This quantitative study assessed the quality of Social Behaviour Change and Communication (SBCC) interventions in improving safe motherhood practices among adolescent mothers. A facility-based cross-sectional study was conducted from October 2024 to December 2024 in Ndola District, Copperbelt Province, Zambia.

Ndola District is an urban area with several public health facilities providing maternal and child health services, including antenatal care, delivery services, postnatal care, and safe motherhood interventions. The study was conducted in 24 urban health centers selected from a total of 54 eligible public health facilities in the district. These facilities were selected because they routinely provide comprehensive maternal and child health services and serve a high number of adolescent mothers.

The study population comprised adolescent mothers aged 15 - 19 years who were either pregnant or had delivered within the previous 12 months and were attending antenatal or postnatal services at the selected health facilities during the study period. All participants had been exposed to SBCC interventions delivered through routine maternal health services; therefore, the study focused on assessing variations in the quality of SBCC interventions rather than exposure status. Adolescent mothers who were severely ill, declined participation, or were not residents of Ndola District were excluded.

The sample size was determined using the formula for cross-sectional studies described by Lemeshow et al. [12]. A 95% confidence level, a 5% margin of error, and a conservative estimated proportion of 50% were applied, resulting in a minimum required sample size of 394 adolescent mothers. The conservative proportion was used due to limited prior evidence on the quality of SBCC interventions among adolescent mothers in the study setting.

A multi-stage sampling approach was employed. In the first stage, 24 health centres were purposively selected from the 54 eligible facilities based on their provision of comprehensive maternal and child health services, high adolescent client attendance, and suitability for data collection. In the second stage, simple random sampling was used to select eligible adolescent mothers attending antenatal and postnatal clinics at each selected facility. Eligibility was confirmed using clinic records, and participants were recruited after providing informed consent.

Quantitative data were collected using an interviewer-administered structured questionnaire designed to capture socio-demographic characteristics, safe motherhood practices, and the quality of SBCC interventions. Face-to-face interviews were conducted with adolescent mothers attending antenatal and postnatal clinics at the selected health facilities.

The questionnaire comprised three sections. Section A collected socio-demographic and obstetric characteristics, including age, marital status, educational level, parity, and distance to the health facility. Section B assessed safe motherhood practices, including timing and adequacy of antenatal care visits, birth preparedness, and place of delivery. Section C assessed the quality of SBCC interventions, including counselling received, sources of maternal health information, perceived comprehensiveness of SBCC messages, and self-reported knowledge gained.

Prior to the main study, the questionnaire was pilot tested among approximately 10% of the calculated sample size at a health facility not included in the final study sample. The pilot test assessed clarity, consistency, and contextual appropriateness of the tool. Necessary revisions were made before data collection.

The primary outcome variable was safe motherhood practice. This was assessed using a set of composite indicators reflecting key components of the maternal continuum of care, including antenatal care, delivery preparedness, postnatal care, family planning counselling, and access to maternal health services. Specific indicators included perceptions of the comprehensiveness of safe motherhood information received, improvement in knowledge through SBCC sessions, appropriateness of antenatal care (ANC) initiation timing, satisfaction with guidance received during the first ANC visit, adequacy of ANC visits attended, satisfaction with ANC services, clarity of birth preparedness information, confidence in delivery plans due to SBCC guidance, satisfaction with the place of delivery, perceived safety of the delivery environment, recognition of pregnancy complications through SBCC messages, satisfaction with care received for complications, satisfaction with postnatal care services, motivation to attend postnatal check-ups, clarity of family planning counselling, confidence in choosing a family planning method, accessibility of maternal health services, satisfaction with family planning services, and the ability of SBCC sessions to overcome barriers to accessing services.

These items were measured using a five-point Likert scale, with response options ranging from Strongly Disagree (1), Disagree (2), Not Applicable (3), Agree (4), and Strongly Agree (5). The “Not Applicable” option was included to accommodate respondents who had not yet experienced certain stages of the maternal care continuum, such as delivery or postnatal services.

For analysis, responses were aggregated to generate an overall safe motherhood score for each participant. The total score was converted into a percentage score by dividing the observed score by the maximum possible score for applicable items and multiplying by 100. Participants who attained 70% or above were categorized as practicing safe motherhood, while those who scored below 70% were classified as practicing unsafe motherhood.

The main independent variable was the quality of Social and Behavior Change Communication (SBCC) interventions. This was measured using a series of Likert-scale items assessing the clarity, relevance, cultural appropriateness, and effectiveness of SBCC messages delivered during antenatal and postnatal care. Indicators included clarity and understandability of SBCC messages, relevance of the information to respondents’ needs, opportunities for participation during sessions, ability to ask questions or provide feedback, adequacy of time allocated for SBCC sessions, regularity of sessions during ANC and PNC visits, use of a language understood by the respondent, respect for cultural beliefs, and the perceived influence of SBCC sessions on health behaviors, nutrition practices during pregnancy, recognition of danger signs, birth preparedness, postnatal care attendance, exclusive breastfeeding, and decision-making regarding family planning.

Like the safe motherhood variable, responses were aggregated to produce a composite SBCC quality score, which was then converted into a percentage. Respondents who scored 70% or higher were classified as having received adequate SBCC, while those scoring below 70% were categorized as having received inadequate SBCC. Other independent variables included age, parity, educational level, marital status, distance to the health facility, timing of antenatal care initiation, adequacy of antenatal visits, birth preparedness status, and place of delivery.

Data was entered into Microsoft Excel for coding and cleaning before being exported to the Statistical Package for Social Sciences (SPSS) version 28 for analysis. Descriptive statistics were used to summarize socio-demographic characteristics, safe motherhood practices, and the quality of SBCC interventions.

Chi-square tests and Fisher’s exact tests were used to examine associations between the quality of SBCC interventions and safe motherhood practices. Binary logistic regression analysis was conducted to assess the relationship between SBCC quality and safe motherhood outcomes while controlling for potential confounders. Statistical significance was set at p < 0.05 with a 95% confidence level.

Ethical approval was obtained from the University of Zambia Biomedical Research Ethics Committee (UNZABREC) under approval number 5166-2024. Permission to conduct the study was obtained from the National Health Research Authority and relevant health facility authorities. Participation was voluntary, and written informed consent was obtained from all participants. For participants under 18 years of age, assent and parental or guardian consent were obtained. Confidentiality and anonymity were maintained.

A total of 394 adolescent mothers aged 15 - 19 years participated in the study. The largest proportion of respondents was 19 years old (46.4%), followed by those aged 18 years (27.7%) and 17 years (17.0%). Smaller proportions were aged 16 years (7.6%) and 15 years (1.3%).

Regarding marital status, most respondents were married (69.5%), while 30.5% were single. In terms of educational attainment, half of the respondents (50.3%) had completed primary education, while 37.6% had secondary education. A smaller proportion (12.2%) had never attended school.

With respect to occupation, 42.1% of respondents were dependents, 30.7% were engaged in small-scale business, and 27.2% were housewives. Concerning living arrangements, slightly more than half of the respondents (50.5%) lived with their parents or guardians, while 31.2% lived with a partner or husband. Smaller proportions lived alone (9.4%) or with other relatives (8.9%).

Regarding reproductive history, most respondents (69.8%) had experienced one pregnancy, while 26.9% had experienced two pregnancies, and 3.3% reported three or more pregnancies. Nearly half of the respondents (47.0%) reported having one living child, whereas 39.8% had no living children, and 13.2% had two or more children.

In terms of access to health services, most respondents (62.2%) reported taking 30 - 59 minutes to reach the nearest health facility, while 27.4% reported travel times of less than 30 minutes, and 10.4% required between one and two hours to reach a health facility (Table 1).

Table 1. Sociodemographic characteristics (n = 394).

Safe motherhood practices were assessed across antenatal care, delivery, postnatal care, family planning, and access to maternal health services using Likert-scale items. Overall, high levels of agreement were reported across most indicators, including satisfaction with antenatal care services, birth preparedness information, delivery planning, and access to maternal health services.

After aggregation of scores, 61.2% (n = 241) of respondents were classified as practicing safe motherhood, while 38.8% (n = 153) were classified as practicing unsafe motherhood (Table 2).

Table 2. Safe motherhood practices (n = 394).

The results in Table 3 show the perceived quality of Social and Behaviour Change Communication (SBCC) interventions among adolescent mothers. Out of the total 394 respondents, the majority 345 (87.6%) perceived the SBCC interventions as adequate, while a smaller proportion 49 (12.4%) perceived them as inadequate.

Table 3. Perceived Quality of SBCC Interventions (n = 394).

The association between sociodemographic characteristics and safe motherhood practices was assessed using the Chi-square test. Fisher’s exact test was applied where expected cell counts were less than five as shown in Table 4. The analysis showed that marital status, level of education, occupation, living arrangements, number of living children, and time taken to reach the health facility were significantly associated with safe motherhood practices (p < 0.05).

Married respondents reported a higher proportion of safe motherhood practices (76.7%) compared with single respondents (54.4%). Education level was also associated with safe motherhood status, with respondents who had never attended school demonstrating the highest proportion of safe practices (79.2%), followed by those with secondary education (63.5%), while respondents with primary education reported lower safe practices (55.1%).

Occupation showed a significant association with safe motherhood practices. Housewives had the highest proportion of safe practices (74.8%), compared with businesswomen (56.2%) and dependents (56.0%).

Living arrangements also demonstrated a strong association with safe motherhood practices. Respondents living with partners or husbands reported higher safe practices (79.7%), followed by those living alone (81.1%), while respondents living with parents or guardians reported lower safe practices (48.7%).

The number of living children was significantly associated with safe motherhood practices. Respondents with one or two living children reported higher safe practices (76.8% and 76.9%), compared with those who had no living children (37.6%).

Distance to the health facility was another significant factor. Respondents who reported taking 30 - 59 minutes to reach the health facility showed higher safe motherhood practices (67.3%), compared with those living within 30 minutes (47.2%).

However, age and number of pregnancies were not significantly associated with safe motherhood practices.

The analysis also examined the relationship between SBCC adequacy and safe motherhood practices. A statistically significant association was observed between the two variables. Respondents who reported adequate SBCC exposure demonstrated substantially higher safe motherhood practices (67.0%), compared with those who reported inadequate SBCC exposure (20.4%). Conversely, most respondents who reported inadequate SBCC exposure (79.6%) were classified as practicing unsafe motherhood behaviors.

These findings indicate that adequate SBCC interventions play an important role in promoting safe motherhood practices among adolescent mothers.

Table 4. Factors associated with safe motherhood (Chi-Square) (n = 394).

*Statistically significant at p < 0.05.

A binary logistic regression analysis was conducted to identify factors associated with safe motherhood practices among respondents. First, bivariate binary logistic regression analysis was performed to examine the association between each independent variable and safe motherhood practices. The results were presented as Crude Odds Ratios (COR) with 95% Confidence Intervals (CI).

Variables that were statistically significant in the bivariate analysis were then included in a multivariable binary logistic regression model to control for potential confounding effects. The results of this model were presented as Adjusted Odds Ratios (AOR) with 95% Confidence Intervals (CI) as indicated in Table 5.

MultivariableAnalysisResults

After adjusting for other variables in the model, living arrangement, number of pregnancies, number of children alive, and SBCC exposure remained statistically significant predictors of safe motherhood practices. Respondents living with a partner or husband were more likely to practice safe motherhood compared with the reference group (AOR = 4.29, 95% CI: 1.02 - 18.03, p = 0.047). Similarly, respondents living alone also had higher odds of practicing safe motherhood (AOR = 3.18, 95% CI: 1.02 - 9.95, p = 0.046).

The number of pregnancies was also significantly associated with safe motherhood practices. Respondents who had two pregnancies had lower odds of practicing safe motherhood compared with those with one pregnancy (AOR = 0.17, 95% CI: 0.07 - 0.41, p < 0.001). Likewise, respondents with three pregnancies had lower odds of safe motherhood practices (AOR = 0.05, 95% CI: 0.01 - 0.24, p < 0.001).

The number of children alive showed a strong positive association with safe motherhood practices. Respondents who had one living child had significantly higher odds of practicing safe motherhood compared with those with no living children (AOR = 12.51, 95% CI: 5.85 - 26.74, p < 0.001). Similarly, respondents with two living children had higher odds of practicing safe motherhood (AOR = 35.29, 95% CI: 9.59 - 129.83, p < 0.001).

Exposure to Social and Behavior Change Communication (SBCC) was the strongest predictor of safe motherhood practices. Respondents who reported adequate SBCC exposure were significantly more likely to practice safe motherhood compared with those with inadequate exposure (AOR = 19.15, 95% CI: 7.25 - 50.59, p < 0.001).

However, marital status, education level, occupation, and travel time to the health facility were not statistically significant predictors after adjustment for other variables in the model (p > 0.05).

Table 5. Binary logistic regression (n = 394).

Note: COR = Crude Odds Ratio; AOR = Adjusted Odds Ratio; CI = Confidence Interval. Reference categories are indicated.

This study provides important insights into the socio-demographic characteristics of adolescent mothers and how these factors relate to safe motherhood practices and engagement with Social and Behaviour Change Communication (SBCC) interventions. The respondents were aged 15 - 19 years, with the majority being 19 years old, reflecting patterns widely documented in sub-Saharan Africa, where adolescent pregnancy remains common. Early motherhood in these contexts is often shaped by social norms, cultural expectations, and socioeconomic challenges that influence adolescents’ access to reproductive health services and maternal health outcomes [13][14].

Marital status was significantly associated with safe motherhood practices in the bivariate analysis. Married adolescents demonstrated a higher proportion of safe motherhood practices compared with single adolescents. Similar findings have been reported in studies conducted in Ghana and Iran, where marital status influenced adolescents’ access to reproductive health services and maternal care utilization [13][15]. Married adolescents may benefit from greater social and partner support during pregnancy, which can facilitate access to antenatal care and other maternal health services. However, marital status did not remain statistically significant after adjusting for other variables in the multivariable logistic regression model, suggesting that its influence may be mediated by other socioeconomic or household factors.

Education was also associated with safe motherhood practices in the bivariate analysis. Adolescents with higher levels of education demonstrated relatively better safe motherhood practices compared with those with lower educational attainment. Education is widely recognized as a key determinant of maternal health behaviours because it improves health literacy, enhances understanding of health information, and promotes utilization of maternal health services [16][17]. Adolescent who had higher education level were more likely to attend at least four ANC visits compared to those with no education, this was especially true in the urban areas. In addition, women with partners with higher education level were also more likely to have optimal ANC attendance [18]. However, in the multivariable analysis, education did not remain a statistically significant predictor after adjusting for other factors, indicating that structural and contextual influences may play a more dominant role in determining safe motherhood behaviours among adolescent mothers.

Occupational status also reflected the socioeconomic vulnerability of adolescent mothers in this study. A large proportion of respondents were dependents, with relatively fewer engaged in income-generating activities. This finding is consistent with studies conducted in Zambia and other parts of sub-Saharan Africa where adolescent motherhood frequently disrupts education and limits economic opportunities [19]. Although occupation was significantly associated with safe motherhood practices in the bivariate analysis, this association did not remain significant after adjustment in the multivariable model.

Distance to the health facility was another factor associated with safe motherhood practices at the bivariate level. Respondents who reported moderate travel time to health facilities demonstrated higher levels of safe motherhood practices compared with those living closer to health facilities. Similar patterns have been reported in other studies examining maternal health service utilization in resource-limited settings [20][21]. However, this association did not remain statistically significant in the adjusted model, suggesting that other factors such as household support and exposure to health information may have a stronger influence on maternal health behaviours.

Overall, these findings suggest that socio-demographic characteristics may influence adolescent mothers’ engagement with maternal health services. However, when considered within a multivariable framework, their effects appear to be mediated by other contextual factors.

One of the most important findings of this study was the strong association between the perceived adequacy of Social and Behaviour Change Communication (SBCC) interventions and safe motherhood practices among adolescent mothers. The majority of respondents perceived SBCC interventions as adequate, and adolescents who reported adequate SBCC exposure were significantly more likely to practice safe motherhood compared with those who reported inadequate SBCC exposure.

The multivariable logistic regression analysis further confirmed that SBCC exposure was the strongest predictor of safe motherhood practices in this study. Adolescents who reported adequate SBCC exposure had substantially higher odds of practicing safe motherhood compared with those who reported inadequate exposure. This finding highlights the critical role of communication-based interventions in influencing maternal health behaviours among adolescent mothers.

SBCC interventions aim to improve health outcomes by increasing knowledge, influencing attitudes, and promoting positive behavioural practices through targeted communication strategies. Among adolescent mothers, effective SBCC interventions can enhance awareness of antenatal care, birth preparedness, skilled delivery, and postnatal care services. Evidence from previous studies indicates that well-designed SBCC programs significantly improve maternal health behaviours by empowering women with knowledge and encouraging positive health-seeking behaviours [22][23].

In addition, the effectiveness of SBCC interventions often depends on their cultural relevance and responsiveness to the needs of the target population. Adolescents are more likely to respond positively to health messages that are delivered in familiar language and reflect their social and cultural context [24]. Designing adolescent-friendly SBCC interventions that address the specific needs and challenges faced by adolescent mothers is therefore essential for improving maternal health outcomes.

This study identified several key factors associated with safe motherhood practices among adolescent mothers. In the multivariable logistic regression analysis, living arrangement, number of pregnancies, number of children alive, and SBCC exposure remained statistically significant predictors of safe motherhood practices.

Living arrangement emerged as an important determinant of safe motherhood behaviour. Adolescents living with partners or husbands had significantly higher odds of practicing safe motherhood compared with those in the reference group. This finding suggests that partner support may play an important role in facilitating access to maternal health services and encouraging positive health behaviours during pregnancy. Interestingly, adolescents living alone also demonstrated higher odds of safe motherhood practices. This may reflect greater autonomy in decision-making and increased ability to independently seek maternal health services.

The number of pregnancies was also significantly associated with safe motherhood practices in the adjusted model. Adolescents with multiple pregnancies had lower odds of practicing safe motherhood compared with those experiencing their first pregnancy. This finding may reflect the complex social and economic challenges associated with repeated adolescent pregnancies, which can limit access to health services and increase vulnerability.

The number of living children showed a strong positive association with safe motherhood practices. Adolescents who had one or more living children were significantly more likely to practice safe motherhood compared with those with no living children. This may reflect increased maternal experience and familiarity with maternal health services among adolescents who have previously given birth.

Importantly, exposure to SBCC interventions remained the most influential factor associated with safe motherhood practices. Adolescents who reported adequate SBCC exposure were substantially more likely to practice safe motherhood compared with those reporting inadequate SBCC exposure. This finding underscores the importance of strengthening SBCC programs as a strategy for improving maternal health behaviours among adolescent mothers.