Formative Research on Individual, Couple, Family, Community, and Service-Level Factors that Impact the Use of Sexual and Reproductive Health Services by Young Parents in Two Regions of Madagascar in 2016

Authors: Andriantsimietry S., Ranjalahy Rasolofomanana J., Rakotovao JP., Razakariasy ME., Razafimandimby E., Noeliarivelo L., Ranjalahy Rasolofomanana A., Favero R., Yahner M., Igras S., Ralaison HL., Rakotondrainibe T., Hook C., Nankam K., Gray M., Andriamiharisoa H., Harifetra Z., Randrianirina FJ., Rakotomanga R., Rakotomanalina R.

www.mcsprogram.org

This report is made possible by the generous support of the American people through the United States Agency for International Development (USAID) under the terms of the Cooperative Agreement AID- OAA-A-14-00028. The contents are the responsibility of the Maternal and Child Survival Program and do not necessarily reflect the views of USAID or the United States Government.

The Maternal and Child Survival Program (MCSP) is a global, United States Agency for International Development (USAID) Cooperative Agreement to introduce and support high-impact health interventions with a focus on 24 high-priority countries with the ultimate goal of ending preventable child and maternal deaths within a generation. The Program is focused on ensuring that all women, newborns and children most in need have equitable access to quality health care services to save lives. MCSP supports programming in maternal, newborn and child health, immunization, family planning and reproductive health, nutrition, health systems strengthening, water/sanitation/hygiene, malaria, prevention of mother-to-child transmission of HIV, and pediatric HIV care and treatment. Visit www.mcsprogram.org to learn more.

March 2016

Table of Contents

Background and Rationale ...... 1 Objectives of the Formative Research ...... 1 Methodology ...... 2

Data Analysis ...... 3 Limitations of the Study ...... 3 Findings ...... 4 Profiles of Young Parents ...... 4 Attitudes of Young Parents ...... 4 Attitudes toward Young Parents ...... 4 Findings by Level of Influence ...... 5 Individual Level ...... 5 Couple Level ...... 7 Limited Contribution of the Young Father ...... 7 Choice of the Place of Delivery ...... 7 Decision to Use FP ...... 7 Family Level ...... 8

Community Level ...... 9 Health Center Level ...... 10 References ...... 14

Formative Research on Individual, Couple, Family, Community, and Service-Level Factors that Impact the iii Use of Sexual and Reproductive Health Services by Young Parents in Two Regions of Madagascar in 2016

iv Formative Research on Individual, Couple, Family, Community, and Service-Level Factors that Impact the Use of Sexual and Reproductive Health Services by Young Parents in Two Regions of Madagascar in 2016 Background and Rationale

In Madagascar, childbearing begins early: 57.3% of women have already become mothers or are pregnant by the age of 19. Rapid repeat pregnancy is frequent among younger mothers: among mothers aged 15– 19 years, the median number of months between births is 25.1, compared to 32.7 among all women.1 Madagascar’s maternal mortality ratio has remained unchanged over 10 years at 478 maternal deaths per 100,000 live births.2,3 UNFPA Madagascar estimates that nearly one-third of maternal mortality in Madagascar may be among adolescents aged 15–19.4 The 2008/9 Demographic and Health Survey reported a national contraceptive prevalence rate for any method at 40%, with lower rates for youth: 25% of women aged 15–19 years and 37% of women aged 20–24 years in union were using family planning (FP). Modern method use for these two youth groups was 17% and 28%, respectively.

Health consequences of early pregnancy and childbirth in mother and child are well-documented in lower and middle income countries. Early pregnancies increase the risk of maternal mortality, young women under age 20 are twice as likely to die in childbirth as women over 20, and women below age 15 are five times as likely to die in childbirth. Children of adolescent mothers have a 34% higher risk of death in the neonatal period, and a 26% higher risk of death by age five.5

There is a clear need for interventions to connect pregnant and parenting young people to health services, ensuring uptake of maternal and newborn care (MNC) and antenatal care (ANC) services as well as healthy timing of a subsequent pregnancy. Yet globally, few models and better practices for reaching first- time parents (FTPs) exist. In Madagascar, USAID’s global Maternal and Child Survival Program (MCSP) is developing and testing an intervention to increase access to and use of essential ANC, MNC, and FP services that will concurrently create enabling environments and strengthen youth assets to allow first- time mothers and fathers, and mothers and fathers-to-be to realize their sexual and reproductive health (SRH) choices, and access services that are responsive to their needs. The first step involved formative research to identify factors at individual, family, community levels, as well as within health services, that influence FTPs’ access to and use of SRH services.

Objectives of the Formative Research The primary research question was: for FTPs, what factors influence their intentions to seek services and to use ANC, MNC, and FP (including postpartum FP) services at relevant times in their reproductive life course?

Sub-questions included: What are important social factors operating at family, peer, and community/institution levels that influence FTPs to seek services and use ANC, MNC, and FP services at appropriate moments in their reproductive life course? How does the young couple’s communication and decision-making vis-a-vis SRH influence intentions to seek and use services at appropriate life course moments? What are primary sources of ANC, MNC, and FP information for FTPs? What are the experiences of FTPs who receive ANC, MNC, and FP services? What are local health facility responses to FTPs seeking services?

“First-time parents” in this study were defined as: women and men aged 15–24, who have one or two children or are pregnant (first or second pregnancy), and who may or may not be in a traditional, civil, and/or church- sanctioned union. “First-time parents” and “young parents” are used interchangeably.

Formative Research on Individual, Couple, Family, Community, and Service-Level Factors that Impact the 1 Use of Sexual and Reproductive Health Services by Young Parents in Two Regions of Madagascar in 2016 Methodology

The research used a logical framework based on a model of healthy adolescence;6 this framework aimed to capture the situation of young parents according to multiple levels of influence (see Figure 1). Five levels of influence were included: individual, couple, family, community, and health system. This approach allows both for clarifying the positive influences that lead young parents to change behavior and for identifying negative influences that prevent them from changing their SRH behavior.

Figure 1: Ecological model of levels of influence for first-time parents

Health System

Community

Family

Couple

Individual

Research methods The study used four data collection methods:

• Compilation of SRH service data from facility registers contributed to understanding the extent to which available services reach young parents as well as to create a descriptive profile of young parents who currently access ANC, MNC, and FP services. Data were compiled from all study facilities from the previous six months. • Focus group discussions (FGDs) were conducted with FTPs who did not use (or who had limited use of) SRH services for their last pregnancy and childbirth, parents and kin of FTPs, and community health workers (CHWs). • In-depth interviews (IDIs) were conducted with FTPs who used SRH services during their last pregnancy and childbirth, influential non-family adults, and health providers. • Health facility rapid assessments were conducted using a checklist to understand the extent of availability and quality of ANC, MNC, and FP services in all six facilities.

The research was conducted in two phases. Phase One focused on the experiences and systems responses to FTPs who had used ANC, MNC, and/or FP services in the past 12 months. IDIs and FGDs were conducted with FTPs, service providers, and CHWs. Phase Two data collection focused on factors at the family, community, and institutional levels outside of the formal health sector that influence FTPs in seeking and using services. FGDs were conducted with FTPs who did not use ANC or MNC services during their last pregnancy and childbirth, and IDIs were conducted with community influentials and family and kin “types” who play important roles supporting FTPs (identified via Phase One IDIs with FTPs).

2 Formative Research on Individual, Couple, Family, Community, and Service-Level Factors that Impact the Use of Sexual and Reproductive Health Services by Young Parents in Two Regions of Madagascar in 2016 Table 1: Summary of activities and distribution of participants across activities Steps Methods Participation

Compilation of ANC, MNH, and FP registers FGDs with CHWs 4 FGDs (31people) Phase 1 IDIs with providers 8 IDIs

IDIs with young parent users (identified in registers) 24 IDIs

Rapid analysis = identification of influential close relations/people

IDIs with influential people 12 IDIs

FGDs with young parent non-users 24 FGDs (176 people) Phase 2 FGDs with parents and close relations of youth 4 FGDs (12 people) Rapid assessment of health facilities 6 health facilities

Study sites in Menabe included: the Basic Health Center (Centre de Santé Basique, or CSB) of Ankilizato (rural), CSB of Bemanonga (peri-urban), and District Hospital (Centre Hospitalier du District, or CHD) of Miandrivazo (urban). Sites in Vakinankaratra included: the CSB of Ankazomiriotra (rural), CSB of Andranomanelatra (peri-urban), and CHD of Betafo (urban).

Participation in FGDs or IDIs was subject to four key eligibility criteria. Each participant had to reside within 10 kilometers of the health facility and provide full consent. In addition, any underage participant had to have parental permission, and individual participants could not be related to any other study participant.

The study received approval from the Ethics Committee of biomedical research of the Ministry of Public Health of Madagascar and the Institutional Review Board of the Johns Hopkins University.

Data Analysis

All FGDs and IDIs were recorded in Malagasy (official Malagasy or dialect, depending on the language used during the discussion), then transcribed, translated into French, and entered into the qualitative data analysis software ATLAS.ti. Each translated transcription was read and coded according to a codebook, which listed and matched all codes with each question of the FGD or IDI guide. Based on the coding, several paragraphs of the transcriptions were matched to the relevant codes. New codes were identified as the analysis progressed.

Limitations of the Study

• Register compilation and data analysis were limited by the unavailability of some registers (e.g., no postnatal care [PNC] registers at the CSB II of Ankazomiriotra) and incomplete registers (no age, no data on the side effects of FP even when registers provided for the collection of such data). • The qualitative research allowed for determining and understanding the key factors influencing use of SRH service by young parents. However, it did not allow for ranking these factors by order of importance (as would have been possible with a quantitative survey) for the purpose of prioritizing response strategies. • The formative research provided information on influence factors in the two regions of Menabe and Vakinankaratra. The recommendations made based on research findings apply to these two regions in the context of a pilot intervention, and cannot be systematically generalized to other regions.

Formative Research on Individual, Couple, Family, Community, and Service-Level Factors that Impact the 3 Use of Sexual and Reproductive Health Services by Young Parents in Two Regions of Madagascar in 2016 Findings

Profiles of Young Parents The average age of the young parents encountered during this formative research was 19, and most became sexually active at an early age (between 12 and 13). From an economic perspective, it is important to note that six out of 10 of these young parents are farmers. Although they have been farming since childhood, they do not know how to manage their own business and are “beginner and dependent” managers. Income generated from agriculture is seasonal and limited, accounting for the very precarious situation in which these young parents live. Additionally, most FTPs are not significantly involved in events or associations outside the home.

In most cases, they start life as a couple following an unexpected pregnancy. In general, parents and youth have little to no communication about SRH before the pregnancy. Usually, the pregnancy was unwanted and they are unprepared for it, and the young parents are often forced by one or both sets of parents to enter into union. Nearly all young parents maintain relationships with their family and the community. Cases where they are cut from their family are rare; none are cut from the community.

Attitudes of Young Parents All young parents faced with pregnancy expressed experiencing fear: young men and women are both highly fearful of the responsibilities they will have to take on as parents, especially parenting and economic responsibilities. Young mothers are especially afraid of the physical changes that occur during pregnancy and also worry that complications may occur at delivery and lead to death.

Young fathers indicated a tendency to shy away from the responsibility and harbor wariness; many wonder if the child is truly theirs and wish to have clear confirmation. Young mothers fear that their partner will leave them. Parents on either side play a key role in maintaining the couple in union during this period. Future young parents also fear severe reprimand from their parents when they disclose the pregnancy and fear their community’s criticism when pregnancy occurs out of wedlock, during their studies, or while they are still too young.

In spite of these deep fears, all young parents consider pregnancy a happy event as it epitomizes a “personal achievement” regardless of their young age and precarious economic conditions. Pregnancy also means that the family lineage is continuing, it is seen as a blessing, or even an asset, for the young parents and the family as a whole.

“A first child is quite an achievement, this child is my first treasure.” Young father, 18–24 years, FGD with male non-users in urban areas, Menabe

Attitudes toward Young Parents The perceptions and attitudes of the community and friends towards young parents are positive when they are aged 20 to 24; they are consistently perceived as mature and independent youth. However, when young people become parents before the age of 18, perceptions and attitudes are negative. On one hand, the community stigmatizes the young parents and addresses them as immature, incapable, and dependent children. On the other hand, friends can be more of a burden than a support: they are deceitful, give bad advice, and are disheartening, as reported by young parents. Young parents reported that they feel hated, disrespected, and put down by the community and friends. In the face of pressure from their community and friends, young parents perceive their own parents as the only reliable source of support.

“Society will find it shocking that a very young child is pregnant.” Young mother, 18–24 years, FGD with female non-users in rural areas, Vakinankaratra

4 Formative Research on Individual, Couple, Family, Community, and Service-Level Factors that Impact the Use of Sexual and Reproductive Health Services by Young Parents in Two Regions of Madagascar in 2016 Findings by Level of Influence Individual Level Limited knowledge of SRH On an individual level, the young men and women have very limited knowledge of SRH. A small number of young parents from Vakinankaratra mentioned the importance of attending ANC during pregnancy. Likewise, they talked about preparing for the child’s arrival but such preparation is mostly logistic. The need for and importance of umbilical cord care was mentioned by many young parents of the two regions, although actual practices are not always sound. A few young men in Vakinankaratra talked about the benefits of exclusive breastfeeding for the young mother and her baby.

“If you want the pregnancy to have a good outcome, you need to attend the antenatal clinic to monitor the baby’s health.” Young Mother, 15–17 years, FGD with female non-users in peri-urban areas, Vakinankaratra

Young parents feel that the best time to have a second child is two to six years after the birth of the first child. Young parents base this estimation on the following observations: the first child grows well, the young mother is in good health, and the family has a stable or prosperous economic situation.

Young parents in both regions have no or limited knowledge of birth planning and nearly all describe harmful practices during and after pregnancy, such as doing manual labor during pregnancy to make the cervix open and reduce pain during delivery and giving sugar water to newborns. In Menabe specifically, wrong knowledge largely derives from the influence of traditional birth attendants (known as matrones) on FTPs who do not have contact with the health system (non-users of SRH services).

Another limiting factor noted with many non-users of SRH services in Menabe is that any form of preparation for the baby’s arrival is forbidden. Due to customs and habits, reinforced by the precarious economic situation of the families, young parents are inclined to wait until the baby is delivered and expected to survive before preparing for its arrival.

Low Exposure to Information on SRH among Most Young Parents Very few FTPs are exposed to SRH messages; primary sources of information on SRH for young parents include their family (especially the mother or mother-in-law), community (neighbors or friends), and CHWs or health workers of specific projects such as Marie Stopes. Other FTPs were informed by the media, including posters displayed in health centers or radio shows aired in collaboration with public or private health facilities. A few young fathers used their phone to inform themselves about pregnancy. A few CHWs reported that they more information about ANC and FP to inform their work.

Formative Research on Individual, Couple, Family, Community, and Service-Level Factors that Impact the 5 Use of Sexual and Reproductive Health Services by Young Parents in Two Regions of Madagascar in 2016 Summary: factors of influence at the individual level

Three major issues stand in the way of behavioral change:

The social and economic situation of the FTPs is precarious. Poverty prevails in the regions and affects youth in particular. In some localities, the situation is aggravated by security concerns.

Some local customs make young girls especially vulnerable. For instance, having multiple partners is encouraged by some parents and communities for economic reasons. Further, because of early sexual activity and pregnancy, youth tend to enter couple life at a very young age. In addition, some young pregnant girls/mothers do not receive the support they need because they are rejected by their partner and/or parents.

Third, there is a lack of information. FTPs are not in a position to face pregnancy as the information at their disposal, as well as their existing knowledge, are extremely limited.

Nevertheless, a number of positive factors were identified and can be leveraged to influence the behavior of FTPs to increase uptake of SRH services:

Connection and support: Youth are not excluded from the community but are, in most cases, surrounded by parents, friends (including school friends), church members, members of various associations (soccer club), and/or other members of the community (neighbors and CHWs). During pregnancy, most young mothers receive support from their mother or mother-in-law and sisters. The support system extends to the community level (e.g., CHW, midwife, matrone, neighbors, Catholic nuns, choir director).

Expectations: Although their situation is tough before and during the pregnancy, FTPs believe in the importance of being healthy as a family, as well as the importance of completing their studies, having a reliable job, and leading a peaceful family life.

Specific information needs identified by FTPs include:

Table 2: Information needs identified by first-time parents Family Planning Pregnancy/ANC Other Young Couples What is the ideal number of children? When should I have the first ANC Should I go to the health facility for a What is FP? How does it work? visit? prenuptial visit? What are the advantages of FP? Why does my baby need to be What are the side effects of FP? weighed? Can we have a child after using FP? Why don’t CHWs care for adults? Young Mothers What are side effects of What should I do if my period is late? Why does my baby refuse to eat? contraceptive methods? Where should I go for health care during pregnancy? Young Fathers Which contraceptive methods are not reversible? Are there FP methods that involve men?

6 Formative Research on Individual, Couple, Family, Community, and Service-Level Factors that Impact the Use of Sexual and Reproductive Health Services by Young Parents in Two Regions of Madagascar in 2016 Couple Level

Limited Contribution of the Young Father During pregnancy, the first priority of young fathers is to stabilize their financial situation so that they may assume marital and economic duties in support of their partner. Despite good intentions, support provided by the young father is not necessarily financial, since he can seldom afford it. Instead, the help provided by the young father comes in two forms: 1. Psychological and moral through advice, encouragement, and moral support during the pregnancy. Sometimes, they express encouragement by self-adjusting their behavior (coming home on time, no longer drinking alcohol). Support from the father also includes encouragement for his partner to attend ANC and PNC at the CSB, reminding her of appointments and sometimes accompanying her. Physical: young fathers help their partners by doing household chores and running errands in her place. This type of help is provided at all stages from pregnancy to delivery. In nearly all cases, young fathers are especially involved in transporting the young future mother from home to the health center.

Choice of the Place of Delivery Young mothers are more opinionated regarding the choice of the place of delivery than their male partners. Most young mothers report that they decide the place of delivery since their interests are concerned. They decide on their own or often with the help of their mother, mother-in-law, or sisters. Involvement of young fathers in determining the place of delivery is mixed; some allow their partner to decide the place of delivery because they think they have the knowledge required to decide, with some young fathers reporting that they participate in the discussion as responsible husbands and fathers. On the other hand, some young fathers felt it is reasonable to allow their parents to decide the place of delivery and fully rely on their opinion. In any case, parents (especially mothers or mothers-in-law) hold an important role in deciding the place of delivery. It is important to underscore that educated young fathers are more inclined to support their partner to deliver at a health facility.

Several criteria are taken into account when trying to decide the place of delivery, the most decisive ones being: quality of the delivery services, provider skills, safety (low risk of complications and death), costs, distance/proximity of the health facility, and quality of the relationship with the providers. Family influences and past experiences with a health facility or, in more frequent cases, the matrone, weigh significantly in the decision. It also depends on how close they are with these people, how discreet they are, and how close by they live. Generally, mothers, mothers-in-law, or sisters meet these criteria.

“Personally, I want it to be my mother because she is accommodating, she is loving. She gives me affection and does everything I want then she fixes things. That’s why I love her.” Young mother, 15–17 years, FGD with female non-users in peri-urban areas, Menabe

Decision to Use FP Several factors may trigger FTPs to discuss birth spacing, for instance: the enduring precariousness of the child’s health, blatant instability of their family’s economic situation, resumption of periods after the delivery, and a deep wish to improve things for their family. Sometimes, the discussion between the young parents can be triggered by external pressure coming from parents or close relations.

Couples discuss the steps to be taken to procure a modern FP method, relevant advice, and find out about any constraint relating to the FP method considered. They also discuss the side effects they fear from using modern FP methods. The various fears of the young father are also addressed, especially his suspicions that the woman may want to use FP in order to be unfaithful.

Formative Research on Individual, Couple, Family, Community, and Service-Level Factors that Impact the 7 Use of Sexual and Reproductive Health Services by Young Parents in Two Regions of Madagascar in 2016 FTPs did not report open or comprehensive discussion within couples on the decision to use FP. Young mothers are more inclined and determined to use FP, whereas many young fathers vehemently question the validity of modern FP method use and are opposed to their use by their partners.

Most young mothers are unequivocal: they are the ones who make the decision on using a FP method (alone or with the guidance and influence of their mother, CHW, or a neighbor). Sometimes, they decide without asking their partner’s opinion; they consider that pregnancy, delivery, and child care affect them first and foremost and FP should be similar. Young mothers seem inclined to use FP methods and have a few fears about side effects.

“I have the last word because I do all the work.” Young mother, 15–17 years, IDI with female users in urban areas, Menabe

Many young fathers fully leave FP-related decisions to the woman, believing that ensuring the health of the child and couple is the woman’s job. However, other young fathers use their position as head of household and breadwinner to pressure the young mother into not using FP methods; these young fathers report jealousy and a fear of side effects.

Family Level

The family members most frequently mentioned as providing help from pregnancy to delivery, during baby care, and FP method selection are the mother, mother-in-law, and sisters. They are present nearly throughout all these steps, whether together or in turn. Other close relatives help the FTPs but at a lesser extent: these include the grandmother, the father-in-law or father, and other close relations.

During pregnancy, the support provided by the mother, mother-in-law, or sisters consists in providing guidance and psychological support to the young mother and replacing the young mother on any daily chores that she can or should no longer perform. Sometimes, the mother or sister goes to ANC with the young mother or refers her to a CHW for adequate pregnancy monitoring. When they can, the parents help by providing the necessary supplies and making various gifts (financial donation, farmable land).

On the day of delivery, the mother, mother-in-law, or sister continue to provide encouragement and psychological support to the young mother. Depending on family habits, family members encourage the young mother to deliver at the health facility or with a matrone—most often the latter. The preparation of supplies and meals, laundry, and various errands are all entrusted to close relations. Transportation of the future young mother to the health center is generally entrusted to men (i.e., father, father-in-law, or husband), who also assume responsibility for arranging for safe travel to the hospital in areas with insecurity.

Regarding baby care, the mother or mother-in-law are the main helpers of FTPs. Their contributions come in various forms: encouraging the young parents to follow the instructions of the matrone or midwife, keeping the mother warm, closely monitoring the young mother’s diet to maintain quality breast milk, following up important aspects relating to the young mother’s or child’s health (immunizations, PNC), and teaching all aspects of baby care to the young mother. (Note that umbilical cord care was never mentioned spontaneously).

“Seeing those people really gave me heart. If I hadn’t seen them, I would have felt like I had not family. I thought about them and the baby came out rapidly.” Young mother, 15–17 years, IDI with female users in peri-urban areas, Menabe

Regarding the demand for or choice of FP method(s), the contribution of the family (especially the mother, mother-in-law, or sister) consists of asking the provider about specifics of the FP method, advising or orienting the young mother on informing herself through the CHW or CSB, or contributing

8 Formative Research on Individual, Couple, Family, Community, and Service-Level Factors that Impact the Use of Sexual and Reproductive Health Services by Young Parents in Two Regions of Madagascar in 2016 to cover service costs. Some family members encourage the use of FP methods by sharing positive testimonies on past experiences.

Summary: Factors of Influence at the Couple and Family Levels

Several factors of influence at couple and family level are enabling for behavioral change:

Support and follow-up: The young father is willing and motivated to help his partner to the extent of his means and capacity. Educated fathers seem favorable to going to health centers. The mother, mother-in-law, and sister are present throughout nearly all steps and are dedicated to helping the young mother. They go with the young mother to ANC visits and closely monitor the health of the mother and child to the extent of their knowledge and habits. However, SRH service users do not consistently attend PNC visits and non- users rarely attend.

Connections: Delivery is a time when the family gathers around the FTPs to support them; this help enables the young parents to overcome difficulties such as a lack of financial means, immediate support in case of emergency/referral, or depression. However, the involvement and influence of the mother, mother-in-law, or sister in decisions relating to the young parents’ health is not always positive. Out of habit or conviction, many mothers or mothers-in-law insist on turning to matrones for delivery.

Behavior regulation: the family, mainly the mother, has strong influence from past experiences with matrones. This has a clear impact on the way FTPs think and make decisions.

Community Level

Different community members are available at different levels to help FTPs with their needs. Matrones, CHWs, and midwives are frequently mentioned from pregnancy to delivery. Female neighbors and friends were also identified among the community members who help young parents.

During pregnancy, FTPs receive advice, typically pertaining to healthy feeding and exercising for pregnant women, from nearly all community members. Midwives and matrones are especially appreciated for all forms of prenatal care, which is perceived as important.

At delivery, matrones and midwives are among the key support providers as they help the young mother deliver and provide any necessary medicine (midwife) or traditional medicines (matrone). Both register births with the commune. (Birth registration is a system jointly initiated by public health facilities and the commune to limit recourse to matrones; however, matrones also use this system). Although matrones offer a range of services spanning from pregnancy to traditional FP, they are mainly present at delivery. Other community members are present to facilitate delivery: for example, CHWs share information on delivery- related services available at health facilities with FTPs. Other CHWs provide transportation, such as a cycle rickshaw for pregnant women from home to the health center. Sometimes, neighbor(s) and friend(s) help by providing company.

”It is the CHW who helped us, he gave us a hand because the contractions started at night... He lent us the cycle rickshaw to transport her!” Young father, 15–17 years, IDI with male users in peri-urban areas, Menabe

After delivery, young mothers receive support for baby care from the CHWs and their female friends. CHWs participate in teaching breastfeeding to young mothers while friends provide various home care to the baby. Stronger involvement of CHWs, physicians, and midwives is noted when FTPs chose an FP method. They sensitize non-user young parents, encourage the use of FP methods, and explain existing offers. In so doing, some CHWs explain how FP is not hazardous. Sometimes, they assist in monitoring by reminding users of the date of their next injection. However, CHWs lack information and evidence to counter rumors and misconceptions that prevent many FTPs from using FP.

Formative Research on Individual, Couple, Family, Community, and Service-Level Factors that Impact the 9 Use of Sexual and Reproductive Health Services by Young Parents in Two Regions of Madagascar in 2016 Summary: factors of influence at the community level

Three factors enabling behavioral change are noted at the community level: • The influence of CHWs with young parents, at all levels, from pregnancy to delivery and past delivery. • Gender norms that require the young mother to be the prime person in charge of family health and life. • The widespread custom of community groups to accompany the pregnant woman as she goes to the health center to deliver, for security purposes.

Three other factors may hinder behavioral change: • Young parents having extremely limited resources. • The important place in society held by matrones.

Various sociocultural norms, including: youth becoming sexually active at a very early age; persistence of arranged marriages; prevalence of multi-partnership and endogamy; and strong stigmatization of single, young, and underage parents.

Health Center Level In general, use of ANC service is well below the national average for women under 20 (80.9%) and aged 20 to 30 (83.4%).7 In women under the age of 18, use of ANC services in first pregnancy (49.2%) is well below the national average of 85.4% (all ages). Similarly, the proportion of those who completed four ANC visits, 12.2%, is much lower than the national average of 51.5% among all women. However, attendance at the first ANC visit was higher in all six health facilities in the study (56.0%) than the national average (28.7%, all ages). Most youth attended an ANC visit in the first 16 weeks, but few complete four visits. ANC attendance varies by facility; in Bemanonga and Miandrivazo, less than 20% of girls aged 10–14 attended a first ANC visit.

For iron and folic acid, tetanus shots, and albendazole, the services received as part of ANC by young mothers under 18 who attended all four ANC visits are similar in the two regions. However, Menabe distributes long-lasting insecticide-treated bed nets and offers HIV tests, which were not observed in Vakinankaratra. No CSB or CHD offered chlorhexidine or syphilis testing even though there were no stock-outs of the tests during the survey days in three health facilities.

Figure 4: Services received by young mothers under 18 who completed four ANC visits

90% 78.60% 80% 70% 56.70% 60% 53.60% 52.90% 50% 40% 25.80% 30% 16.70% 20% 14.30% 10% 0% 0.00%0.00% 0.00% 0.00% 0.00% 0.00% 0%

Menabe Vakinankaratra

Only 30.5% of the women seen at the ANC unit delivered at the health facility. During the FGDs and IDIs, many young mothers reported that the only reason they attended ANC services was to avoid being rejected by the health facility in case of complications.

10 Formative Research on Individual, Couple, Family, Community, and Service-Level Factors that Impact the Use of Sexual and Reproductive Health Services by Young Parents in Two Regions of Madagascar in 2016 Antenatal Consultation ANC service users appreciate all activities involving careful assessment of maternal and child health (i.e., blood pressure measurement, weighing, communication of the estimated date of delivery, information on the growth of the baby, satisfactory answers to all questions, and provision of advice). The provision of medicines and administration of immunizations are appreciated and encourage ANC attendance. Young parents who are in contact with the CHWs or are exposed to ANC messages are more inclined to attend ANCs.

Some non-users of ANC services, including those who used the services of matrones, are nevertheless convinced of the benefits of ANC for the mother and child. Further, the positive influence of previous use of SRH services by a close relation or family member promotes a positive attitude towards ANC.

However, ANC service users are especially critical of the long waiting times on ANC days, especially when they notice that the person in charge does other tasks while patients are waiting. Young fathers who use ANC services (as caretakers) highlight cases where the health worker is away for a long time when the FTPs have dedicated a full day and traveled a long road to attend ANC. They are also unhappy with the lack of explanations during visits, especially when the provider gives vague answers or fails to address the actual concerns of the patient.

Young mothers who use ANC services reported that providers are stern and unfriendly, especially trainees (midwife, nurse). Trainees are, overall, perceived as new and inexperienced. Young mothers who use ANC services share other dissatisfactions linked with the taste of iron tablets, fear (or taboo) of injections, and the travels required by ANC, which they deem excessively frequent.

Some young mothers do not attend ANC because they are young and are ashamed of being seen at the CSB by the community. Other FTPs, due to a lack of information or knowledge on the usefulness and purpose of ANC, are not convinced of the necessity of ANC. In addition, the pressing influence of the spouse or family (mainly the mother or mother-in-law) who prefer the matrone, poses a strong barrier to many young parents. For some FTPs, this is exacerbated by fears resulting from rumors on the potential side effects of tetanus shots or the pressure of some religious denominations regarding immunization.

Delivery Use of delivery services is higher among young mothers aged 18–24, ranging from 17.4% (CSB II of Ankilizato) to 69.1% (CHD of Miandrivazo). The rate of use of this same service ranges from 3.2% (CSB II Betafo) to 13.8% (CSB II Bemanonga) among young mothers aged 15–17.

Figure 5: Use of delivery services by young mothers aged 10–24 during the first delivery

80% 69.1% 70% 60% 52.3% 53.4% 50% 45.7% 40% 30% 24.8% 17.4% 20% 13.8% 9.8% 7.2% 10% 5.3% 3.9% 3.2% 0%

Ages 10-14 Ages 15-17 Ages 18-24

Formative Research on Individual, Couple, Family, Community, and Service-Level Factors that Impact the 11 Use of Sexual and Reproductive Health Services by Young Parents in Two Regions of Madagascar in 2016 Factors promoting the use of delivery services FTPs who use services at the health facility are satisfied because they are convinced that the management of delivery is better and offers the guarantee of lower risks. They are appreciative of the comfort provided by the management of delivery, range of advice provided, and services to accommodate young parents. They believe that the care provided allows for preventing infections and hemorrhage, and appreciate that the health facility reduces death risks and can properly manage complications as it practices surgery and has all required medicines. However, though they may be convinced, FTPs often do not deliver in facilities because of their parents’ or family’s pressure to continue to use the services of matrones.

The major complaints about delivery services include: the midwife makes them wait a long time even though delivery seems imminent, delivery management is partially or fully ensured by a trainee, there is a stock-out of important medicine at a critical moment of the delivery, the cost of delivery at the health facility is high and/or is liable to increase according to contingencies or required referrals, and costs are not fixed (e.g., changes according to the sex of the baby, more expensive for boys).

Three barriers to use of facility-based delivery services were consistently cited. Many FTPs and influential individuals interviewed felt that the risk of complication at delivery or during out-of-facility monitoring is extremely low. This perception results from confidence in the skills and knowledge of matrones or the pressing influence of close relations (e.g., mothers) who are used to using matrones’ services. A second barrier—for non-users of SRH services who are nevertheless convinced of the importance of delivering at the health facility—are financial and/or logistic. Thirdly, FTPs are ashamed to show up in front of the provider without essential items for the baby or mother (diapers, clothes, etc.).

Family Planning Factors promoting the use of FP services Young parents who use FP services (Figure 8) are convinced that modern FP methods are effective. Most appreciate the peace of mind resulting from the use of an effective FP method and are happy that a range of methods is available to facilitate their choice. Free access to and accessibility of FP methods, as well as the quality of the reception by the provider feature among the criteria determining use or non-use. Many young parents who do not use FP and use matrone services follow the matrones’ advice to use traditional methods for prevention of a subsequent pregnancy (herbal tea to be drunk regularly).

Figure 8: Use of FP services by young mothers aged 10–24 over the six months preceding the study 45% 40.0% 40% 35% 32.5% 30% 25% 19.2% 20% 15.5% 15% 10% 7.9% 6.4% 5.0% 4.1% 1.7% 5% 0.0% 1.2% 0.0%0.0% 0.0%0.0% 0%

14-Oct 15-17 18-24

12 Formative Research on Individual, Couple, Family, Community, and Service-Level Factors that Impact the Use of Sexual and Reproductive Health Services by Young Parents in Two Regions of Madagascar in 2016 Some FTPs who use FP methods become reluctant to continue due to side effects. Others are unhappy with a recent increase in cost from MGA 300 to MGA 1,500 (~USD 0.09 to USD 0.45); others reported that the provider gave little or no explanations to help youth understand their method options and the potential side effects.

The main barriers to FP use among young mothers are primarily due to misperceptions of FP. Some think that FP methods shorten life or cause more or less significant disturbances, such as “cooling the womb” and causing frigidity and discomfort during sexual relations. Some mentioned financial grounds for not using FP methods or tradition which prohibits the use of injectables.

Summary: factors of influence at SRH service level

Several factors at the health facility level could promote use of SRH services by young parents: • Some user young parents and fewer non-users of SRH services are clearly aware of the health benefits that the various SRH services bring and are convinced of their usefulness. • In general, users of SRH services are satisfied with the reception by and communication with providers. There is minimum trust in the relationship between young parents and providers (especially the CHW). However, young parents certainly put forward their general expectations (in terms of cost) and special expectations in case of critical situation (e.g., when delivering). • The fact that some services such as PNC and FP are free in some health facilities is highly appreciated by the young parents.

Several factors also stand in the way of the use of SRH services by young parents:

Sometimes services are only partially available as a result of occasional stock-outs of medicines or unavailability of equipment in case of complication. • FP services, although existing and available, are not generally attractive to FTPs because of rumors. These rumors sometimes come from providers themselves when they try to convince youth that a given method does not suit them because of its potential side effects, or are spread by former users who experienced side effects when using some FP methods. • The expectations of young parents in terms of reception and service come down to having a compassionate provider who listens, is available, and is not stern. Some young parents say that they do not wish to be seen by providers in training and that they would appreciate if providers thoroughly explained the different FP methods they can choose from. • Young parents find the costs of services high and do not like the fact that the cost of delivery services is not fixed. Indeed, the amount can significantly vary and increase particularly if complications arise during delivery.

Recommendations Collaborations

• Establish a collaboration system involving multiple community actors (CHWs, matrones, local authorities) including specification of the distribution of maternal and child survival roles and responsibilities • Collaborate with faith-based institutions to convey information on SRH to young couples receiving prenuptial counseling, as well as youth in general • Collaborate with microfinance institutions to propose a health funding system for target groups • Collaborate with security forces to define secured routes to allow villagers to safely access health facilities

Improvement of SRH services

• Build the capacities of health workers on the reception and retention of youth (interpersonal communication, young parents’ needs, addressing rumors on FP, etc.)

Formative Research on Individual, Couple, Family, Community, and Service-Level Factors that Impact the 13 Use of Sexual and Reproductive Health Services by Young Parents in Two Regions of Madagascar in 2016 • Build the capacities of CHWs to sensitize youth on the use of SRH services (messages oriented on correct knowledge on SRH, and the importance/benefits of using the services) • Organize joint health facilities (CSB and CHD) by determining the most appropriate collaboration and activity distribution system (including ANC and deliveries) • Entrust the first ANC visit to a health worker who, where necessary, can then introduce the young parents to a trainee and ensure effective supervision of the latter • Encourage attendance at ANC visits following the first • Insist on a delivery preparedness plan (specify in the ANC card, monitoring to be ensured by CHW to encourage facility-based delivery at the facility) • Strengthen FP service offered by CHWs (provide adequate prior training, FP products, and management tools) • Assess the causes of stock-outs of medicines, FP products, vaccines, and other products, and actions to be taken to ensure full and consistent supply of all services • Promote SRH services in rural areas (ANC campaigns during medical outreach), in schools, and with the community and youth (open door days at the health facility) • Build on the “cycle rickshaw ambulance” component of the Madagascar Community-Based Integrated Health Project for emergency transportation in rural and peri-urban areas • Establish specific service days and hours for youth • Provide information on the price of services and ensure transparency of pricing • Train health workers on correct and consistent filling of SRH registers and establish a system for periodic processing and use of register data

References

1 Institut National de la Statistique (INSTAT) et ICF Macro. 2010. Enquête Démographique et de Santé de Madagascar 2008-2009. Antananarivo, Madagascar: INSTAT et ICF Macro. 2 INSTAT. 2013. Madagascar Millennium Development Goals National Monitoring Survey. Antananarivo, Madagascar: INSTAT. 3 INSTAT et ICF Macro. 2010. Enquête Démographique et de Santé de Madagascar 2008-2009. Antananarivo, Madagascar: INSTAT et ICF Macro. 4 Lane, C and Andriamiadana, J. 2012. Assessment of USAID/Madagascar Youth Programming and Recommendations for Future Action to Improve Reproductive Health Outcomes among Malagasy Youth. USAID. 5 World Health Organization (WHO). 2011. WHO Guidelines on Preventing Early Pregnancy and Poor Reproductive Outcomes Among Adolescents in Developing Countries. Geneva: WHO. 6 Blum RW, Bastos FI, Kabiru CW, Le LC. Adolescent health in the 21st century. Lancet. 2012. Vol 379:1567–1568. 2012. 7 INSTAT. 2012–2013. Enquête nationale pour le suivi des Objectifs du Millénaire pour le Développement à Madagascar, Objectif 5 : Améliorer la santé maternelle. Antananarivo, Madagascar: INSTAT.

14 Formative Research on Individual, Couple, Family, Community, and Service-Level Factors that Impact the Use of Sexual and Reproductive Health Services by Young Parents in Two Regions of Madagascar in 2016