium Development Goal 5? Fact Sheet. Geneva, WHO, 2008 2. World Health Organization: Global Health Estimates 2015: Deaths by Cause, Age, Sex, by Country and by Region, 2000-2015. Geneva, WHO, 2016 3. Blanc AK, Winfrey W, Ross J: New findings for maternal mortality age patterns: aggregated results for 38 countries. PLoS One 2013; 8:e59864 4. Anasi SNI, Allison GO: Sociodemographic determinants of information sources availability and use among pregnant women in Ilisan-Remo, Ogun State, Nigeria. J Hosp Librariansh 2018; 18:47 5. Das A: Information-seeking among pregnant women: a mixed method approach, Florida State University [dissertation]. Available: http://purl.flvc. org/fsu/fd/FSU_migr_etd-7348; 2013. 6. Ghiasi A: Health information needs, sources of information, and barriers to accessing health information among pregnant women: a systematic review of research. J Matern Fetal Neonatal Med 2019, https://doi.org/10. 1080/14767058.2019.1634685 7. Owusu-Addo SB, Owusu-Addo E, Morhe ES: Health information-seeking behaviours among pregnant teenagers in Ejisu-Juaben Municipality, Ghana. Midwifery 2016; 41:110 8. Iran - Child Marriage Around The World. Girls Not Brides, Available: https:// www.girlsnotbrides.org/child-marriage/iran/. Accessed October 10, 2019. 9. Child marriage in Southern Asia. Policy options for action. Available: https:// www.icrw.org/wp-content/uploads/2016/10/CHILDMARRIAGE-F-13.pdf. Accessed October 11, 2012. 10. Tehran Times: Child brides, sufferers of the lost childhood. Available: https:// www.tehrantimes.com/news/420152/Child-brides-sufferers-of-the-lost-childhood. Accessed January 9, 2018. 11. Country Policy and Information Note-Iran: Forced marriage. Available: https:// assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_ data/file/636488/CPIN_-_Iran_-_Forced_marriage_August_2017.pdf. Accessed October 13, 2019. 12. All Human Rights for All in Iran: Child early marriages and child mothers in the Islamic Republic of Iran. Available: https://www.ohchr.org/Documents/Issues/ Children/2030/AllHumanRightsForAllInIran.pdf. Accessed October , 2016.
13. Graneheim UH, Lundman B: Qualitative content analysis in nursing research: concepts, procedures and measures to achieve trustworthiness. Nurse Educ Today 2004; 24:105 14. Hsieh HF, Shannon SE: Three approaches to qualitative content analysis. Qual Health Res 2005; 15:1277 15. Polit DF, Beck CT: Essentials of nursing research: appraising evidence for nursing practice. Philadelphia, PA, Wolters Kluwer Health/Lippincott Williams & Wilkins, 2014 16. Dehlendorf C, Levy K, Ruskin R, et al: Health care providers’ knowledge about contraceptive evidence: a barrier to quality family planning care? Contraception 2010; 81:292 17. Warner D, Procaccino JD: Toward wellness: women seeking health information. J Am Soc Inf Sci Technol 2004; 55:709 18. Nikbakht Nasrabadi A, Sabzevari S, Negahban Bonabi T: Iranian women’s experiences of health information seeking barriers: a qualitative study in Kerman. Iran Red Crescent Med J 2015; 17:e25156 19. Taheri S, Taghizadeh Z, Tavousi M: Explaining effective factors on access to maternal health information during pregnancy: a qualitative study. J Res Med Dent Sci 2018; 6:50 20. Attanasio L, Kozhimannil KB: Patient-reported communication quality and perceived discrimination in maternity care. Med Care 2015; 53:863 21. Asifere WN, Tessema M, Tebeje B: Clients’ satisfaction with health care providers’ communication and associated factors among pregnant women attending antenatal care in Jimma town public health facilities, Jimma zone, Southwest Ethiopia. Int J Pregnancy Child Birth 2018; 4:223 22. Chaibva CN, Ehlers VJ, Roos JH: Midwives’ perceptions about adolescents’ utilisation of public prenatal services in Bulawayo, Zimbabwe. Midwifery 2010; 26:16 23. Mishra VK: Muslim/non-Muslim differentials in fertility and family planning in India. East West Center Working Papers , Population and Health Series 2004;, pp 112 24. Bonso G: Assessment of the quality of antenatal care (Anc) services among teenage mothers in the Maamobi District Hospital in Accra. University of Ghana, 2015. [doctoral dissertation]. 25. Tsawe M, Susuman AS: Determinants of access to and use of maternal health care services in the Eastern Cape, South Africa: a quantitative and qualitative investigation. BMC Res Notes 2014; 7:723 26. Bookari K, Yeatman H, Williamson M: Informing nutrition care in the antenatal period: pregnant women’s experiences and need for support. Biomed Res Int 2017; 2017:4856527 27. Wilunda C, Scanagatta C, Putoto G, et al: Barriers to utilisation of antenatal care services in South Sudan: a qualitative study in Rumbek North County. Reprod Health 2017; 14:65 28. Adhikari R: Effect of women’s autonomy on maternal health service utilization in Nepal: a cross sectional study. BMC Womens Health 2016; 16:26 29. Alemayehu M, Meskele M: Health care decision making autonomy of women from rural districts of Southern Ethiopia: a community based cross-sectional study. Int J Womens Health 2017; 9:213 30. Mangeli M, Rayyani M, Cheraghi MA, et al: Factors that encourage early marriage and motherhood from the perspective of Iranian adolescent mothers: a qualitative study. World Fam Med 2017; 15:67 31. Spink A, Cole C: Information and poverty: information-seeking channels used by African American low-income households. Libr Inf Sci Res 2001; 23:45 32. Jat TR, Ng N, San Sebastian M: Factors affecting the use of maternal health services in Madhya Pradesh state of India: a multilevel analysis. Int J Equity Health 2011; 10:59 ~ a Y, et al: Weight, diet, and physical 33. Thornton PL, Kieffer EC, Salabarría-Pen activity-related beliefs and practices among pregnant and postpartum Latino women: the role of social support. Matern Child Health J 2006; 10:95
Student Research Committee, School of Nursing and Midwifery, Shahroud University of Medical Sciences, Shahroud, Iran Reproductive Studies and Women's Health Research Center, Shahroud University of Medical Sciences, Shahroud, Iran Clinical Research Development Unit, Bahar Hospital, Shahroud University of Medical Sciences, Shahroud, Iran 4 Nursing and Midwifery Collage, Arak University of Medical Sciences, Arak, Iran 2 3
a b s t r a c t Study Objective: To date, no study has reported barriers to accessing pregnancy-related health information among married women younger than the age of 19 years. Indeed, the voice of the girls being married is absent in the literature. We sought to explore the barriers to accessing pregnancy-related health information from the perspective of Iranian married adolescent women. Design: Qualitative study. Setting: The research was conducted in Mashhad city (health care centers) and Shahrood County (a maternity teaching hospital, and urban/ rural health care centers) in Iran. Participants, Interventions, and Main Outcome Measures: Twenty-four married adolescent women aged 14-19 years were recruited through purposive sampling. Individual in-depth interviews were tape-recorded, transcribed verbatim, and analyzed using conventional content analysis. Prolonged engagement with participants, maximum-variation sampling, member checking, peer deferring, and external audit were used to enhance the rigor of the study. Results: The results showed 3 categories: “structural barriers,” “individual barriers,” and “sociocultural barriers.” The structural barriers category consisted of 2 subcategories, namely, poor quality of education and counseling in the health care centers, and transportation barriers. The 2 subcategories of the individual barriers category consisted of affective barriers and cognitive barriers. The sociocultural barriers category included the following 2 subcategories: husband's decision-making power and fear of being labeled infertile. Conclusion: The barriers identified in this study should be considered when designing educational interventions for married adolescent women. Moreover, further research is needed to enhance current knowledge on this topic. Key Words: Iran, Health information, Married adolescents, Pregnancy, Qualitative study
Introduction
Globally, approximately 16 million girls aged 15-19 years and approximately 2 million girls younger than the age of 15 years give birth each year, constituting 11% of all births.1 Complications during pregnancy and childbirth are the leading cause of death for girls aged 15-19 years.2 According to data from 38 countries, maternal mortality ratio for girls aged 15-19 years is 28% higher than for women aged 2024 years.3 A number of studies have suggested that access to accurate and timely health information before and during pregnancy can reduce complications and adverse outcomes associated with pregnancy.4 Providing pregnancy-related health information to women will enable them to engage in preventive health behaviors, recognize problems when they occur, communicate effectively with health care providers (HCPs), make informed health decisions, and improve self-care capabilities.5,6
The authors indicate no conflicts of interest. * Address correspondence to: Afsaneh Keramat, PhD, Hafte Tir Square, Shahroud, Iran; Phone 009823-32395054; fax: 023 32395009. E-mail address: [email protected] (A. Keramat).
Although several studies have investigated problems associated with adolescent pregnancy, few have focused on information needs and barriers to accessing pregnancyrelated health information from the perspective of adolescent mothers. In a qualitative study on the health information-seeking behaviors of pregnant adolescents, unavailability of teenager-friendly antenatal services, feeling ashamed to talk about pregnancy-related issues, negative attitudes of HCPs, and perceived social stigma associated with teenage pregnancy were key barriers that limit pregnant adolescents’ access to health information.7 In this study, most of the participants (27/28) were not married. In Iran, premarriage sex is not acceptable for adolescent girls, thus, most adolescent pregnancies in our country occur within marriage. The legal age of marriage in Iran is 13 years for girls. However, the Iranian civil code allows girls younger than the age of 13 years get married with the consent of their father or the permission of a court judge.8 As in many other countries in the world where child marriage is common, girls in poorer, more rural areas of Iran like Sistan va Baluchistan and Khorasan Razavi Provinces are more likely to marry in childhood.9,10 The United Nations Children's Fund estimates that 3% of Iranian girls are
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married before their 15th birthday and 17% are married before their 18th birthday.8 The numbers could be even higher, because many rural marriages in Iran are often held in secret and are not officially recorded.11 Considering the social structure in which traditional gender roles persist and women get pregnant within the first few years of their marriage, child marriage in Iran is often accompanied by teenage pregnancy and early motherhood. In Iran, approximately 6.3% of all live births are to mothers aged younger than 20 years.12 To our knowledge, no study has reported barriers to accessing pregnancy-related health information among married adolescents in Iran or other countries. Indeed, the voice of the girls being married is absent in the literature. To address this gap, we conducted a qualitative study to explore barriers to accessing pregnancy-related health information from the perspective of Iranian married adolescent women.
Data Analyses
Data were analyzed using conventional qualitative content analysis (CA).13 CA is particularly useful when little is known about the phenomenon of interest. It is divided into 3 distinct approaches: conventional CA, directed CA, and summative CA. Conventional CA allows gathering data directly from research participants without imposing preconceived categories or previous theoretical perspectives.14 In this part of the research, the transcribed interviews were read several times to get a sense of the whole. The texts were divided into meaning units, which were then condensed, abstracted, and labeled with codes. The extracted codes were interpreted and compared on the basis of differences and similarities and grouped into subcategories and categories. MAXQDA software version 10 (VERBI GmbH) was used to facilitate data analysis. The first author was responsible for data analysis and the other coauthors, especially the corresponding author, checked this process. Disagreements were resolved through discussion.
Methods Study Design and Setting
The present qualitative study was part of an exploratory sequential mixed methods study that investigated the reproductive health needs of married adolescent women in Iran. The research was conducted in Mashhad city (health care centers) and Shahrood County (a maternity teaching hospital, and urban/rural health care centers). Mashhad is the second most populous city in Iran and the capital of Khorasan Razavi Province. This province ranks among the top provinces with highest number of registered child marriages. Shahrood County is a county in Semnan Province. Shahrood, the capital of the county, is the largest and the most populous city of Semnan Province. We chose urban/rural health care centers and a maternity teaching hospital to increase the chances of recruiting volunteers from different educational levels, social status, and place of residence.
Data Collection
Data were collected using semistructured, in-depth interviews from November 2017 to March 2018. A purposive sampling method was used to recruit nonpregnant and pregnant married adolescents for in-depth interviews. Interviews were conducted in a private room at the maternity teaching hospital or health care centers. All interviews were performed by the first author, who began collecting data with a general question (such as “What are the barriers faced by married adolescent women in accessing pregnancy-related health information?”). During the interviews, further probing questions (such as “Could you explain more?” “Could you provide an example?”) were asked to elicit deeper responses. Data saturation was achieved with 21 respondents; however, 3 additional interviews were done to ensure the accuracy of the data. All interviews, which lasted between 30 and 80 minutes, were digitally recorded and transcribed verbatim.
Rigor and Trustworthiness
The criteria of credibility, dependability, transferability, and confirmability were applied to enhance the rigor of the research.15 Credibility was established through field notes, prolonged engagement with participants, complete immersion in the data, checking findings with participants (member check), and 3 coauthors (peer debriefing). Confirmability and credibility of research findings was strengthened using maximum-variation sampling. The external audit was used to enhance confirmability and dependability of the data. During the external audit, the correctness of analysis was approved by 2 academic members who were familiar with the analysis of qualitative studies. To ensure the transferability of the data, findings were checked by 4 adolescent women who did not participate in the research. Ethical Approval
Ethical approval of the study was obtained from the Ethics Committee of Shahroud University of Medical Sciences before data collection (IR.SHMU.REC.1396.69). Moreover, the purpose of the research interview was clearly explained to the participants and written informed consent for participation in the study was obtained from them. Results
The participants were 24 married girls aged between 14 and 19 years. The characteristics of participants are reported in Table 1. The analysis of semistructured interviews identified 3 categories, 6 subcategories, and 10 main codes for barriers to accessing pregnancy-related health information from the perspective of married girls (Table 2). Structural Barriers
Two subcategories emerged within the “structural barriers” category; these were the poor quality of education
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Table 1 Characteristics of Participants ID
Age, Years
Location
P1 P2 P3 P4 P5 P6 P7 P8 P9 P10 P11 P12 P13 P14 P15 P16 P17 P18 P19 P20 P21 P22 P23 P24
17 18 17 18 18 17 18 18 18 18 17 16 18 17 17 15 17 16 19 17 14 17 18 17
Rural Urban Urban Rural Urban Urban Urban Rural Rural Urban Suburban Suburban Urban Urban Urban Rural Urban Rural Suburban Rural Rural Urban Suburban Rural
G/P 1/0 1/1 1/0 1/0 1/1 2/1 1/1 1/0 1/0 1/0 1/1 1/0 1/0 0/0 2/1 1/0 1/1 1/0 2/2 1/0 1/0 1/0 1/1 1/0
Pregnant
Duration of Marriage
Educational Level, Grade
Husband's Age, Years
Husband's Educational Level, Grade
Yes, 38th week No, 1 day after birth Yes, 34th week Yes, 18th week No, 5 days after birth Yes, 14th week No, 2 months after birth Yes, 38th week Yes, 37th week Yes, 8th week No, 3 months after birth Yes, 20th week No No Yes, 38th week Yes, 26th week No, 1 month after birth Yes, 39th week No, 1 day after birth Yes, 40th week Yes, 8th week Yes, 27th week No, 4 months after birth Yes, 37th week
10 Months 21 Months 1 Year 6 Month 13 Months 4 Years 15 Months 1 Year 13 Months 2 Years 3 Years 11 Months 15 Months 7 Months 4 Years 8 Months 2 Years 11 Months 4 Years 15 Months 4 Months 3 Years 15 Months 9 Months
8 9 12 12 8 8 0 8 11 13 7 10 12 12 7 8 8 8 5 5 6 9 8 8
26 20 26 31 30 24 25 28 24 26 25 27 23 24 22 21 28 21 25 25 19 32 24 19
6 7 9 10 12 8 1 8 6 8 7 11 11 16 8 11 8 8 5 3 5 11 11 8
G/P, gravidity/parity.
and counseling in the health care centers and transportation barriers. Poor Quality of Education and Counseling in the Health Care Centers
This subcategory includes the following 3 main codes. Inadequate or Inaccurate Provision of Information by HCPs. Some of
participants reported that they had received little or no information about pregnancy-related issues from their HCPs. As this adolescent woman stated: She (Behvarz) just takes my blood pressure, measures my weight, gives me a pill (supplement), and also listens to the baby's heartbeat on Wednesdays when the midwife comes to the health care center. They don't tell me anything. They didn't even inform me of childbirth preparation classes. When I came here (hospital), a lady told me that childbirth preparation classes are held in the hospital, while I didn't know it!dP9
In addition, some participants had received misinformation from their HCPs (midwives and/or obstetricians), but they were unaware that the information they had received was inaccurate, as shown here:
Midwife (HCP) told me if you have a toothache do not visit the dentist at all. You should not pull out your tooth during pregnancy. She also said: If you have a toothache, do not use any medicine, it is harmful.dP5 When I was pregnant, I was worried about having sex. So, I visit the doctor and asked her whether having sex is harmful during pregnancy, and she said: Yes, it's harmful. It's better not to have. So, we (I and my husband) decided not to have sex during pregnancy.dP7 Communication between HCPs and Clients. Most study participants spoke about the importance of clientprovider communication. Some of them indicated that poor or nonexistent communication made them less willing to talk about their sexual and reproductive health concerns with their HCP, for example, one participant said:
Ineffective
When I went the health center, if midwives (HCPs) were comfortable with me; I would be comfortable with them but when they were not comfortable with me, I couldn't ask them anything. So I didn't ask (them) anything.dP15
Table 2 Categories, Subcategories, and Main Codes that Emerged From the Data as Barriers to Accessing Pregnancy-Related Health Information Category Structural barriers
Subcategory
Main Codes
Poor quality of education and counseling in the health care centers
Inadequate or inaccurate provision of health information by HCPs Ineffective communication between HCPs and clients Lack of privacy for counseling Long distance to childbirth preparation classes Feeling ashamed or embarrassed to ask questions They didn't know what information they needed to know Perception of being at low risk for pregnancy-related complications Lack of permission from their husbands to talk about their SRH concerns with others Lack of permission from their husbands to use the Internet Lack of informational support from family
Individual barriers
Transportation barriers Affective barriers Cognitive barriers
Sociocultural barriers
Husband's decision-making power Fear of being labeled infertile
HCP, health care provider; SRH, sexual and reproductive health.
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Moreover, the statements generated by participants showed that the age differences between HCPs and adolescent women can make communication less effective, for example:
know what information they needed to know. Indeed, the limited knowledge about sexual and reproductive health matters acted as a barrier to information-seeking; among them, 1 participant said:
I think if there would be a midwife (HCP) of my own age in the health care center, then I may feel comfortable to ask my questions.dP13
When I was pregnant, I didn't even think to ask questions. It was my first pregnancy. I was young and inexperienced. Now I say to myself, if I knew what to ask, studied more, knew more about delivery, I wouldn't be so stressed during delivery.dP2
Lack of Privacy for Counseling. Some participants said that their
worries regarding the lack of privacy within the health care settings made it difficult for them to ask their health provider questions about pregnancy-related issues, as shown in the following example: Now I don't know how to prevent pregnancy after giving birth, because there are 2 ways, using pills that I don't like and using a condom that my husband doesn't want. The health center is crowded all the time and there are always some other people there, so I can't ask my questions comfortably.dP12 Transportation Barriers
This subcategory consists of 1 main code as described in the following section. Long Distance to Childbirth Preparation Classes as an Information Source. Some adolescent women reported that they were
aware of the existence of childbirth preparation classes; however, long distance, particularly for rural women, was the main reason they did not participate in this training course, as described by one participant: Although the childbirth preparation classes were free I couldn't go to the classes due to long distance. It would have been better if these classes were held in Bastam [a city in Shahrood County]. I could attend the classes when I went to the health center for antenatal care, but there were none.dP3 Individual Barriers
This category emerged from 2 subcategories, namely, affective barriers and cognitive barriers. Affective Barriers
This subcategory consists of the following main code. Feeling Ashamed or Embarrassed to Ask Questions. Most in-
terviewees stated that feeling ashamed to ask questions prevented them from seeking pregnancy-related information, not only from HCPs but also from their family members. As these 2 participants said: I like and expect that HCPs inform me about nutritional tips without asking. I myself am a very shy person and usually don't ask any question.dP16 I feel shy to ask some questions. For example, I wanted to know about baby's position in the uterus, but I felt shy. I thought it would be a bad question. If I asked this question, others might be laughing at me and say how these questions came to your mind?!dP1 Cognitive Barriers
This subcategory has the following 2 codes. They Didn't Know What Information They Needed to Know. Several
participants in the present study stated that they didn't
Perception of Being at Low Risk for Pregnancy-Related Complications. Interview data showed that adolescent women with
lower perceived risk of adverse pregnancy outcome are less likely to seek pregnancy-related health information than those who have a higher-risk perception, as shown here: In our city, it's customary to get married in young ages. Now 20 of my classmates are either pregnant or have already given birth to a child. They had some problems during their pregnancies. For instance, they suffered ectopic pregnancy, high blood pressure, diabetes, and one of them underwent abortion since her child had no heart. For this, I had a lot of stress. Now I am studying a lot not to suffer these kinds of problems.dP10 I had no question (during pregnancy), because I didn't have any problems in pregnancy.dP23
Sociocultural Barriers
This category is classified into 2 subcategories of husband's decision-making power and lack of social support from family. Husband's Decision-Making Power
The statements generated by participants revealed that a husband's decision-making power might act as a significant barrier to access pregnancy-related health information in an adolescent woman. This subcategory consists of 2 codes as described in the following sections. Lack of Permission From Their Husbands to Talk about Their Sexual and Reproductive Health Concerns with Others. Some of the in-
terviewees indicated that their husbands don't allow them to talk about their sexual and reproductive health concerns with others, for example, this participant said: During pregnancy, we (my husband and I) didn't have sex. We thought it may hurt the baby.. I didn't ask anyone about it, because my husband doesn't allow me to talk about such things with others or ask a question about sexual issues from others. He doesn't like it at all.dP11 Lack of Permission from Their Husbands to Use the Internet. In some
cases, opposition from their husbands was the main factor that made them fail to use the Internet as a source of health information, as shown here: Although I have a cell phone, due to some taboo contents on Telegram, my husband doesn't let me use the Internet. He uses the internet but doesn't let me use it.dP19 Fear of Being Labeled Infertile
This subcategory consists of the following main code.
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Lack of Informational Support from Family. Most of the partici-
pants said that they were under social pressure to prove their fertility soon after marriage. Some of them made efforts to hide their decision to become pregnant because of fear of being labeled infertile if they didn't get pregnant immediately. Therefore, concealing pregnancy decision (trying to get pregnant but don't want people to know) is a factor that prevents or delays adolescent women to ask their questions about pregnancy-related matters from their family members when they are trying to become pregnant, as shown here: They (my relatives) tell me: Are you sterile? Why don't you get pregnant?! For this reason, although I want to get pregnant, I haven't told them anything. I don't ask them any question. I want them to know about it later. I don't like to hear this question: Couldn't you still get pregnant!? dP14
Discussion
To our knowledge, this is the first study aimed at identifying barriers to accessing pregnancy-related health information from the perspective of married adolescent women. On the basis of this study's findings, insufficient or inaccurate information provided by HCPs is a major factor that hinders married adolescents' access to pregnancyrelated health information. This finding is consistent with some previous research in Iran and other societies that suggest that receiving inadequate or inaccurate information from health care professionals is a barrier to accessing health care services and information.16e19 We also found that ineffective communication between HCPs and adolescent women is a challenge that study participants face in obtaining pregnancy-related health information. This finding is consistent with previous research, which concluded that ineffective communication between HCPs and pregnant women during antenatal visits poses a serious hindrance to the health information exchange, and negatively affects the pregnant women's trust in providers.20,21 Furthermore, we found that the age differences between midwives and adolescent women can make communication less effective, which was confirmed by Chaibva et al.22 Another barrier that emerged in this study is lack of privacy for counseling within the health facilities. This result supported those of Mishra, who reported that lack of privacy in health facilities can act as a barrier to use reproductive and sexual health services in Muslim women.23 Although childbirth preparation classes, as a source of pregnancy-related health information, are free of charge in our country, long distance (or travel times) was a barrier that led to some participants’ inability or unwillingness to use this available service. This finding is similar to earlier studies that reported that women who have to travel long distances tend to use maternal health services less.24,25 In addition, this study has revealed that embarrassment and feeling shy to ask questions is an important reason why some married adolescents do not use HCPs or family
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members as a source of health information. This result is consistent with the findings of a previous study.7 Furthermore, in our study, some participants did not know what they did not know and thus they were less likely to seek their pregnancy-related information from their HCPs or other sources of information. This finding is in agreement with an Australian study.26 Our results also highlighted that perception of being at low risk for pregnancy-related complications is an obstacle that keeps adolescent women from seeking pregnancyrelated health information. This supports the results of Wilunda et al, who reported that women with higher perceived risk of adverse pregnancy outcome are more likely to attend antenatal care than those who have a lower risk perception.27 The present study showed that husband's opposition is another reason for not using formal and/or informal sources of health information among married adolescent women. A previous study indicated that women with higher autonomy in household decisions are more likely to seek and obtain maternal health care compared with those who did not have autonomy.28 In another study, it was shown that women's decision-making autonomy regarding their own health care is positively associated with their age.29 In Iranian culture, women are expected to become pregnant soon after marriage.30 Hence, it is not surprising that some adolescent women in our study were under pressure from family and relatives to prove their fertility immediately after marriage. Findings of our study showed that feeling such pressure acts as a factor that prevents or delays adolescent women to access informational support from their family members when they are trying to become pregnant. Evidence suggests that not having sufficient network support might act as a barrier to informationseeking among low-income pregnant women.31 Jat et al reported that social support from friends and family members and receiving information from them are related to the use of prenatal care services.32 Another study showed that informational support from friends and family members is a determinant that can lead to improved health outcomes during pregnancy.33 The study has some limitations that should be considered. Similar to all qualitative studies, the use of convenience sampling in this study could limit transferability of our findings. In this study we only explored perceived barriers to accessing pregnancy-related health information among married adolescent women, although they might not be aware of all potential barriers. Further, in this study the interviews were conducted in Persian and then translated into English, which might change the original meanings to some extent. Conclusion
The findings in this study indicate that structural, individual, and sociocultural barriers are perceived hindrances to accessing pregnancy-related health information among married adolescents in Iran. These results have implications for policy makers, planners, and health practitioners to design and develop health promotion programs and
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culturally sensitive health interventions for this group of women. Moreover, because of the limited number of studies in this area, further research is needed. Acknowledgments
This article is extracted from Ashraf Ghiasi PhD thesis in Reproductive Health, financially supported by Shahroud University of Medical Sciences, Iran (grant number 9664).We hereby acknowledge the research deputy for providing research facilities. The authors also give thanks to the married adolescent women who participated in the study. References 1. World Health Organization: Why Is Giving Special Attention to Adolescents Important for Achieving Millennium Development Goal 5? Fact Sheet. Geneva, WHO, 2008 2. World Health Organization: Global Health Estimates 2015: Deaths by Cause, Age, Sex, by Country and by Region, 2000-2015. Geneva, WHO, 2016 3. Blanc AK, Winfrey W, Ross J: New findings for maternal mortality age patterns: aggregated results for 38 countries. PLoS One 2013; 8:e59864 4. Anasi SNI, Allison GO: Sociodemographic determinants of information sources availability and use among pregnant women in Ilisan-Remo, Ogun State, Nigeria. J Hosp Librariansh 2018; 18:47 5. Das A: Information-seeking among pregnant women: a mixed method approach, Florida State University [dissertation]. Available: http://purl.flvc. org/fsu/fd/FSU_migr_etd-7348; 2013. 6. Ghiasi A: Health information needs, sources of information, and barriers to accessing health information among pregnant women: a systematic review of research. J Matern Fetal Neonatal Med 2019, https://doi.org/10. 1080/14767058.2019.1634685 7. Owusu-Addo SB, Owusu-Addo E, Morhe ES: Health information-seeking behaviours among pregnant teenagers in Ejisu-Juaben Municipality, Ghana. Midwifery 2016; 41:110 8. Iran - Child Marriage Around The World. Girls Not Brides, Available: https:// www.girlsnotbrides.org/child-marriage/iran/. Accessed October 10, 2019. 9. Child marriage in Southern Asia. Policy options for action. Available: https:// www.icrw.org/wp-content/uploads/2016/10/CHILDMARRIAGE-F-13.pdf. Accessed October 11, 2012. 10. Tehran Times: Child brides, sufferers of the lost childhood. Available: https:// www.tehrantimes.com/news/420152/Child-brides-sufferers-of-the-lost-childhood. Accessed January 9, 2018. 11. Country Policy and Information Note-Iran: Forced marriage. Available: https:// assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_ data/file/636488/CPIN_-_Iran_-_Forced_marriage_August_2017.pdf. Accessed October 13, 2019. 12. All Human Rights for All in Iran: Child early marriages and child mothers in the Islamic Republic of Iran. Available: https://www.ohchr.org/Documents/Issues/ Children/2030/AllHumanRightsForAllInIran.pdf. Accessed October , 2016.
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