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Pregnancy among women of advanced maternal age (those 35 years or older) or among women of high parity (those having had 5 or more births) is linked to maternal and infant mortality. Yet little is known about the drivers of these pregnancies as they are often neglected in existing family planning and reproductive health programs. To better understand the context in which advanced maternal age and high parity pregnancies occur and the acceptability of discussing associated pregnancy risks, the Health Communication Capacity Collaborative (HC3) conducted formative qualitative research between January and March 2015 on the perception and determinants of such pregnancies in rural and urban areas of Niger and Togo. We supplemented this research with secondary analyses of data from Demographic and Health Surveys and a 2014 Niger survey. Our formative research showed that urban Togolese participants demonstrated more knowledge about advanced maternal age and high parity pregnancy risks than did participants in Niger as a whole. We found that such pregnancies were generally seen as part of reproductive norms in situations where fertility rates remain exceptionally high, especially in Niger. Social, gender, and religious norms, including competition between co-wives, also drove women into high parity and advanced maternal age situations, particularly in Niger, highlighting the need to bring men and community and religious leaders into family planning conversations to increase acceptance. The study also provided important insights needed to address these high-risk pregnancies through culturally appropriate health communication interventions. A main insight was that providers often had incomplete information about advanced maternal age and high parity pregnancies and lacked communication skills, protocols, and tools to appropriately discuss such pregnancy risks with clients. HC3 used these and additional findings to create an Implementation Kit (I-Kit) for family planning and maternal and child health program managers with guidance and tangible tools to address advanced maternal age and high parity pregnancy through social and behavior change communication. The I-Kit includes health communication materials to engage women, men, decision makers, communities, health care providers, journalists, and others. In 2016 and 2017, one organization each in Niger and Togo piloted the I-Kit, integrated selected I-Kit tools into their unique programs, and documented their experiences. Both organizations credited the I-Kit with expanding the scope of their programs to now address advanced maternal age and high parity pregnancy and provided concrete suggestions for adapting the materials according to activity and intended audience.

High-Risk Advanced Maternal Age and High Parity Pregnancy: Tackling a Neglected Need Through Formative Research and Action