Well-Care Visit Attendance and Retention Among Children of Adolescent Mothers in the Eastern Cape, South Africa: A Mixed-Methods Study

Children born to adolescent mothers (10-19 years) are a rapidly growing demographic in Southern Africa, who face higher risks of infant mortality and morbidity compared to children born to adult mothers. In 2024, the World Health Organization issued guidance for regular well-care visits to bolster the delivery of health promotion and prevention interventions for children. The need for preventive and health promotion services remains high, particularly among high-risk groups such as children of adolescent mothers. Evidence remains limited on the utilisation of well-care services in low- and middle-income countries, especially for children of adolescent mothers with and without perinatal HIV exposure. In this thesis, mixed methods were used to examine utilisation of well-care visit services among children born to adolescent mothers living in urban and rural settings of the Eastern Cape, South Africa. The first study estimates age-appropriate vaccination coverage and timeliness and compares differences by maternal HIV status. The second study examines factors influencing well-care visit attendance and estimates the proportion of children attending each recommended visit up to 18 months. The third study quantitatively examines factors associated with retention in the well-care visit schedule up to 18 months. Data were used from an observational cohort study (2017-2025) of adolescent mothers (n=1015) and their children (n=1123) recruited using health facility and community-based sampling approaches. Quantitative socio-demographic and healthcare access data were collected from adolescent mothers, and primary caregivers, using self-report questionnaires. Well-care visit and vaccination dates were extracted from photographs of pages for available child health records (n=1052; 93.7%). Semi-structured interviews with adolescent mothers (n=16) explored factors influencing attendance at well-care visits. Utilisation of well-care services is suboptimal among children of adolescent mothers, especially children of adolescent mothers living with HIV. There was weak evidence that positive maternal HIV status was associated with lower well-care utilisation. Vaccination coverage and well-care visit attendance decline as child age increases, with better retention observed in rural compared to urban areas. Findings challenge deficit-based narratives about adolescent mothers and highlight that their motivation and capability to utilise well-care services are not lacking. Children of adolescent mothers are missing opportunities for early detection of health and developmental issues and timely referrals. Support for retention should be universal for all adolescent mothers and their children, regardless of HIV exposure, to promote equitable access and improve child health outcomes. Efforts to improve well-care utilisation should address intersecting disadvantages and be simultaneously HIV-sensitive and age-responsive. This thesis addresses a critical gap in understanding how to support engagement with well-care services in high-risk populations.