“No culture stops me from taking tablets”: Exploring community-level factors influencing pregnant women’s IPTp-SP uptake in Nigeria

Nigeria bears the highest burden of malaria cases in the world, and pregnant women are uniquely vulnerable to the disease. Malaria in pregnancy (MiP) may have negative implications for maternal and neonatal health. The World Health Organization (WHO)-recommended intermittent preventive treatment with sulphadoxine-pyrimethamine (IPTp-SP) helps to prevent MiP. However, due to the influence of significant others, the decision-making power regarding health may be outside the purview of pregnant women. Using the social norms theory, this study investigates the role of community factors affecting the use of IPTp-SP among pregnant women. The study adopted qualitative methods, including focus group discussions with pregnant women and in-depth interviews with significant others, including community leaders, traditional birth attendants, religious leaders, spouses and mothers-in-law. Six focus group discussions and seventeen in-depth interviews were conducted with pregnant women and stakeholders, respectively. Data were managed using NVivo (version 12) and analyzed thematically and deductively in line with the social norms theory. We found that most of the pregnant women demonstrated interest in using IPTp-SP. While they recognized the role of significant others in health decision-making, many expressed agency and resistance against social norms opposing their use of IPTp-SP. They exhibited varying degrees of defiance against domination by spouses and mothers-in-law and gave legitimacy to healthcare professionals. Pregnant women and TBAs adopted mixed approaches (traditional and orthodox medicines) to preventing MiP. Pregnant women deferred to their religious leaders than to their community leaders. For this study's sample, descriptive norms were more critical. Most women emphasized their will to make health decisions and prioritized their health and their babies, defying the long-standing social norms that militate against women's health-seeking behaviour.