# Pregnant and breastfeeding women’s intention to follow medical advice before antibiotic use: a comparative pilot analysis using the theory of planned behavior in Mahajanga, Madagascar

## TL;DR

This study explores how pregnant and breastfeeding women in Madagascar decide whether to seek medical advice before taking antibiotics, finding that social norms in cities and access issues in rural areas are key factors.

## Contribution

The study applies the theory of planned behavior to understand antibiotic use intentions among pregnant and breastfeeding women in Madagascar, highlighting urban-rural differences.

## Key findings

- In urban areas, social expectations (subjective norms) most strongly predict intention to seek medical advice.
- In rural areas, perceived behavioral control (access and self-efficacy) is the strongest predictor of intention.
- Obtaining antibiotics from official sources was linked to lower intention in rural areas.

## Abstract

Antibiotic misuse among pregnant and breastfeeding women is a critical public health challenge in low-resource settings. Individual attitudes, social expectations, and structural barriers shape women’s intentions to follow medical advice. Thus, this study investigates how attitudes, subjective norms, and perceived behavioral control shape pregnant and breastfeeding women’s intentions to seek medical advice prior to antibiotic use.

Using the theory of planned behavior (TPB), this mixed-methods study collected data from 115 women in the urban and rural districts of Mahajanga, Madagascar. Qualitative analysis explored statements and informational practices, whereas linear regressions, partial least squares regressions (PLS-R), and binary logistic regression (BLR) identified determinants of intention.

Overall, 79.1% of women expressed a willingness to consult healthcare providers, although this was often undermined by unclear prescriptions, family influence, and limited access to care. In urban areas, subjective norms (SN) were the strongest predictor of intention, reflecting the role of social expectations. In rural areas, perceived behavioral control (PBC) was most influential, underscoring the importance of access and self-efficacy. Logistic regression confirmed these patterns: favorable attitude (ATB) (p = 0.005) and high PBC (p = 0.029) significantly increased intention in rural areas. Obtaining antibiotics from official sources was associated with a significantly lower intention in rural areas (p = 0.037).

Strengthening women’s intention to follow medical advice requires addressing knowledge gaps, improving communication, and reducing structural barriers. Interventions should be focused on access and empowerment in rural areas and education and social norms in urban areas. In both urban and rural areas, the engagement of community health workers is a trusted mediator. These findings highlight the need for interventions that integrate both behavioral and structural approaches to ensure rational antibiotic use in terms of maternal and child health.

The online version contains supplementary material available at 10.1186/s12889-026-26190-1.