Engaging Families for Healthy Pregnancies

"What drives women to have pregnancies after the age of 35 or to have five or more children? Both of these pregnancies present high risks to both the mother and newborn....[L]ittle research has been conducted to understand the behavioral determinants driving these high-risk pregnancies."

This desk review examines the knowledge, attitudes, and behaviours related to pregnancies amongst women in developing countries in 3 high-risk situations: advanced maternal age (AMA); high parity, or HP (having had 5 or more live births); and rapid repeat pregnancies within 6 months of an abortion or miscarriage. Healthy timing and spacing of pregnancy (HTSP) emphasises the role of spacing between pregnancies and "helps prevent adverse maternal, perinatal and neonatal health outcomes, such as increased risk of stillbirth, prematurity, low birth weight and neonatal mortality, as well as maternal mortality, pre-eclampsia, induced abortion and miscarriage."

Peer-reviewed and gray literature documents published between January 1 1998 and December 31 2013 that focused on countries designated as Heavily Indebted Poor Countries (HIPC), low-income, or lower middle income by the World Bank were identified through database searches. These documents specifically addressed knowledge, attitudes, and behaviours related to AMA, HP, or PA (post-abortion)/PM (post-miscarriage) pregnancies and focused on women, families, and caregivers rather than at the community or policy level. A total of 28 documents met the criteria; in addition, 13 key informants (KIs) were contacted, 8 of whom were ultimately interviewed.

Behavioural drivers that emerged shared some similarities but differed by country context. Key drivers included: desire for a son; family and spousal pressure to have a large family or a woman's own desire for a large family; death of a child; desire to have children following remarriage; contraceptive failure; religious or cultural prohibitions on use of contraception; lack of availability of long-acting methods; discontinuation of contraception; or simply that the pregnancy was "by mistake". One example from each of the categories of high-risk pregnancies follows:

• This review identified only one study - from the United States (US) that directly addressed drivers of AMA pregnancy: "In 'Are They Still Having Sex?: STIs [sexually transmitted infections] and Unintended Pregnancy Among Mid-Life Women' (Sherman et al, 2005), the authors noted a 'lack of attention to the needs of women in this age range by public health advocates and health care providers, and a dearth of interventions addressing their unique characteristics and circumstances'."
• Regarding HP: "A recent study in Nepal documented social pressure to have large families, even among women who say they want a small family (Jennings & Barber, 2013). The study showed that although 73% of the individuals surveyed reported that two children is their ideal number, about half of the married women had more than two children and it appeared that neighbors' family size preferences have significantly influenced progression to larger families among women, even independent of their own preference."
• Regarding PA/PM: "For example, a study from Egypt noted there are structural barriers to FP counseling immediately after an abortion (Youssef, Abdel-Tawab et al, 2007)." In many countries, FP services are administratively and physically separate from post-abortion care (PAC) facilities. This particular study also found that only about a third of PAC providers mentioned that all PA patients should be offered FP counseling or that all FP methods could be used by PA patients.

According to the review, a number of studies and KIs raised issues that are not specific to any of the high-risk pregnancy situations detailed above but could be helpful to those designing interventions. For example, the value of male involvement in FP is emphasised. "An analysis of DHS [Demographic and Health Surveys] data by Gebreselassie and Mishra (2007) found that older women, men over 45, and a 5-year-plus age gap were all associated with disagreement within couples on FP in the ten countries studied. The study found that FP issues were discussed more frequently among couples where the wife is 15-34 years old, compared to couple where the wife is 35-49 years old. The husband's age also influenced spousal communication; 'in most of the countries, the proportion of couples in which both partners discussed family planning issues declines with increasing age of the husband.' In addition, the number of living children had a strong positive influence on joint approval of FP couples' discussion of FP in most cases. The authors suggest that more discussion in couples with larger families indicates a latent demand for fertility control."

This fact from the review indicates a research gap: "[V]ery few papers identified in this review explicitly met the inclusion criteria; the review found that these topics have simply not been studied, and have not been a focus of HTSP interventions...." According to the review, a number of KIs surmised that "the HTSP approach to promote FP [family planning] was designed in part as an alternative to messages about limiting family size, which is seen as a politically and culturally sensitive topic in some settings. On a more practical level, many more pregnancies can be affected with a focus on younger and low-parity women simply because those groups are having the majority of babies." HC3 is planning to carry out a study in Niger and Togo later in 2014 and will use those findings to develop a set of core tools and resources to strengthen programmes aimed at preventing these high-risk pregnancies.