Malaria-Related Psychosocial Factors, Past Antenatal Care-Seeking Behaviors, and Future Antenatal Care-Seeking Intentions by Maternal Age in Malawi and Democratic Republic of the Congo

"In Malawi and the DRC, youth-friendly social and behavior change interventions to increase ANC-related ideation could increase future early ANC attendance among young women to improve malaria and birth outcomes."

Antenatal care attendance in the first trimester of pregnancy (early ANC) is associated with a greater likelihood of reducing the risk of malaria in pregnancy (MIP), a risk that is heightened for adolescents, who account for 20% of pregnancies in sub-Saharan Africa. The extent to which age influences ANC-seeking intentions is unclear, presenting an opportunity to explore how models of communication and behaviour change can be applied to this particularly vulnerable group to optimise their pregnancy outcomes. This study explores ideational factors and past behaviours related to women's intention to attend early ANC among young mothers compared with older mothers in Malawi and the Democratic Republic of the Congo (DRC).

The ideation model of strategic communication and behaviour change refers to how views and ideas (ways of thinking) are developed and disseminated within communities through communication and social interaction. Ideational factors also influence intention, an important and proximal determinant of behaviour. The 8 ideational factors explored in the surveys included: perceived severity, perceived susceptibility, knowledge about malaria and prevention of MIP, perceived self-efficacy to go to ANC early, perceived response efficacy of intermittent preventive treatment during pregnancy (IPTp), favourable perceptions toward health facilities and providers, perceived supportive community norms (if ANC attendance or IPTp uptake is considered common in their community), and involvement in decision-making related to ANC.

The study used data from national Malaria Behavior Surveys conducted in Malawi and the DRC in 2021 under the Breakthrough ACTION project. It used multivariable logistic regression models controlling for demographic characteristics to evaluate associations between early ANC intention and ideation. Analysis included 2,148 women aged 15-49 years (Malawi: 827, DRC: 1,321). ANC ideation was lower among young (aged 15-20 years) than among older (aged 21-49 years) women in Malawi.

The study found that the proportion of pregnant women and girls in Malawi and DRC attending at least 4 ANC visits is relatively low, at 51% in Malawi and 43% in DRC. Young mothers with higher ANC ideation were more likely to intend to attend ANC early in their next pregnancy in both countries. Specific ideational factors associated with intention to attend ANC early varied by country and included positive attitudes, knowledge of ANC, and positive self-efficacy.

One unexpected finding is the negative association of community ANC norms and intention to attend ANC in the first trimester among older women in the DRC alone. This negative association is presumed to be due to factors such as the unique health care context of the DRC, in which additional barriers such as high perceived costs might outweigh community norms, as well as perhaps a lower importance on community norms in regard to important behaviours.

Overall: "This analysis suggests that ideational factors that could influence intentions to seek ANC care early may vary depending on the age group of the mother and, therefore, could benefit from more nuanced and targeted behavior change approaches to improving MIP outcomes. Not only were the significant ideational factors different between younger and older participants, but they were also different among these groups in different countries, confirming the importance of country context as well as age."

The researchers suggest that malaria-related ideation can be improved through a variety of youth-focused social and behaviour change (SBC) interventions. They should be tailored to the specific group in question. For instance, between Malawi and the DRC, there are marked differences in media access, previous malaria message exposure, and resources, which are important considerations for implementation. For example, compared with their older counterparts, more young pregnant women in this analysis less exposure to malaria-related messages that support early ANC in Malawi. Activities could include targeted messaging centred around building the factors that comprise malaria ideation. A process for co-developing approaches that meet the complex needs of youth should, as a principle, include young people.

In conclusion: "these observations should prompt assessment of youth-related ideational and behavioral issues in additional contexts, as they may vary between and within countries. Armed with information about the most influential factors shaping young pregnant women's care-seeking behavior, ministries of health and SBC practitioners across the globe may more effectively address the unique needs of this segment of the population and capitalize on an important opportunity to increase early ANC, prevent MIP, and improve pregnancy outcomes more generally. Although generating demand for services among this group is essential, ensuring that their experience of care is youth friendly and nonstigmatizing once they arrive is equally important."