Prevalence and factors associated with uptake of repeat HIV testing among pregnant women in Blantyre, Malawi

Abstract

Introduction

Repeat HIV testing during pregnancy is significant to detect new maternal HIV infections and mitigate the risk of mother-to-child HIV transmission. Despite guidelines advocating retesting of initially HIV-negative pregnant women, there is limited information on the implementation of these recommendations. The aim of this study is to assess the magnitude of repeat HIV testing uptake in the third trimester and its associated factors.

Methods

We conducted a convergent parallel mixed method study from November 2021 to April 2022 to determine the prevalence and associated factors for a repeat HIV test among women in the third trimester from Ndirande and Lirangwe primary health facilities in Blantyre. Our quantitative approach involved a retrospective review of antenatal records from July 2020 to June 2021. STATA version 14 was used for descriptive analysis. Frequency distributions, fisher’s tests and multivariable logistic regressions were used to examine the association between repeat HIV testing and selected explanatory variables. The qualitative component was exploratory following phenomenological design. Data were collected from 44 pregnant women and 10 health workers who were purposively selected through focus group discussions in-depth and key informant interviews. Transcripts were coded deductively and inductively manually. The thematic analysis of the data was informed by the Consolidated Framework for Implementation Research (CFIR).

Results

Analysis of 369 antenatal records, with 302 from Ndirande and 67 from Lirangwe primary health facilities, revealed that only 30 (8.13%) participants received a repeat HIV test in the third trimester from both facilities. Increasing age reduced the likelihood of accessing repeat HIV testing in the third trimester compared to younger women (OR = 0.43; 95% CI: 0.05–3.86). Age, gravidity, and parity did not significantly impact the probability of retesting. Key factors impeding repeat HIV testing included unfamiliarity with the intervention, inadequate resources and clinic operations. In contrast, confirmation of HIV status and improved neonatal outcomes were motivators for repeat HIV testing.

Conclusion

Information and counselling on the benefits of repeat HIV testing later in pregnancy is key in increasing uptake and implementation of the service in future pregnancies. In addition, strengthening the clinic operations and improving availability of resources is vital in the implementation and uptake of repeat HIV testing among pregnant women.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-025-26176-5.

Background

Human Immunodeficiency Virus (HIV) among pregnant women is a critical public health issue with significant implications for both maternal and child health. Mother-to-child-transmission (MTCT) of HIV is the main mode of transmission leading to the increase in pediatric HIV infections, accounting for 90% of new childhood infections globally [1, 2] HIV testing for pregnant women is a significant aspect for the success of prevention of mother-to-child transmission of HIV (PMTCT). While initial HIV screening among pregnant women during early pregnancy is known to decrease chances of MTCT, omission of HIV screening in late pregnancy and during breastfeeding excludes women who seroconvert thereby underscoring the relevance of a repeat HIV test for those that were uninfected at the initial test.

Repeat HIV testing and counselling (HTC) in late pregnancy and postpartum period is key for identification and initiation of treatment for HIV infected pregnant women to prevent perinatal HIV transmission [3]. As such, HIV re-testing in late pregnancy is one of the recommendations that has been adopted by the international elimination of MTCT agenda [4]. Additionally, WHO advocates repeat HIV testing among pregnant women in the third trimester particularly in areas with high prevalence of HIV to prevent MTCT [5]. This is important in sub Saharan Africa, where the prevalence of HIV among pregnant women remains high, ranging from 3 to 22.5% [6–8]. Furthermore, women in Sub Saharan Africa have a higher risk of acquiring HIV more during antepartum period as compared to postpartum period [1, 9–11] because of increased viremia associated with incident infection [3, 12–14] making repeat HIV testing (HTC) among this group of high-risk women imperative [3, 12, 15].

Prevention of mother-to-child HIV transmission remains a key strategy in Malawi for reducing new HIV infections among children. While HIV infection among pregnant women has decreased from 7% in 2018 [8] to 5.4% in 2022, the prevalence remains high, which means that a substantial number of new HIV infections among children are likely to occur during pregnancy and breastfeeding due to seroconversion. Malawi adopted a repeat HIV testing strategy in the third trimester of pregnancy in April 2019 with an aim of strengthening PMTCT services to achieve high provider-initiated testing and counselling (PITC) and ART coverage for pregnant and postpartum women [16, 17]. The repeat HIV testing strategy is operationalized through national antenatal care guidelines, which recommend eight antenatal visits during pregnancy—five of which are scheduled for the third trimester [16]. Initial HIV testing for pregnant women who are HIV-uninfected is conducted during the first antenatal visit, while repeat HIV testing is recommended once during any visit in the third trimester. To ensure effective implementation, healthcare providers, including HIV diagnostic assistants, received on-the-job training on the new guidelines.

While national coverage of initial HIV testing and counselling (HTC) among pregnant women is at 98% in Malawi, the coverage of repeat HTC in the third trimester is inconsistently implemented nor recorded. Previous studies conducted on implementation of repeat HIV test among pregnant women regionally [18, 19] have reported low prevalence of repeat HIV testing during pregnancy with South Africa reporting a prevalence of 62% [20], Zambia 24.6% [21] and Kenya 32% [19]. Factors influencing uptake of repeat HIV test among pregnant women included having a previous negative HIV result, knowledge of importance of repeat test, young age and resources [20–23]. Currently in Malawi there is limited information on implementation and factors that influence uptake of repeat HTC in the third trimester of pregnancy. To ensure that Malawi maximizes the opportunities to prevent MTCT of HIV there is a need to understand the implementation of repeat HIV testing in the third trimester of pregnancy. Therefore, this study aimed to assess the magnitude of repeat HIV testing in the third trimester of pregnancy and its associated factors.

Conceptual framework

This study was guided by the Consolidated framework for implementation research (CFIR). The CFIR framework consists of five domains which are intervention, inner and outer setting, individual characteristics, and process by which the implementation is accomplished. The framework was chosen because of its ability to comprehensively identify potential factors influencing implementation of an intervention through the constructs under each domain [24, 25].

In this study four domains, intervention characteristics, inner setting, process by which the implementation is accomplished, and individual characteristics assisted in identifying factors influencing implementation of repeat HIV testing among pregnant women. The intervention characteristics and process by which the implementation is accomplished focused on factors related to perceptions of providers as well as recipients of the intervention towards the intervention in terms of significance, the process to provide or receive the intervention and the procedures involved. The inner setting assisted in providing factors associated with availability of resources and readiness of personnel to provide the intervention while the individual characteristics provided personal factors which influenced uptake of the intervention. We eliminated one concept of the framework (Outer setting) because it did not fit with the study.

Methods

Study design

We conducted a convergent parallel mixed method study from November 2021 to April 2022 to determine the prevalence and associated factors for a repeat HIV test among women in the third trimester from Ndirande and Lirangwe primary health facilities in Blantyre. The quantitative component involved a retrospective review of antenatal registers from July 2020 to June 2021, the period when repeat HIV testing among pregnant women was initiated and implemented. The retrospective review of antenatal registers provided precise, measurable data on repeat HIV testing frequency among pregnant women, enabling a comprehensive analysis of historical trends [26]. On the other hand, the qualitative component was exploratory following phenomenological design. The design provided room for a deep exploration of pregnant women’s subjective experiences and perceptions related to repeat HIV testing during antenatal care. Additionally, using a mixed-method design ensured a comprehensive view of factors impacting repeat HIV testing implementation, strengthening the study’s validity and breadth [27].

Study setting

The study was conducted in Blantyre district, the commercial city, situated in the southern region of Malawi. The study sites were Ndirande and Lirangwe primary health facilities located in the urban and rural parts of Blantyre district respectively. Ndirande and Lirangwe health centers are government owned and operate under Blantyre District Health Office and have the following departments: laboratory, pharmacy, Low risk antenatal clinic, outpatient department with a short-stay facility for pre referral case management and maternity. Ndirande health center is located three kilometres from the centre of Blantyre, while Lirangwe health center is situated to the north of Blantyre, 54 kms away from the city. The catchment population for Ndirande and Lirangwe is 150,096 and 33,019, respectively. Ndirande facility serves urban communities with low social economic status while Lirangwe serves rural community whose economy depends on peasant farming and small-scale businesses. At Ndirande health center, initial antenatal booking is done every Monday and Wednesday, and subsequent visits are conducted every Tuesday, Thursday, and Friday. On the other hand, Monday’s and Tuesdays are for initial booking and subsequent visits respectively at Lirangwe health center. During booking, all pregnant women in both facilities undergo provider-initiated HIV testing and counselling while subsequent HIV tests during pregnancy in both facilities are offered at the Outpatient Department after receiving antenatal care services. The HIV test available is the rapid model which requires a finger prick to obtain a blood sample for antibody –antigen blood test. At booking, on average Ndirande health center attends to 296 pregnant women while Lirangwe has 99 antenatal women per month. At the time of the study, there were 35 and 14 health care workers at Ndirande and Lirangwe health centers respectively with varying qualifications ranging from clinicians, nurse/midwives, and HIV diagnostic assistants. The study was conducted in Blantyre district because it has a high HIV prevalence rate of 9.4%. The health facilities were selected purposively to achieve representation of the district as the facilities were from urban and rural settings. In addition, purposive sampling provided opportunity to have a broader picture of associated factors for repeat HIV testing among pregnant women from diverse sources through subjective data.

Sampling and sample size for quantitative approach

All women who attended antenatal clinics at Ndirande and Lirangwe health centers from July 2020 to June 2021 represented the study population. Antenatal records of women having negative HIV test results at initial antenatal visit and had more than one antenatal contact, one of which conducted in the third trimester were recruited into the study. We excluded women’s antenatal records which indicated the status of HIV infected test result and absence of antenatal contact in the third trimester following a negative initial HIV test result.

The sample size for the retrospective review of registers was computed using the single population formula [32] n = Z2 P(1-p) /d2 e (n = sample size, p = expected proportion of clients with repeat HIV test, Z = confidence interval—statistic corresponding to the level of confidence, d = margin of error—corresponding to effect size)

By considering the local rates of repeat HIV testing among pregnant women at 40% (Blantyre District Health Office, 2020), a total of 369 antenatal records meeting the criteria were chosen for review out of the overall 7702 expected pregnancies across both facilities. The allocation of sample sizes was guided by the facility-specific expected pregnancies: 6300 for Ndirande, thus yielding a sample size of 302 women, and 1402 expected pregnancies for Lirangwe, resulting in a sample size of 67 women. The study followed a systematic random sampling [28] and used antenatal registers for 2020/2021 in the two facilities because they were the most recent ones basing on the period HIV repeat test was introduced in the antenatal clinics in 2019 [6]. A random start point was selected from a box of random numbers, and it was between serial numbers 1 and 10.

Sampling, sample size and recruitment of participants for qualitative approach

The study population comprised all pregnant women attending antenatal care at Ndirande and Lirangwe Health centers, all HIV diagnostic assistants (HDAs), all health center in charges, all nurse/midwives working in maternity units, safe motherhood coordinator, prevention of mother-to-child (PMTCT) coordinator and District Health Officer for Blantyre district. Participants were purposively sampled with variations such as age, gravidity, number of antenatal visits and marital status for participants for focus group discussions (FGDs) and in-depth interviews (IDIs). On the other hand, variations such as cadre, years of service, roles and responsibilities related to implementation of repeat HIV testing during pregnancy were considered during recruitment of the key informants (KIs). Purposive sampling while observing maximum variations widened the scope of our responses and in ensuring validity of the responses [29–31]. Total sample for the qualitative data was 54 who participated in FGDs, IDIs and Key informant interviews (Table 1) which was an adequate sample for qualitative approach. The number of participants in qualitative research is not fixed and can vary depending on the research question, methodology, and the specific context of the study as it would allow to uncover a variety of opinions basing on information power, but to limit the sample size at the point of saturation [30, 32]. The sampling frame and sample size are illustrated in Table 1.

Table 1.

Sample and sampling technique for qualitative study

Participant type	Method of data collection	Number	Sampling technique	Rationale
Nurse/midwives	Key Informant interviews	6	Purposive	These were key to the provision of ANC services at various levels
Doctor/Clinical Officer	Key Informant interviews	2	Purposive	These were key in the running of the services at the facilities which included mobilizing resources for antenatal care
HIV Diagnostic assistants	Key Informant interviews	2	Purposive	These were responsible for conducting laboratory tests including HIV
Antenatal mothers	In-depth interview	12	Purposive	These are recipients of antenatal care including HIV testing and were interviewed individually
Antenatal mothers	Focus group discussions	32 (4FGDs)	Purposive	These are recipients of antenatal care including HIV testing and they participated in focus group discussions

A group information session was held once with the women who had come for antenatal care at the antenatal clinics; those who were interested were then screened for eligibility and were asked to remain after antenatal services for informed consent and participation. Key informants were informed of the study physically and some through mobile phones. None of the participants who were approached refused participation

Data collection

Quantitative approach: retrospective antenatal register review

A checklist in English language that depicted elements of the antenatal register was used to collect data from the antenatal registers of June 2020 to July 2021 (file 1). The checklist was crafted to align with the specific objectives of the study, which focused on assessing the proportion of women receiving repeat HIV testing during antenatal care. To ensure the checklist’s face validity, experts in midwifery, possessing substantial experience and expertise in antenatal care, critically reviewed the checklist’s content to assess its alignment with the intended measurement goals. This iterative process of revision helped enhance the checklist’s clarity, relevance, and effectiveness in measuring the predetermined parameters related to HIV testing among pregnant women during antenatal care. Before full-scale implementation, the revised checklist underwent a piloting phase at South Lunzu and Limbe health centers, facilities which had clients sharing similar characteristics with the study participants. The aim was to test the checklist’s practicality, comprehensibility, and feasibility in real-world settings. Insights gained from this pilot study facilitated further adjustments to refine the checklist, ensuring its suitability for capturing pertinent data accurately. To ensure reliability two trained midwives from the study sites were recruited to administer the final version of the checklist. This choice aimed to ensure reliability in data collection, as these professionals possessed the necessary clinical expertise and familiarity with antenatal care practices and data collection. Their use of the checklist helped maintain consistency and accuracy in recording information from the antenatal registers as the checking of the original data was against the set standard presented through the checklist.

Qualitative approach

Data were collected through in-depth and focus group discussions with pregnant women who had received antenatal services and key informant interviews with healthcare workers who provide antenatal care to the pregnant women. Through interviews and discussions, nuanced emotions, decision-making processes, and contextual insights were unveiled. The guides for the interviews and focus group discussions were developed in English based on the study objectives and the concepts of the CFIR framework which guided the study. The study objectives assisted in formulating open ended questions for FGDs, IDIs and KIIs on magnitude of repeat HIV testing during the third trimester and factors which influenced its uptake, focusing on individual and health system factors (File 2, 3 and 4). Concepts of the framework which were intervention characteristics, individual characteristics, process for implementation and inner setting assisted in formulating probes which helped in capturing rich information on factors associated with uptake of repeat HIV testing among women in the third trimester. The in-depth interviews and discussion guides were translated from English language into local language, Chichewa by experts in both English and Chichewa languages to allow participants who were not familiar with English express themselves freely during the in-depth interviews and discussions. The interview and discussion guides were piloted at Limbe and South Lunzu Health centers as the facilities had similar characteristics with the study sites.

Piloting of instruments help to identify vague questions, flow of questions, unacceptable language, duration of the interview and discussions [26]. Revisions were made on the question which sought information on how individual characteristics would influence uptake of repeat HIV testing during late pregnancy by adding a probe about nature of the HIV testing. The revised piloted guides (file 2,3 and 4) were used to correct data by two trained research assistants who had strong background in qualitative research and knowledge of antenatal services after obtaining consent. The interviews and focus group discussions were conducted in private places. We triangulated the methods of data collection by using FGDs, IDIs and KIIs to achieve a comprehensive understanding of the phenomena, repeat HIV testing during pregnancy [26] Data was captured using digital audio recorder and field summaries which captured participants’ behaviors which could not be captured by the recorders. After each interview and discussion, the data collectors summarized key findings and shared them with the participants as a form of member checking [29]. Each study participant participated in interviews and focus group discussions once. Data collection was conducted from November 2021 to April 2022 and there were no repeat interviews nor discussions.

In-depth interviews and focus group discussions

Participants for in-depth interviews were sampled from the women who participated in the FGDs, and variations such as age, education, gestational age, and parity were observed. Conducting IDIs after participating in FGDs enabled participants to reflect more on their personal experiences. Furthermore, IDIs allow participants who might not be comfortable to express themselves in a group to feel more at ease to express their views and opinions during the individual interviews [26]. We interviewed the women after receiving antenatal care to allow them to be focused during the interviews. All participants were identified with numbers and focus group participants were advised to identify themselves with the given number before contributing during the discussions. Interviews took 35 to 45 min while FGDs took 50 to 85 min.

Key informant interviews

Key informant interviews were conducted in English language at the convenient time for the key Informants to avoid disturbing their work. The interview guide for the key informants further included areas on guidelines concerning repeat HIV testing and implementation of repeat HIV testing intervention focusing on their readiness to conduct repeat HIV testing and the process (file 3). Each KII took 35 to 45 min.

Trustworthiness of qualitative data

Piloting of the research instruments, using the same interview and discussion guides, prolonged immersion of the researchers (MC and MK) by reading the transcripts several times, member check after each interview and focus group discussion and inclusion of direct quotes in the results section assured credibility and dependability [32–34] Conformability was achieved by data triangulation through source and methods as information collected from multiple sources and methods help in confirming emerging issues [35]. Variations which were observed during recruitment procedures facilitated transferability of the study as views came from individuals with a variety of experiences. Additionally, the study has provided detailed background information to establish study context and detailed methodology to ensure transferability as well [32] .

Quantitative and qualitative data management

Quantitative and qualitative data were kept in a lockable cupboard and in a computer protected with password at the principal investigator’s office and the data were accessible to researchers only.

Quantitative data analysis

Quantitative data were entered in a computer using Microsoft excel 2010 and it was a single blinded data entry. The data were revised and cleaned to achieve completeness. The excel sheet was then imported into STATA version 14 for descriptive analysis where frequencies were tabulated. Frequency distributions were run to check for data entry errors (missing/unrecognized values and codes). Mean ages with standard deviations as the numerical representation of age was presented and categorical variables for gravidity, parity, and repeat HIV testing, were presented as counts for each category in both locations. The dependent variable was repeat HIV testing, and the independent variables were maternal characteristics (age, marital status, parity, and geographical location). Descriptive statistics was done to summarize participants’ information and was presented by tables. The presence of an association between the independent and outcome variable was checked by the fisher’s test. Additionally, each independent variable was fitted separately into bivariate logistic analysis to evaluate the degree of association with repeat HIV test. Variables with p-values < 0.05 in 95% CI were considered independent factor associated with uptake of repeat HIV testing in the third trimester. We could not consider multivariate associations because the registers did not capture adequate sociodemographic details that are a prerequisite for such analysis.

Qualitative data analysis

Qualitative data were transcribed verbatim prior to removing participants’ identifiers. Transcripts in Chichewa were translated into English and were verified by researchers (MK MC and ALNM). Another researcher fluent in both Chichewa and English helped translate to preserve the meaning of the content. The transcripts were managed manually, and the data were analyzed thematically guided by the six stages of thematic analysis according to Braun and Clarke which are familiarization with the data, generating initial codes which lead to codebook development, searching for themes, reviewing themes, defining, and naming themes and producing the report. The thematic analysis framework was chosen as it allowed the data to be coded deductively and inductively [33]. In addition, the four concepts from the CFIR framework namely intervention characteristic, inner setting, implementation process and individual characteristics guided the analysis of the data. The concepts under each CFIR domain assisted in generating initial a priori codes and generation of themes (Table 2).

Table 2.

Demographic characteristics of the study participants for qualitative approach

		Data source and type of participants
Variable	Characteristic	IDI	FGD	KII
No. of participants	Total	12	32	10
Age (years)	median (IQR)	25.5(23.5,29.25	25.5(22,29)	34(31,39.5)
Sex	Male			5
	Female	12	32	5
Marital status	Married	11
	Single	1
Religion	Christian	11	28	10
	Muslim	1	4
Occupation	Business	3	6
	Housewife	9	26
	Clinical officer			1
	HIV Diagnostic Focal Person			2
	Nurse Midwife Technician			2
	Nursing Officer			2
	PMTCT coordinator			1
	S Medical Officer			1
	Safe motherhood coordinator			1
Years of Service	median (IQR)			9(7.25,17)
Years in Current Position	median (IQR)			5(4,7.25)
Education	Primary	3	9(28.13)
	MSCE	9	23	1
	Diploma			5
	BSC			4
RHIV	7 m	2	2
	Nil	9	29
	Prev	1	1
Visit	median (IQR)	3.5(3,4)	4(3,4.5)
Parity	median (IQR)	2(1,3)	1.5(1,3)
Gravida	median (IQR)	3(2,4.25)	3(2,4)

The researchers (MC and MK) read all the transcripts against the recorded data several times to familiarize themselves with the data. Significant issues basing on the study objectives, the conceptual framework of CFIR which guided the study, including emerging issues were noted. One transcript was selected randomly for inductive and deductive coding by MC to generate initial codes. The stage of searching for themes was achieved by allowing the co-investigators (ALNM and MK) and an independent researcher who was not part of the research team review the transcript which was coded by MC after they had coded a clean copy of the same. From there an agreement was made on the codebook to be used for indexing the rest of the transcripts (File 5). Furthermore, the codebook was continuously updated with emerging codes from the data. The coded data were categorized based on the similarities, recurrence, and differences across the data set to create themes. The first author (MC) checked the themes against the recorded data to establish a coherent pattern and fitting of the data into the themes identified. The process was done to review, define and name themes which were presented as results after the verification process. The report highlighted one overarching theme which had subthemes and categories.

Results

Quantitative data

We enrolled 369 participants and of these, 302 (81.8%) were from Ndirande. The participants’ ages ranged from 16 to 42 years. Most participants (53.9%) fell into the 16–24 age bracket. Additionally, 238 (64.5%) participants were experiencing their second pregnancy, and 178 (42.8%) had given birth at most twice (8.13%) underwent a repeat HTC in the third trimester across both facilities. Out of these 30 participants receiving a repeat HTC in the third trimester, 20 (29.85%) were from Lirangwe health center, while 10 (3.31%) were from Ndirande (Table 1).

Association between antenatal women characteristics and repeat HTC

The adjusted analysis indicated that among antenatal women aged 25–34, the likelihood of receiving a repeat HTC was 1.38 times higher (95% CI: 0.45–4.28) compared to those in the 16–24 age group. Conversely, women aged ≥ 35 years showed lower odds of having a repeat HTC compared to those aged 16–24, with an OR = 0.43 (95% CI: 0.05–3.86) (Table 3). Statistically significant differences in repeat HTC were observed only among pregnant women aged 35 and above.

Table 3.

Summary of sample demographics

Characteristics	Lirangwe	Ndirande	Totals
Age
16–24	34	165	199
25–34	22	120	142
>=35	11	17	28
Mean age	24.08	23.99	24.8
+/-Std dev	5.88	5.67	5.75
Gravidity
1–2	46	192	238
3–4	18	93	111
> 5	3	16	19
Parity
0–2	41	137	198
3–4	25	31	56
> 5	1	4	5
Repeat HTC
Unknown	47	292	339
Done	20	10	30

Similarly, the adjusted odds ratio for receiving a repeat HTC among antenatal women with gravidity 3–4 was 0.78 (CI 0.22–2.72) compared to those with gravidity 1–2. Furthermore, for women with gravidity five and above, the adjusted odds ratio was 2.46 (CI 0.25–24.23) (Table 3). No statistically significant differences in repeat HTC were identified across categories of gravidity among antenatal women.

Likewise, the adjusted odds ratio for receiving a repeat HTC among antenatal women with parity 3 to over 5 was 1.44 (CI 0.30–6.98). Additionally, the adjusted odds ratio for receiving a repeat HTC at Ndirande health center was 0.08 (CI 0.03–0.18) compared to Lirangwe health center.

Qualitative results

We conducted 4 focus group discussions with 32 antenatal women and 12 in-depth interviews with antenatal women. The ages of the participants for FGD and IDI ranged from 18 to 48 years old, and majority were married. Out of the 32 participants 20 of them had attempted secondary education and their parity ranged from 0 to 6.

We interviewed 10 key informants and of these six were nurse/midwives two clinicians and two HIV diagnostic focal persons. Out of the six nurse/midwives, four were registered nurse midwives. The two clinicians were in charges of the facilities. Out of the 10 key informants, four had bachelor’s degree and their years of experience ranged from two years to 19 years. The demographic characteristics of the antenatal women and key informants are presented in Table 4.

Table 4.

Association between antenatal women characteristics and repeat HTC

	Repeat HTC		Unadjusted OR (95% CI)	Adjusted OR (95% CI)
Variable	Yes	No
	N (%)	N (%)
Age
16–24	16 (8.08)	182 (91.92)	Reference	Reference
25–34	12 (8.39)	131(91.61)	1.04 [0.48–2.28]	1.38 [0.45–4.28]
>=35	2 (7.14)	26 (92.86)	0.88 [0.19–4.02]	0.43 [0.05–3.86]
Gravidity
1–2	18 (7.59)	291 (92.41)	Reference	Reference
3–4	8 (7.08)	105 (92.92)	0.97 [0.39–2.20]	0.78[0.22–2.72]
>=5	4 (21.08)	15 (78.95)	3.24 [0.97–10.80]	2.46 [0.25–24.23]
Parity
0–2	23(76.67)	284 (83.78)	Reference	Reference
3->5	7(23.33)	55 (16.22)	1.57[0.64–3.84]	1.44 [0.30–6.98]
Facility
Lirangwe	20 (29.85)	47(70.14)	Reference	Reference
Ndirande	10 (3.31)	292(96.69)	0.81 [0.04–0.18]	0.08[ 0.03–0.18]

One overarching theme; determinants of repeat HIV testing in the third trimester which had sub themes; barriers and facilitators of repeat HIV testing in the third trimester was developed. The subthemes were categorized basing on the components of the CFIR conceptual framework which guided the study (see Fig. 1).

Fig. 1.

Determinants of the uptake of repeat HIV testing during pregnancy

Determinants of the uptake of repeat HIV testing during pregnancy

The determinants of repeat HIV testing in the third trimester had two subthemes: barriers and motivators for the uptake of repeat HIV testing in the third (Fig. 1).

Barriers for uptake of repeat HIV testing in the third trimester

Individual level barriers

Unfamiliarity with the intervention

Healthcare workers and women from both facilities explained that HIV retesting was not encouraged by health workers. The health workers and participants from both in-depth interviews and focus group discussions from both facilities stated that repeat HIV testing was not emphasized during the usual health talks which are used to motivate women to follow health practices during perinatal period. Instead, health talks emphasize on birth preparedness, immunization and initial HIV testing which made women unaware of the service which appeared to be optional ultimately hindering its uptake.

“Pregnant women would like to receive repeat HIV test, but doctors do not encourage us to have the test and when doctors give information, repeat HIV testing is not included… there is no leader to direct us.” IDIO3 Ndirande.

“Because the women are not given information about repeat HIV testing, and they are only informed about initial testing so for them to go for repeat HIV testing is difficult.” Midwife1 Ndirande.

“This is my fifth time, but I have never heard them say ‘for those women who were already tested, they should go for blood testing again’ no, I have never heard.” IDIU4 Lirangwe

In both health facilities some women were aware of repeat HIV testing during the third trimester as they had heard it from friends and radio. However, they felt that it was not their responsibility to demand for such a service rather it was the duty of health care providers to reinforce the implementation of repeat HIV testing by reminding women who had come for subsequent antenatal care to receive the repeat test.

“Some women have the knowledge about the repeat HIV testing which they got from radio, friends …. but they debate to say if the nurse is not saying anything about repeat HIV testing, should I go for it? …because we cannot command them, we have no power to demand the repeat HIV test.” IDIO 2 Lirangwe

Fear

Participants from FGDs, in-depth interviews and key informants from both study sites felt that most women had no drive to receive repeat HIV testing because of fear of the consequences following a positive HIV result which could lead to psychosocial problems such as stigma, loss of marriage and anxiety.

A health care worker narrated what women say.

Why should I get tested for the second time? if found positive then I will die together with the baby, should I worry about the virus and should I also worry about the birth of the baby? … so it’s better I should not get tested and I stay ignorantly.” KI midwife 3 Ndirande

“They are afraid that if they are found HIV positive that would be the end of their marriage; so they opt not to chase their husbands away by getting retested.” IDIO 5 Lirangwe.

A healthcare worker narrated that COVID-19 pandemic affected the uptake of repeat HIV testing as women shunned antenatal services due to restrictive measures which were put in the facilities and fear to contract COVID 19 infection.

“…the challenge we experienced of repeat blood testing during covid pandemic was that women were deciding not to go for blood test because of fear …wherever you go, they have already set up to give you COVID-19 related things. So that’s the time we encountered a bit resistance.” KI midwife 2 Lirangwe

Perceived low risk

Participants from Lirangwe in the age bracket of 26 years and above felt that the HIV negative status from the initial testing made women feel that they were safe and that the negative HIV status remains forever. Furthermore, participants reiterated that that being single discouraged women to go for repeat HIV testing because they felt that they were free from HIV infection since they had no partner who could bring them the HIV infection.

“People thought that because they were tested the first time then there is no need to get tested the second time if anything results from the first test remain.” IDIO 2 Lirangwe

…. So, many of them who are not married say that ‘I don’t have a husband, and I don’t see the reason why I should go for blood test again …. I had already tested that first time that means the status is still the same till now.’’ KI midwife 1 Lirangwe

Discontinuation of antenatal care attendance

Women from both facilities expressed that some women after initial visit stop coming for antenatal services as they felt that the initial visit is enough since it is like a passport which can enable them to receive care during the perinatal period without problems. Healthcare workers from both Ndirande and Lirangwe and participants in IDIs from Lirangwe stated that transport costs disabled pregnant women to continue accessing antenatal care.

“When they come to attend antenatal clinic during initial visit and their results from HIV test are negative, some women never come back, …they can go to delivery room freely, so they just wait for delivery at home.” FGDO 8 Ndirande

“They might be willing to do so but because of lack of transport money might make them not to get the test again.” IDIO 1 Lirangwe

Delay in initiating and reporting for antenatal services

Women and health care workers from facilities explained that a delay in antenatal booking and delay in reporting to the facility for antenatal care deter pregnant women from receiving repeat HIV testing in the third trimester. women who start antenatal care towards the end of second trimester or in third trimester may not fit in the timelines for repeat HIV testing during pregnancy.

“Sometimes you start antenatal very late may be at 7 or 8 months and in that case, it is difficult to have two HIV tests within that short period.” IDIO 6 Lirangwe

A delay in reporting to the clinic entails that a woman misses some aspects of antenatal care services such as antenatal health education which is informative on the procedures and set of services that a woman is expected to access. In addition, a delay in reporting to the clinic led to women finding health providers on recess which made the women to return home without HIV retesting.

“Because we promote women coming early to receive health education…. so, if they are late when they are assessed and found to have no complications they are told to go back and come another day so that they can attend the health education with others…that may make them miss retesting.” KI midwife 3 Lirangwe.

“Because we come late, so when we go there the counsellor would say ‘this is time for lunch’, she closes the office and off she goes, that means we will be waiting, or we will just leave with without doing HIV retesting.” FGDU 7 Lirangwe.

“Sometimes HCT providers come late, around 9, so there are about 50 or 60 women…., it takes. very long….so those things can make women to say ‘aah, I was already tested during initial visit, they should not waste my time let me go home.” KI midwife 2 Ndirande

“Sometimes we come here very early, and we do everything, but we must wait for the people who do the HIV tests to come. They come very late, and you cannot wait just to be tested again for HIV.” FGDU 3 Lirangwe.

Inner setting factors

Inadequate resources

Participants reported that sometimes the two facilities have one midwife and one HCT provider in each facility which is inadequate as compared to the number of women reporting for subsequent antenatal care in both facilities. This lack of human resources affects provision of services and result in long periods of waiting for women which is a deterrent for accessing a repeat HIV testing.

That one [inadequate personnel] is a very big problem which discourages women from accessing a repeat HIV test because sometimes there is only one person doing the test and there are so many women who need to be retested, and it takes a long time. IDIO5 Lirangwe

“Some women are missed and not offered a repeat HIV test secondary to a shortage of staff, especially during subsequent visits, which usually have an increased workload for the limited health personnel present due to the higher volume of women attending those visits.” KI midwife 1 Ndirande

“There can be one health provider (HCT provider) with several people wanting to test, so when women see that there’s a large number of people and it’s taking time, they give up waiting and return home without retesting.” IDIO 6 Ndirande

Healthcare workers from both facilities expressed that lack of test kits impeded uptake of repeat HIV testing among antenatal women because they would refrain from offering HIV services routinely or may defer time points for offering a repeat HIV test among maternity clients A healthcare worker expressed that when test kits are limited in stock, they prioritize high risk clients and repeat HIV testing among pregnant women is often sidelined.

“So, when the test kits are few and we are having stock outs we halt routine HIV tests so we do it on people who really need the test that might be on high risk for example those with recurrent STIs, so we missed a lot of women for repeat test.” KI Clinician Ndirande

“But I remember there was a time at the VCT they had ran out of test kits and repeat tests were not done …… So, they (HCT providers) preferred to repeat the HIV test after the women had delivered.” KI midwife 3 Lirangwe

The intervention characteristics

Discomfort with HIV testing procedure

Healthcare workers from Ndirande narrated that during initial HIV testing, a tiny sample of blood is collected from a finger prick for rapid HIV testing. The invasive nature of the finger prick for obtaining a sample brings some discomfort which some women may not want to go through again, hence avoiding repeat HIV testing.

“But majority of women ask “should they prick me again when I am negative…… then test me again in third trimester for what? Because I am already negative for now, so we miss them just like that….” KI HTC provider Ndirande

“Because of the blood sample collected and the needle pricks, some women scare their friends that if you go to the facility they prick and take such an amount of blood, maybe those kinds of testimonies deter women to come for repeat test.” KI HCT provider Ndirande

Preterm birth

Older participants from FGDs in Lirangwe and younger participants from focus group discussions in Ndirande expressed that women may miss repeat HIV test because of premature childbirth which may occur anytime during the third trimester, which is the expected time for repeat HIV test.

“The reason for not taking a repeat test is that you could deliver maybe like in the eighth or seventh month, like that one with the baby, she said that she was supposed to get retested this month and it has happened that today she is with a baby, you see.”FGDO 7 Lirangwe.

Implementation process

Clinic operations

Healthcare workers reported that in most instances the appointment days for subsequent antenatal care visits and repeat HIV test are not aligned in both facilities since the repeat test is any day in the third trimester. This lack of synchronization of dates translates into some women being given two separate dates for appointments, one for subsequent antenatal care and the other for repeat HIV testing. In such cases women would prioritize and prefer the subsequent antenatal care contact.

“I believe that sometimes the dates for subsequent antenatal care and repeat HIV testing are different …. majority of the women stick to the date given for subsequent antenatal care hence missing the repeat test.” KI HCT provider Ndirande.

Furthermore, it was noted that HCT services and other antenatal care services are offered at two separate places in both facilities. In addition, in both facilities women are referred for repeat HIV testing after they have received all the antenatal care, and the repeat test is the last thing unlike initial HIV testing which is done before the women are done physical assessments. Due to this arrangement some women just go back home instead of going for the repeat test.

“We are missing some women; we could talk with them properly and they would give their consent ‘Ye, I will go’ but the process from there and going to the other place for retesting, we don’t know what happens in between from the maternity to blood testing place… if we were in one building, it’s easier to make a follow up for that woman.” KI midwife 1 Lirangwe.

“For the repeat HIV test, women first receive their antenatal care and then are refered for testing so some do not come … unlike the initial test, HIV testing is done before other antenatal care activities therefore women have no choice but go for the test.” KI HCT provider Lirangwe

Women and healthcare workers reported that HCT providers come to antenatal clinic only on days for initial antenatal care visit and are not available on the days women report for subsequent care at the antenatal clinic. Therefore, women who may need repeat HIV test were referred to have it at the outpatient department which was not conducive for pregnant women.

“They are available once at the first antenatal visit on Monday and Wednesday …. today is Thursday and there is no HIV testing staff this is also what makes a woman not to have second HIV test.” FGDO2 Ndirande

“So, when they go there for repeat blood test on Thursday at the outpatient department (OPD) there were many people, so they will go back without the test.” KI midwife Ndirande

Motivators to conduct repeat HIV testing

Individual factors

HIV Status confirmation

Participants from in-depth interviews and focus group discussions felt that being in heterosexual marriage was associated with risk for HIV infection for the women due to extra marital relationships men may have. Therefore, repeat HIV test was a need for them to know their HIV status and depending on the outcome to start treatment and lead a health life. Furthermore, participants expressed that frequent illnesses could indicate exposure to HIV infection hence the need for repeat HIV testing to confirm one’s previous negative HIV status.

“Being married women with the first test you doubt the results, you ask yourself that is it really true that am HIV negative or not? when you get tested again that’s when you are sure that you body is fine.” FGDU 5 Lirangwe

“Sometimes if you are suspicious about yourself because you are frequently sick, at times because of how your husband is moving, you are scared that you feel like ‘let me go and get tested again so that I should know and get treated otherwise you cannot come for retesting when you are just fine.” FGDO4 Ndirande

Prospects of having an HIV uninfected baby and early initiation of antiretroviral therapy

Participants stated that the need for a healthy baby and opportunities for antiretroviral therapy in case of HIV infection made them go for repeat HIV testing. Participants were of the view that initial test is not enough because after the initial test, the women continue to have sex with their male partners and in case of unfaithful partner, women are likely to be exposed to HIV infection which can be transmitted to the unborn baby. Therefore, conducting repeat HIV testing confirms their sero negative status or if infected they can receive treatment which can prevent mother to child HIV transmission.

“The factors that can facilitate me as a woman, to go for repeat HIV test is that I should know my status and if there is a problem with my status the doctor should deal with it quickly so that the baby should not be affected.” FGDU1 Lirangwe.

“The other thing that promote an individual and say let me go for blood testing again … the issue, is to know my status, and if I am infected with the virus my baby is required to be born healthy, without the virus. FDDO 5 Ndirande

Sometimes what can encourage a woman to go for an HIV test is the way she is feeling in herbody. Maybe she is becoming sick more often or maybe the husband is being promiscuous or sometimes when he falls sick often.”IDIO 1 Ndirande

Participants reiterated that in matrilineal societies, where the responsibility of childcare heavily lies on the woman, women would be compelled to know the status of the baby to avoid bearing the burden that comes with raising a baby who is HIV infected. The quest to have an HIV uninfected baby motivates a woman to seek successive HIV tests.

“In some areas when marriage ends the children become the responsibility of the man, unlike here the children belong to the woman… if a woman bears a child that is HIV Infected, she will be the one to carry most of the burden so that forces the woman to go for retest to check her status.” IDIO2 Lirangwe.

Implementation process

Conducive environment

Participants from both facilities reported that cleanliness of the clinic, privacy, good reception, and the counselling which they receive at the HCT sessions were drivers for them to come back for repeat HIV testing during pregnancy.

“So, because of that privacy and confidentially it really encourages us to come back for blood test because that person would not expose us.” FGDO2 Lirangwe

“At the HCT site, testing kits are clean and when you are being given the results of your test, they uphold privacy, and they sometimes offer you advice and that really motivates me to come back.” IDIO2 Ndirande.

Discussion

Our study on the magnitude of repeat HIV testing in the third trimester and its associated factors found that 8.1% of pregnant women received repeat HIV testing in the third trimester. The uptake of repeat HIV testing was associated with age and parity. The barriers to receiving a repeat HIV test included unfamiliarity with the intervention, perceived low risk of acquiring HIV, fear, delay in initiating antenatal care, intervention characteristics, clinic operations and inadequate resources. On the other hand, motivators included a need to have a healthy baby, conducive environment, and HIV status confirmation.

We found a lower proportion of women (8.1%) being retested for HIV during pregnancy than previously reported in Kenya (32%), Zambia (24.6%), South Africa (62%) and United States of America 28.4% [9, 20–22]. The differences in the prevalence of repeat HIV testing among countries could be related to the extent to which repeat HIV testing is implemented and rolled out in specific countries. Additionally, the differences in social demographics across the countries can also contribute to the variations on the prevalence rates of repeat HIV testing among pregnant women [1]. Specifically for Malawi, the low uptake of repeat HIV testing could arise from the low attendance of the successive antenatal visits by most pregnant women [36] which impedes the majority of women from receiving a repeat HIV test in the third trimester, which was also observed in Kenya [22]. Our findings differ with previous findings [37–39] in that more women from the rural facility received a repeat HIV test than those from the urban facility as reported. This difference could be explained by the lack of competing interests that people in the rural areas may have unlike the urban counterparts who have other commitments to meet such as work obligations. Furthermore, the volume of work in rural health facilities could be less than in the urban one due to disparities in catchment area population which made health providers encourage women to have repeat test. In our study the catchment population for the urban and rural facilities were 150,096 and 33,019 respectively with 35 health care providers in the urban facility and 14 health care workers in the rural facility. In support of the foregoing, previous studies have reported perceptions of extra workload by health care providers as a factor that discourages the implementation of repeat HIV testing in the third trimester [19, 21, 22, 40].

Our findings are that older age and higher parity were associated with increased uptake of repeat HIV testing remain congruent to findings from studies done in Uganda, Haiti, Malawi and Tanzania [6, 41–44]. This may be attributed to the fact that advanced age may lead to high parity which may enable women to have a greater exposure to information and knowledge about mother to child HIV transmission including benefits of repeat test. This could increase women’s motivation to be retested for HIV. In contrast other studies have indicated younger age as a determinant factor for uptake of HIV testing [44, 45]. This could be because young age is associated with engaging in risky sexual practices that could lead to HIV infection forcing them to know their HIV status [40, 41].

Unfamiliarity with the intervention secondary to a lack of sensitization about the need for it was reported as a barrier for the uptake of repeat HIV testing in the third trimester. The lack of emphasis by health care providers despite being oriented to the guidelines could be due to health care providers avoiding more responsibilities that come with offering of a repeat HIV test [19]. This finding corroborates with results from previous studies in Kenya that reported inadequate information on the significance of repeat testing among health workers and pregnant women as a deterrent for uptake of repeat HIV testing among pregnant women [19, 22, 45]. Cognizant that Provider initiated testing and counselling is a known strategy that increases uptake of HIV testing [38, 39] there is a need to train healthcare providers on their role in promoting awareness of the relevance of a repeat HIV test may enhance uptake of the test by pregnant women in the third trimester. Going forward, considerations may be undertaken to make repeat HIV testing in late pregnancy mandatory just like initial HIV testing during pregnancy for provider-initiated testing and counselling to be effective.

Although some women were aware of repeat HIV testing in the third trimester, they reported that it was not possible for them to demand for the service from health care providers. This resonates well with what studies have reported that negative attitude of health care providers displayed in disrespectful behaviors prevent women and their families from accessing health services [22, 46, 47]. Health systems should develop mechanisms to empower its clientele through awareness of the prevention of mother to child HIV transmission services available and clients’ rights as far as utilization and accessibility of such services is concerned. In the same vein, healthcare providers should be oriented to other models of care such as human centered design which provides room for recipients of care to demand services basing on their needs [48].

In our study inadequate resources such as health workers and test kits deterred women from accessing repeat HIV testing in the third trimester, as was reported in earlier studies as well [21, 22, 49]. Lack of health workers made the clinical operations to be unfavorable for pregnant women to access repeat HIV testing because it meant that they had to access the service from another department outside of the maternity department [3, 45, 50]. Clinic operations need to be well organized alongside with adequate health care workers to attract clients as these may prevent delays and stigma which is associated with low uptake of interventions such as HIV testing [22]. We propose that repeat HIV test during third trimester should be given prominence through provision of synchronized or integrated care [46]. This can be achieved by offering all subsequent antenatal care services including PMTCT under one roof, isolating one visit from the visits which are made in the third trimester to be a specific visit for repeat HIV testing in addition to the antenatal subsequent care [45]. In addition, task shifting might be employed to fill the gap of health providers by training and encouraging midwives to perform HIV testing alongside their regular duties [3, 18, 21].

Lack of test kits has also been reported as a hindrance for uptake of initial HIV testing in other studies [51–53]. Lack of test kits for repeat HIV testing could also have been fueled by the facilities priorities and rationing of resources which might have led to giving preference to initial HIV testing rather than repeat HIV testing during pregnancy [42]. Investing in resources to strengthen national stock buffering capacity and use of electronic ordering systems by institutions should be a priority [3]. Intervention characteristics such as needle pricks associated with blood draw was mentioned as one of the factors preventing women from demanding repeat HIV testing a similar finding in studies done elsewhere [7, 52, 53]. This is because rapid HIV testing which demands a finger prick to obtain sample for HIV testing is the main mode of HIV testing in antenatal clinics in Malawi [54]. Employing other innovative interventions such as oral HIV self-testing may be essential in improving uptake of repeat HIV testing as reported in other studies [53, 55, 56].

Our findings that a perceived low risk of being infected with HIV and fear of consequences following seropositive as individual barriers for repeat HIV testing have been reported in previous studies [3, 55, 57]. A perceived low risk may result from lack of knowledge on HIV issues as evidenced by the study participants in this study and other studies conducted elsewhere which have highlighted individual’s view that initial HIV negative status remains forever [50, 52]. In our study women were afraid of HIV positive result as it could lead to divorce and loss of source of their income which has also been reported by other studies [1, 50]. Fear of the outcome of repeat HIV is influenced by the level of knowledge of individuals and male partner support [58–60]. In the study the fear associated with repeat HIV testing may be associated with the fact that male partner involvement is not encouraged during repeat test as reported by some participants in our study. Literature has revealed that participation of male partner in PMTCT yield good health outcomes and improves uptake of HIV services including HIV testing [1, 52].

In the study, preterm births were a hindrance for uptake of repeat HIV testing, a factor which has not been reported in other studies in the region [20–23]. This factor may have been mentioned by the participants because preterm births are common in Malawi with a prevalence of 19.7% [58]. While causes of preterm births are multiple and complex, late antenatal booking may predispose women to preterm birth [59] .This is because the first antenatal care contact is an essential opportunity to assess the pregnancy and identify women who may need additional care and support [59, 60]. By adhering to the first contact interventions, midwives can identify and address potential risk factors earlier on, which can help to improve maternal and neonatal outcomes [37, 60]. In addition late antenatal booking contributes to inadequate antenatal contacts which, coupled with substandard care due to unavailability of essential equipment and human resource deprive pregnant women from receiving interventions which may assist in preventing pregnancy related complications such as preterm birth [60]. In Malawi only 24% of pregnant women initiate antenatal care in the first trimester while 50.6% attain four antenatal contacts [37, 60]. Shortage of nursing and midwifery personnel stands at 63%, which is far below the WHO recommendation of 1 per 175 people [61]. Therefore, promotion of early antenatal initiation among women through social and behavior change communication campaigns should be urgently employed. Furthermore, health facilities particularly antenatal clinics should have adequate personnel and supplies to enhance adherence of health care providers to the antenatal care standards [37, 59].These interventions are likely to prevent preterm births. Strengthening antenatal care by employing other models of prenatal care such as group antenatal care may also assist in reducing preterm births which impedes uptake of repeat HIV testing in the third trimester. Motivators for uptake of repeat HIV testing included HIV status confirmation, need for better outcome and conducive environment as reported elsewhere [22, 38, 39, 62]. Understanding these motivators may inform strategies to facilitate uptake of repeat HIV test among pregnant women. Furthermore, adherence to the repeat HIV testing will ultimately enhance HIV diagnosis and linkage of seroconverted women to antiretroviral treatment which will contribute to the eradication of pediatric HIV.

Conclusion

Strategies aimed at enhancing third trimester HIV retesting coverage and identifying women with new maternal HIV should aim at eliminating individual and health system barriers and promoting individual and health system related motivators for repeat HIV testing in the third trimester. Mothers, their families and health care workers are to receive information education and counselling on the benefits of repeat HIV testing later in pregnancy as it is key in increasing implementation of repeat HIV testing later in pregnancy. In addition, strengthening the clinic operations and improving availability of resources is vital in the implementation and uptake of repeat HIV testing among pregnant women.

Study strengths and limitations

The use of mixed method approach is a strength because it allowed triangulation of data collection methods and sources. In addition, the study was conducted in urban and rural communities which provided diverse information applicable in both settings. Our results need to be considered with the limitations inherent in a qualitative study where sample sizes are small and purposively selected which leads to gathering of specific views as such the results only transferable to similar settings. The use of retrospective registers also renders itself to having incomplete records however the use of a mixed method approach allowed for collection of more data to explain the phenomenon.

Abbreviations

CFIR

Consolidated framework for implementation research

COMREC

College of Medicine Research Ethics Committee

FGDs

Focus group discussions

FGDO

Focus group discussion above 25 years old

FGDU

Focus group discussion under 25 years old

HDAs

HIV diagnostic assistants

HTC

HIV testing and counselling

IDIs

In depth interviews

IDIO

In depth interviews above 25 years old

IDIU

In depth interviews under 25 years old

KIIs

Key informant interviews

MCTC

Mother-to-child-transmission

PMTCT

Prevention of mother to child HIV transmission

WHO

World Health Organization

Authors’ contributions

MC and MK designed the study. All authors contributed to the literature search. MK analyzed quantitative data while MC analyzed qualitative data. ALNM and VM provided technical guidance on data collection, interpretation, analysis and development of the study and manuscript.

Funding

Research reported in this publication was supported by the Fogarty International Center of the National Institutes of Health under Award Number D43 TW0010060-01. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.”

Data availability

The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.

Declarations

Ethics approval and consent to participate

The study was approved by the University of Malawi, College of Medicine Research and Ethics Committee (COMREC) P.08/21/3386. Blantyre District Health Office, which is responsible for the management of health services for the study sites provided institutional clearance. All the participants gave either written informed consent or witnessed consent with a thumb print if illiterate in the presence of an impartial witness as per approved guidelines of COMREC. Codes were used on the checklists and during interviews and focus group discussions as identifiers to achieve anonymity. The participants were assured that participation was voluntary and could withdraw any time and would still access antenatal care.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.