Closing the Gap between R and MNCH: Observational Study of Pregnancy Intentions and Maternal, Newborn and Child Health Behaviors in 18 sub-Saharan African Countries

Closing the Gap between R and MNCH: Observational Study of Pregnancy Intentions and Maternal, Newborn and Child Health Behaviors in 18 sub-Saharan African Countries | Authorea try { document.documentElement.classList.add('js'); } catch (e) { } var _gaq = _gaq || []; _gaq.push(['_setAccount', 'G-8VDV14Y67G']); _gaq.push(['_trackPageview']); (function() { var ga = document.createElement('script'); ga.type = 'text/javascript'; ga.async = true; ga.src = ('https:' == document.location.protocol ? 'https://ssl' : 'http://www') + '.google-analytics.com/ga.js'; var s = document.getElementsByTagName('script')[0]; s.parentNode.insertBefore(ga, s); })(); Skip to main content Preprints Collections Wiley Open Research IET Open Research Ecological Society of Japan All Collections About About Authorea FAQs Contact Us Quick Search anywhere Search for preprint articles, keywords, etc. Search Search ADVANCED SEARCH SCROLL BJOG: An International Journal of Obstetrics and Gynaecology This is a preprint and has not been peer reviewed. Data may be preliminary. 2 March 2025 V1 Latest version Share on Closing the Gap between R and MNCH: Observational Study of Pregnancy Intentions and Maternal, Newborn and Child Health Behaviors in 18 sub-Saharan African Countries Authors : Bolanle Olapeju 0000-0002-2958-2708 [email protected] , Anna Maria van Eijk , Michael Bride , Anna Passaniti , Saade Ahmed Abdallah , Gabrielle C. Hunter , Safia Mohammed , Leila Kaze , Judith Nalukwago , and Zoé Mistrale Hendrickson Authors Info & Affiliations https://doi.org/10.22541/au.174092599.93376287/v1 351 views 245 downloads Contents Abstract Abstract Introduction Methods Results Discussion Conclusion Contributions to Authorship Details of Ethics Approval Availability of data and materials Funding Table/Figure Caption List Supporting Information References Information & Authors Metrics & Citations View Options References Figures Tables Media Share Abstract Objective: This study explores the relationship between pregnancy intentions and maternal, newborn and child health (MNCH) behaviors. Design and Setting: Secondary data analysis of recent (2018-2023), cross-sectional Demographic and Health Surveys from 18 sub-Saharan African countries. Population: Survey respondents were women aged 15–49 years old with a child less than a year old who responded to survey questions about their pregnancy intentions for that child (N= 39,936). Methods: Logistic regressions and meta-analysis using fixed effects explored the relationship between pregnancy intentions and MNCH behaviors across study countries adjusting for sociodemographic and contextual variables. Measures: Pregnancy intentions were defined as i) intended versus unintended. MNCH behaviors included i) early ANC, ii) 4+ ANC contacts (ANC4+), iii) 3+ doses of intermittent preventive treatment of malaria in pregnancy (IPTp3+), iv) receipt of tetanus toxoid and v) immediate breastfeeding. Results: Overall, 24% of women did not want their index pregnancy (ranging from 11% in Burkina Faso to 48% in Gabon). Unintended pregnancies were associated with reduced odds of early ANC (aOR: 0.69, 95% CI: 0.66, 0.73), IPTp3+ (aOR: 0.85; 95% CI: 0.80, 0.90), receiving tetanus toxoid (AOR: 0.75; 95% CI: 0.69, 0.81), and immediate breastfeeding (AOR: 0.83; 95% CI: 0.80, 0.86). Conclusions: Study findings corroborate the role of reproductive health agency and pregnancy preparedness in optimizing maternal, newborn and child health outcomes. Integration of reproductive health services, malaria service delivery, and social and behavior change interventions can help to improve pregnancy outcomes. Closing the Gap between R and MNCH: Observational Study of Pregnancy Intentions and Maternal, Newborn and Child Health Behaviors in 18 sub-Saharan African Countries Authors : Bolanle Olapeju 1* , Anna Maria van Eijk 2 , Michael Bride 3 , Anna Passaniti 3 , Saade Ahmed Abdallah 4 , Gabrielle C. Hunter 3 , Safia Mohammed 5 , Leila Kaze 6 , Judith Nalukwago 7 , Zoé Mistrale Hendrickson 8 Affiliations : 1 Department of Preventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA 2 Liverpool School of Tropical Medicine, Liverpool, United Kingdom 3 Johns Hopkins Center for Communication Programs, Baltimore, Maryland, USA 4 PwC Kenya. Nairobi, Kenya 5 Zanzibar Malaria Elimination Program, Ministry of Health, Zanzibar, Tanzania 6 Burundi National Malaria Control Program, Bujumbura, Burundi 7 Makerere University, Kampala, Uganda 8 Department of Behavioral and Community Health Sciences, University of Pittsburgh School of Public Health, Pittsburgh, Pennsylvania, USA * Corresponding Author 4301 Jones Bridge Road. Bethesda, Maryland. USA Email: [email protected] Phone: 3012951585 Shortened running title: Closing the Gap between R and MNCH. Abstract Objective: This study explores the relationship between pregnancy intentions and maternal, newborn and child health (MNCH) behaviors. Design and Setting: Secondary data analysis of recent (2018-2023), cross-sectional Demographic and Health Surveys from 18 sub-Saharan African countries. Population: Survey respondents were women aged 15–49 years old with a child less than a year old who responded to survey questions about their pregnancy intentions for that child (N= 39,936). Methods: Logistic regressions and meta-analysis using fixed effects explored the relationship between pregnancy intentions and MNCH behaviors across study countries adjusting for sociodemographic and contextual variables. Measures: Pregnancy intentions were defined as i) intended versus unintended. MNCH behaviors included i) early ANC, ii) 4+ ANC contacts (ANC4+), iii) 3+ doses of intermittent preventive treatment of malaria in pregnancy (IPTp3+), iv) receipt of tetanus toxoid and v) immediate breastfeeding. Results: Overall, 24% of women did not want their index pregnancy (ranging from 11% in Burkina Faso to 48% in Gabon). Unintended pregnancies were associated with reduced odds of early ANC (aOR: 0.69, 95% CI: 0.66, 0.73), IPTp3+ (aOR: 0.85; 95% CI: 0.80, 0.90), receiving tetanus toxoid (AOR: 0.75; 95% CI: 0.69, 0.81), and immediate breastfeeding (AOR: 0.83; 95% CI: 0.80, 0.86). Conclusions: Study findings corroborate the role of reproductive health agency and pregnancy preparedness in optimizing maternal, newborn and child health outcomes. Integration of reproductive health services, malaria service delivery, and social and behavior change interventions can help to improve pregnancy outcomes. Funding : none Keywords : Africa, behavior, intentions, integration, pregnancy, prevention Key Message What is already known on this topic Unintended pregnancies and adverse maternal, newborn and child health outcomes remain significant public health challenges in sub-Saharan Africa The link between pregnancy intentions and the continuum of maternal, newborn and child health behaviors has not been recently systematically explored across Africa What this study adds Women with unintended pregnancies were less likely to seek antenatal care, receive tetanus toxoid immunizations and intermittent preventive treatment for malaria in pregnancy. They were also less likely to immediately initiate breastfeeding after delivery. How this study might affect research, practice or policy Results corroborate the need for better integration of reproductive health to improve MNCH behaviors and outcomes including malaria prevention, highlighting the role of health service delivery and social and behavior change interventions in optimizing pregnancy outcomes. Introduction Background Unintended pregnancies and adverse maternal and neonatal health outcomes remain significant public health challenges in sub-Saharan Africa [1-4]. The persistence of unintended pregnancies and adverse maternal, newborn and child health outcomes may point to systemic shortcomings in healthcare delivery systems[5]. Fragmented, siloed approaches to maternal and child health (MCH) have historically separated reproductive health, malaria control, tuberculosis, HIV and MCH initiatives, undermining opportunities for integrated strategies [6-8]. This fragmentation is further reflected in funding streams and programmatic priorities that predominantly emphasize pregnancy and the postpartum period, with limited focus on pre-pregnancy health promotion and prevention efforts [9, 10]. Reproductive health and MNCH are jointly impacted by social determinants and health service quality [8, 11-16] across the continuum of care and life course [17, 18]. Thus, more attention should be placed on opportunities for synergy in intervention research, design, implementation, monitoring, and evaluation. MNCH and Pregnancy Intentions An underexplored correlate of MNCH is women’s pregnancy intentions - defined as their desires and preferences regarding childbearing [19-21]. Women’s desires regarding the timing and spacing of pregnancies, can impact their health-related behaviors during pregnancy. Isolated studies suggest unintended pregnancies are linked with reduced uptake of recommended behaviors such as early [22-25], and frequent antenatal care (ANC) contacts [22, 26], insecticide-treated net (ITN) use[27], adherence to intermittent preventive treatment (IPTp) of malaria with sulfadoxine-pyrimethamine (SP) [28, 29], postnatal care [18] and breastfeeding [30]. However, no study has systematically explored multiple MNCH behaviors that are associated with pregnancy intentions across sub-Saharan Africa. Study Objectives and Rationale This study seeks to address critical knowledge gaps by exploring the relationship between pregnancy intentions and several MNCH behaviors (early and frequent ANC, receipt of tetanus toxoid or IPTp, mosquito net use during pregnancy and immediate breastfeeding after delivery) in sub-Saharan Africa. Theoretical underpinnings are drawn from self-determination theory [31] which posits that intentions act as a motivational determinant of behavior. A woman may be more likely to actively adopt MNCH-related behaviors when she feels she has control over her reproductive choices (autonomy), believes she is capable of engaging in MNCH-related behaviors (competence), and feels supported by significant others (e.g., spouse, family, or friends) in her decision (relatedness). Thus, having an intended pregnancy can serve to motivate women to engage in health behaviors that ensure that she and her baby remain healthy. We hypothesized that women who did not intend to be pregnant would be less likely to engage in specific behaviors to prevent adverse MNCH outcomes such as ANC, IPTp, mosquito net use and breastfeeding. Methods Design and Setting This study was a cross sectional study design, and used secondary data analysis of recent (2018-2023) Demographic and Health Surveys (DHS) in 18 sub-Saharan African countries. Of note, study countries account for the majority (over 90%) of the global malaria burden [4]. Study Population The DHS respondents include women of reproductive age (15-49). For this study, the sample included women survey respondents i) aged 15-49 years old; ii) with a child less than a year old; and iii) responded to survey questions about their pregnancy intentions for that child (N= 39,936). To specifically assess the relationship between pregnancy intentions and mosquito net use during pregnancy, the analysis included women i) 15 – 49 years old with nets in their household; ii) who were currently pregnant as of the time of the survey; and iii) responded to survey questions about their intentions for their current pregnancy (N=6,406). Measures The primary exposure variable was pregnancy intentions based on two survey questions for the index child: “When you got pregnant, did you want to get pregnant at that time?” and ”Did you want to have a baby later on or did you not want any (more) children?”. Responses were combined, and pregnancy intentions were defined as i) intended, ii) mistimed (i.e., wanted the child later); or iii) unwanted (i.e., not wanted at all). This was subsequently dichotomized into intended versus unintended (mistimed or not wanted at all). MNCH behaviors included i) early ANC defined as the first ANC visit within the first trimester, ii) ANC retention (at least four contacts (ANC4+), iii) Receipt of three or more doses of SP (IPTp3+), iv) Receipt of one or more doses tetanus toxoid immunization, v) mosquito net use the night preceding the survey, and vi) immediate breastfeeding (within the first hour of birth). Sociodemographic and contextual factors were based on available DHS data and a priori knowledge of factors influencing pregnancy intentions and MNCH behaviors. Factors included age group (15-24, 25-34, and 35+ years), residence (urban versus rural), religion (Christian versus. other), education level (secondary versus less), marital status (married versus not), sex of the head of household (male versus female), wealth quintile (first (lowest) to fifth (highest)), number of children under 5 in the household, country and year of survey. Analysis Data management and analysis was conducted using Stata version 17 (Stata Corporation, College Station, TX, USA). The svyset command in STATA was used to weight the data and ensure representation of the study population for each country by the cluster level. Crude and multivariable logistic regression models explored the relationship between pregnancy intentions and MNCH behaviors across study countries adjusting for the aforementioned contextual variables. A two-stage meta-analysis using fixed effects was conducted to pool the country estimates using the metan command. Heterogeneity in effect measures between countries was evaluated using the I 2 statistic. For two specific analyses (mosquito net use among pregnant women and immediate breastfeeding), the sample was too limited to allow adjustment for clustering and analyses of unclustered data was conducted instead. Results Description of Study Sample Table S1 summarizes the characteristics of the study sample (N=39,936), highlighting country-level differences. Overall, about a third of the women lived in rural areas (34%), were aged 15 to 24 years old (37%) and had a secondary education (34%). The majority of women were married (87%) while half of the women were Christian (48%). About a fifth of women lived in female- headed households. Table S1: Description of Study Sample and Pregnancy Intentions Rates of Pregnancy Intentions and MNCH Behaviors Across Study Countries Figure 1 displays the overall and country-level uptake of pregnancy intentions and MNCH behaviors including early ANC, receipt of tetanus toxoid, IPTp3+ and immediate breastfeeding. Considerable variation in intended, mistimed, and unwanted pregnancies were seen across study countries. For example, in Burkina Faso, 87% of pregnancies were wanted, 11% were mistimed, and 2% were not wanted at all. In contrast, Gabon shows lower wanted pregnancies at 51%, with 36% mistimed and 31% unwanted . Overall, 39% of women in the study population attended their first ANC visit within the first trimester, ranging from 18% in Nigeria to 70% in Liberia. Over three-quarters of women received tetanus toxoid immunization during their pregnancy, which was lowest in Mauritania (61%) and highest in Sierra Leone (98%). In contrast, less than a third (30%) of women had IPTp3+, ranging from 11% in Nigeria to 63% in Ghana. More than half, 57% of women breastfed their babies immediately (within the first hour of birth), which was lowest in Senegal (23%) and highest in Rwanda (86%). Figure 1: Rates of Pregnancy Intentions and MNCH Behaviors Across Study Countries Supplemental Figure 1 shows the overall and country level rates of ANC4+ and mosquito net use in pregnancy. Sixty-one percent of women had at least four ANC contacts, which was lowest in Guinea (35%) and highest in Ghana (87%). Similarly, 62% of currently pregnant women used a mosquito net the night before the survey, which was lowest in Mauritania (22%) and highest in Mali (88%). 62% of currently pregnant women used a mosquito net the night before the survey, which was lowest in Mauritania (22%) and highest in Mali (88%). Relationship between Pregnancy Intentions and MNCH Behaviors Across Study Countries Figures 2-4 display forest plots that summarize the relationship between pregnancy intention and early ANC, IPTp3+, and immediate breastfeeding, respectively, across study countries. In Figure 2, women whose recent pregnancies were unintended had 32% lower odds of early ANC (AOR: 0.68; 95% CI: 0.63, 0.72) as compared to those who reported intended pregnancies. At the country level, this significant association was seen in most countries except Côte d’Ivoire, Guinea, Kenya, Sierra Leone, and Zambia. Figure 2: Pregnancy Intentions and Early ANC In Figure 3, women with unintended pregnancies had a third lower odds of IPTp3+ (AOR: 0.68; 95% CI: 0.63, 0.72) overall, although the odds were only statistically significant in four countries. These included Ghana (AOR: 0.59; 95% CI: 0.45, 0.77), Guinea (AOR: 0.66; 95% CI: 0.48, 0.92), Madagascar (AOR: 0.54; 95% CI: 0.40, 0.73), and Mauritania (AOR: 0.58; 95% CI: 0.37, 0.91). Figure 3: Pregnancy Intentions and IPTp3+ In Figure 4, unintended pregnancies were associated with lower odds of immediate (within the first hour) breastfeeding at birth (AOR: 0.83; 95% CI: 0.80, 0.86). This trend persisted in several countries including Cameroon (AOR: 0.73; 95% CI: 0.63, 0.85), Gabon (AOR: 0.68; 95% CI: 0.56, 0.82), Gambia (AOR: 0.80; 95% CI: 0.68, 0.96), Guinea (AOR: 0.51; 95% CI: 0.41, 0.63), Madagascar (AOR: 0.51; 95% CI: 0.41, 0.63), Mali (AOR: 0.68; 95% CI: 0.58, 0.81), Mauritania (AOR: 0.68; 95% CI: 0.59, 0.78), Senegal (AOR: 0.55; 95% CI: 0.42, 0.73), Sierra Leone (AOR: 0.62; 95% CI: 0.52, 0.74) and Zambia (AOR: 0.66; 95% CI: 0.57, 0.76) Figure 4: Pregnancy Intentions and Immediate Breastfeeding Supplemental Figures 2-4 displays forest plots that summarize the relationship between pregnancy intention, tetanus toxoid, ANC4+ and mosquito net use (during current pregnancy) across the study countries. Women whose recent pregnancies were unintended had 25% lower odds of receiving tetanus toxoid (AOR: 0.75; 95% CI: 0.69, 0.81), 30% lower odds of ANC4+ (AOR: 0.70; 95% CI: 0.66, 0.75). However, currently pregnant women with unintended pregnancies did not have significantly lower odds of mosquito net use during pregnancy (AOR: 0.96; 95% CI: 0.80, 1.16). Discussion This study explored the relationship between pregnancy intentions and several MNCH behaviors across multiple countries in sub-Saharan Africa. While there was notable country-level heterogeneity, women with unintended pregnancies were significantly less likely to access early or frequent antenatal care, receive tetanus toxoid, get intermittent preventive malaria treatment, or breastfeed immediately after birth. There are plausible pathways linking pregnancy intention and MNCH behaviors. A woman who is unintentionally pregnant may be less motivated to keep her baby healthy. In addition, she may not want her pregnancy status to be known and may hold back from receiving health services as her status would be disclosed and become publicly known. Furthermore, unintended pregnancies might be associated with younger age, lack of economic resources or social support [11], and this might impact a woman’s ability to access MNCH care services. These pathways are somewhat reflected in the self-determination theory [31] as a woman’s control over her reproductive choices (autonomy) is linked to her ability (competence) to engage in MNCH behaviors (competence), and her support (relatedness) from significant others (e.g., spouse, family, or friends) The observed association between pregnancy intentions and MNCH behaviors serves as a call for better integration of reproductive health research and interventions into malaria prevention and MNCH. Study findings suggest an additional opportunity to prevent malaria and other adverse MNCH outcomes by focusing on the pre-pregnancy period and women’s pregnancy intentions. Research has shown that culturally sensitive family planning programs, including those that take a gender transformative approach (Fisher, 2022) or center women’s reproductive health agency, can help women to meet their reproductive goals and reduce unintended pregnancy [32-34]. The potential gains in preventing malaria could be yet another benefit to improved reproductive health agency, along with other health and educational benefits, for women and their families. This study highlights the potential for holistic, cross-sectoral approaches to reinvigorate progress toward improved MNCH and malaria elimination in sub-Saharan Africa. Funding and coordination are key to achieve better integration of reproductive health services into malaria and MNCH. Advocacy efforts are needed to engage global donor agencies and domestic funding streams to avoid vertical implementation of siloed malaria interventions separately from reproductive, maternal, newborn, child and adolescent health and HIV [35]. Instead, funders should increasingly favor multi-health and multi-sectoral interventions including gender and youth sectors. The African Union [17] has advocated for innovative partnerships across key funders including World Bank, Global Fund, United Nations Children’s Fund (UNICEF), and United Nations Population Fund (UNFPA). All the MNCH behaviors explored in this study are related to health service delivery. Thus, local ministries of health need to review the structure and coordination of MNCH, malaria and reproductive health services. A unified national health strategy may prove beneficial in ensuring holistic collaboration [36], as MNCH, malaria and reproductive health are often managed under different sub-units within the ministries of health. Such a unified health strategy could be complemented with the institution of technical working groups across multiple focal areas including malaria, MNCH and reproductive health in order to foster collaborative decision making in planning, implementation and evaluation of programs [37]. Joint data measurement and action reviews may help identify and track priority indicators for malaria, MNCH and reproductive health [38]. National as well as sub-national monitoring of key indicators is needed to uncover targeted healthcare improvements to improve MNCH, particularly in settings where outcomes remain low, and to support positive maternal health outcomes where progress has been more substantial. Another important key to improving the integration of reproductive health into malaria and MNCH is the design and implementation of contextually relevant programs. Community-focused approaches [39] that are informed by life course theory [40] and stratify pregnancy preparedness interventions for younger women versus older women [41] may be warranted. Interventions for younger women should focus on pre-pregnant women, young couples and adolescent girls. Such interventions could aim to empower young women with reproductive health agency and the ability to envision their reproductive trajectory and plan their pregnancies and future life goals [34, 42]. Recent evidence has shown that cash transfer programs could also be effective in reducing pregnancy rates among young people in low- and middle-income countries [42]. Furthermore, youth friendly programs should aim to integrate preconception care into existing school and adolescent health services. Evidence suggests that education- and other demand-side interventions are an effective approach to improve contraceptive use and reduce unintended pregnancies among young people [32]. Health promotion activities could implement wellness days [43], across communities where community members are provided with integrated health services including family planning, malaria prevention, and disease prevention to address the needs of both younger and older community members. Given the low rates of MNCH behaviors except tetanus toxoid uptake across countries, additional efforts are needed to increase access to and uptake of MNCH services during pregnancy. Study findings corroborate the need for targeted interventions to address barriers, raise awareness, and strengthen healthcare accessibility [44], especially in settings where early ANC attendance remains low, given that early ANC attendance is a strong predictor for ANC4 and, relatedly, IPTp3. In addition, pregnant women are given insecticide-treated nets during ANC in several countries. Demand generation interventions and social and behavior change (SBC) programs could position intended pregnancies as helping to prevent malaria and ensure the health of mothers and babies [45]. SBC interventions should also address stigma surrounding unintended pregnancy, which may lead women, particularly young women, to keep their pregnancies a secret and be a barrier to care-seeking among women with unintended pregnancies [46]. These demand generation activities should be complemented with high quality malaria service delivery including respectful care and supply chain management to improve the of ANC, ITN, and IPTp [45]. Insights from tetanus toxoid immunization program implementation should be leveraged given the notably high rates across most countries [47]. Study findings also suggest directions for future research. Longitudinal or advanced modelling studies may be conducted to better quantify the value of integrating reproductive health into malaria and MNCH using measures such as lives saved or malaria cases averted from planned pregnancies. Where possible, existing health management information systems can be employed to identify and track relevant available data related to MIP and MNCH. Countries should investigate opportunities for intra- and international research collaboration efforts to understand past and current efforts to integrate malaria, MNCH and reproductive health to better understand what works well or does not work well. There are a number of limitations to be acknowledged which should be addressed by more robust studies. This snapshot of national level data does not take into account sub-national variations such as the effective implementation of national policies regarding ANC services, tetanus toxoid immunization, IPTp distribution, or mosquito net coverage. In particular, rates of IPTp3+ and ITN use are highly sensitive to access to these interventions. Most countries distribute ITNs only every three years and drug stocks occur commonly [48]. Of note the study did not see an association between pregnancy intentions and mosquito net use, presumably due to limitations in the DHS methodology to assess ITN use [49] among other unknown reasons. Further, national data may obscure heterogeneous health policies. The cross-sectional nature of this study does not allow inferences of causality and we are careful to position our findings as preliminary. Only variables available in the DHS were used in this analysis, limiting the study’s ability to fully explore key constructs in the self-determination theory. Pregnancy intention was used as a proxy for a woman’s autonomy in her pregnancy decisions while engaging in related MNCH behavior was a proxy for her competence to take action. However, social support was not well explored and pregnancy intentions are not necessarily representative of all domains of autonomy. The study could not investigate the degree to which ability to adopt relevant behaviors might be influenced by the access to and quality of health services. Lastly, all data is self-reported and thus subject to social desirability bias particularly in settings where it is not acceptable to say that pregnancies are unwanted or mistimed. Conclusion In conclusion, this novel study across 18 countries in sub-Saharan Africa, demonstrated that women who intended to be pregnant were more likely to adopt behaviors related to malaria prevention and MNCH. Study findings suggest the importance of reducing unintended pregnancies for malaria prevention, and that the integration of reproductive health services, malaria service delivery, and behavior change interventions can help to improve pregnancy intentions and outcomes. Acknowledgements The authors would like to acknowledge all the women who participated in the surveys and the DHS program. Disclaimer The opinions and assertions expressed herein are those of the author and do not reflect the official policy or position of the Uniformed Services University of the Health Sciences or the Department of Defense. Disclosure of Interests The authors have no competing interests to declare. Contributions to Authorship BO conceived the study. BO, AVE and MB managed the datasets and analyzed the data. BO, AVE, MB, AP, SAA, GH, SM, LK, JN, and ZMH, drafted, edited and approved the final manuscript. Details of Ethics Approval Not applicable. Availability of data and materials The datasets are available from the DHS Program web site, http://www.dhsprogram.com. Funding The authors did not receive any funding for this study. Table/Figure Caption List Figure 1: Rates of Pregnancy Intentions and MNCH Behaviors Across Study Countries Figure 2: Pregnancy Intentions and Early ANC Figure 3: Pregnancy Intentions and IPTp3+ Figure 4: Pregnancy Intentions and Immediate Breastfeeding Supporting Information S1: Description of Study Sample and Pregnancy Intentions S2: Pregnancy Intentions and ANC4+ S3: Pregnancy Intentions and Receipt of Tetanus Toxoid S4: Pregnancy Intentions and Mosquito Net Use During Pregnancy References 1. 1. Fund UNP. State of World Population 2022: Seeing the Unseen-The Case for Action in the Neglected Crisis of Unintended Pregnancy: UN; 2022.2. Bearak JM, Popinchalk A, Beavin C, Ganatra B, Moller A-B, Tunçalp Ö, et al. Country-specific estimates of unintended pregnancy and abortion incidence: a global comparative analysis of levels in 2015–2019. BMJ global health. 2022;7(3):e007151.3. Reddy V, Weiss DJ, Rozier J, Ter Kuile FO, Dellicour S. 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Collection BJOG: An International Journal of Obstetrics and Gynaecology Keywords antenatal care developing countries: obstetrics and gynaecology epidemiology: contraception epidemiology: perinatal fertility control health services research Authors Affiliations Bolanle Olapeju 0000-0002-2958-2708 [email protected] Uniformed Services University of the Health Sciences Department of Preventive Medicine and Biometrics View all articles by this author Anna Maria van Eijk Liverpool School of Tropical Medicine View all articles by this author Michael Bride Johns Hopkins University Center for Communication Programs View all articles by this author Anna Passaniti Johns Hopkins University Center for Communication Programs View all articles by this author Saade Ahmed Abdallah Kenya Ministry of Health View all articles by this author Gabrielle C. Hunter Johns Hopkins University Center for Communication Programs View all articles by this author Safia Mohammed Zanzibar Ministry of Health View all articles by this author Leila Kaze Burundi National Malaria Control Program View all articles by this author Judith Nalukwago Makerere University View all articles by this author Zoé Mistrale Hendrickson University of Pittsburgh Department of Behavioral and Community Health Sciences View all articles by this author Metrics & Citations Metrics Article Usage 351 views 245 downloads .FvxKWukQNSOunydq8rnd { width: 100px; } Citations Download citation Bolanle Olapeju, Anna Maria van Eijk, Michael Bride, et al. Closing the Gap between R and MNCH: Observational Study of Pregnancy Intentions and Maternal, Newborn and Child Health Behaviors in 18 sub-Saharan African Countries. Authorea . 02 March 2025. 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