Background
Remarkable progress has been made in the global fight against malaria. However, 3.4 billion people, including pregnant women, are still at risk of malaria [
1]. The brunt of the global malaria burden is borne by sub-Saharan Africa (SSA) [
1,
2], where over 30 million women become pregnant annually in malaria endemic areas [
2]. Pregnant women are the main adult group at risk for malaria infection in endemic areas in SSA [
2]. In Nigeria, nearly 110 million cases of malaria are clinically diagnosed per year. This makes malaria the most common cause of hospital attendance in all age groups, with estimated annual economic loses of over US$ 835 million from cost of treatment and absenteeism from work and school [
3‐
5]. It is estimated that malaria is responsible for about 11 % of overall maternal mortality in Nigeria [
4,
5].
Malaria in pregnancy (MIP) can have serious health consequences for the woman, unborn child and newborn. The direct effect of MIP on the mother is severe anaemia, resulting in an increased risk of maternal mortality. The indirect consequences of MIP are twofold: (i) intrauterine death/growth retardation of the foetus and (ii) low birth weight in the newborn with consequent higher risks of infant mortality and impaired child development [
2].
A three-prong approach is recommended for the control of MIP in SSA: use of sulfadoxine-pyrimethamine for the intermittent preventive treatment of malaria in pregnancy (SP-IPTp), use of insecticide-treated bed nets (ITNs), and effective case management of malarial illness [
2].
About 90 % of pregnant women in Nigeria attend some form of antenatal care (ANC) service [
4]. This offers an immense opportunity to encourage women to utilise IPTp during ANC visits [
4], particularly in Primary Health Care (PHC) facilities, which are the entry point into Nigeria’s health care system. In 2005, the Federal Ministry of Health (FMOH) in Nigeria adopted the IPTp as a part of focused ANC [
6]. Provision of SP, at no cost to recipients, through Directly Observed Treatment (DOT) supervised by a skilled healthcare provider in public and faith based/NGO antenatal facilities is one of the strategies used to achieve the target of 90 % of pregnant women receiving at least two doses of sulfadoxine-pyrimethamine (SP) in the second and third trimesters of pregnancy [
4].
The current World Health Organization (WHO) IPTp guidelines require that the first dose of SP-IPTp be given as early as possible in the second trimester of gestation with subsequent doses given at least one month apart. The last dose can be administered up to the time of delivery without safety concerns [
7].
According to the 2009 Nigeria Health and Demographic Survey (NHDS), 8 % of pregnant women reported the use of one dose of SP-IPTp [
8]. Studies have reported low use of SP-IPTp in various regions of Nigeria [
9‐
16] and SSA [
17]. Some of the perceived barriers to SP-IPTp use include drug stock-outs in the health facilities, lack of provider knowledge of the IPTp protocol, women’s belief that SP is harmful to the foetus, and low levels of awareness of the use of IPTp as a malaria preventive measure [
10,
15,
17,
18]. Various factors have been identified as predictors of SP-IPTp use in PHC facilities in different regions of Nigeria, all of which vary in seasonality, intensity and duration of malaria transmission [
19]. Knowledge of prophylaxis for malaria prevention is associated with SP-IPTp use in south-west Nigeria [
20,
21], while advanced maternal age, higher education, higher parity, lower gestational age at registration for ANC, and use of ITNs are associated with use of SP-IPTp in northern Nigeria [
14]. However, little is known about the determinants of the use of free SP-IPTp in accordance with the national treatment guidelines among women utilising ANC services in PHC facilities in south-south Nigeria. The aim of this research was to identify the barriers to and determinants of the use of free SP-IPTp by pregnant women attending ANC clinics in PHC facilities in Cross River State, south-south Nigeria.
Discussion
The aim of this study was to identify the barriers to and determinants of the use of SP-IPTp by pregnant women attending ANC clinics in PHC facilities in Cross River State, south-south Nigeria. We observed high knowledge of the use of mosquito bed nets, ITNs and SP as means of preventing MIP. However, the actual use of these measures to prevent MIP was low. Based on the findings, we noted that the lack of autonomy or freedom to receive SP-IPTp during ANC without consulting a household member, stock-outs of free SP, and poor implementation of directly observed treatment in the ANC clinics were potential critical barriers to the use of IPTp. Knowledge and practices related to the prevention of MIP were associated with use of IPTp in the index pregnancy.
Our research findings corroborate results from similar studies conducted in PHC facilities in south-west [
10,
20] and northern [
14] Nigeria which showed high levels of awareness of ITNs and SP as important predictors of MIP-related preventive behaviour. The reported high knowledge of ITNs and SP as malaria preventive measures in pregnancy may be attributed to health education received during ANC, which is widely utilised by pregnant women in Nigeria [
4]. The possible effects of ANC attendance on increasing awareness of malaria preventive measures in pregnancy are further corroborated by a study in Burkina Faso which showed that non-ANC users were significantly less knowledgeable about malaria/anaemia prevention measures than ANC users [
28]. However, we also recognise that the knowledge gap between ANC and non-ANC users can reflect higher educational levels among women who use ANC relative to those who do not [
28].
Late ANC attendance (reflected by late gestational age at registration for ANC) and poor knowledge of the gestational age for taking SP have been identified as individual barriers to the use of SP-IPTp in our study. As previously reported in Gambia [
29], poor knowledge of the correct timing of ingestion of SP was associated with low use of SP-IPTp. This may have serious health implications particularly in a context where women are likely to purchase SP from service providers in the informal health sector (e.g. drug stores), some of whom may be inadequately informed about the appropriate gestational age for the ingestion of SP. As such, health education programmes targeting pregnant women and drug vendors may be needed. This is in view of the literature evidence showing that informal health care providers such as drug vendors, traditional birth attendants and adolescent peer mobilisers are capable of increasing access to and compliance with SP-IPTp [
30].
The lack of autonomy or freedom to receive SP-IPTp during ANC without consultations with a family member, notably the head of the household, is a household barrier to the use of SP-IPTp in this study. Refusal to receive SP during ANC visits may be due to perceived adverse effects of SP on pregnancy as previously reported in Cross River State [
15] and south-west Nigeria [
10,
18]. Iliyasu et al. reported a similar finding in northern Nigeria, but attributed cultural factors as the reasons for refusal of pregnant women to use SP without prior consent from their husbands [
14].
Institutional barriers to the use of SP-IPTp in this study were stock-outs of free SP due to sporadic availability of SPs in health facilities [
31] and poor compliance with DOT. In assessing compliance with Nigeria’s IPTp guidelines, approximately one-third of the pregnant women who used SP-IPTp in this study were directly observed ingesting SP by a health worker. Poor compliance with national preventative treatment guidelines has been reported elsewhere in northern [
14] and south-west [
10,
18] Nigeria. The reasons for poor implementation of DOT in these previous studies included: (i) the practice in which pregnant women received SP from ANC clinic, but took them home in order to have a meal before taking the medicine, and (ii) procurement of SP from drug vendors, often due to drug stock-outs in the health facilities [
3,
10,
14,
21]. Poor compliance with the national guidelines underscores the need to assess and enhance the capacity of PHC facilities in Nigeria to implement the DOT strategy as well as to ensure the availability of free SP in health facilities.
The 41 % prevalence of the use of one dose of SP-IPTp in this study is similar to the 40 % prevalence described by Amoran et al. [
21]. The 41 % prevalence reported in our study shows an improvement over the 8 % prevalence previously reported in the 2009 NHDS [
8] and 27 % prevalence described by Akinleye et al. [
10] in south-west Nigeria. In Cross River State, Esu et al. reported higher (53 %) usage of one dose of SP-IPTp than the 41 % reported in this study [
16]. The higher rate reported by Esu et al. can be attributed to the fact that their study was conducted in both primary and secondary health facilities with the latter recording higher ANC attendance due to the provision of ANC services therein by medical doctors. A plethora of literature showed undercoverage of SP-IPTp in Nigeria [
9‐
16] compared with the Role Back Malaria (RBM) 80 % coverage target in 2010 [
32]. Reception of the recommended minimum of two doses of SP-IPTp was very low in this study because the study participants were not followed-up till delivery due to the cross-sectional design of this study.
Knowledge of ITNs and SP as means of preventing MIP was associated with the use of SP-IPTp in this study. A similar finding was also reported in south-west Nigeria [
21] and some in some sub-Saharan African countries [
17]. A meta-analysis of factors affecting the use of interventions to prevent MIP showed that women who knew the benefits of SP-IPTp, and how and when to take SP were more likely to use SP-IPTp [
17]. Use of ITN also determined the use of SP-IPTp, as was reported by Iliyasu et al. in northern Nigeria [
14]. It is expected that mothers who use ITNs are more likely to be exposed to health education programmes focusing on the consequences of MIP and are, therefore, more willing to use SP-IPTp [
14]. Similar to the findings reported by Akinyele et al. in south-west Nigeria [
10], there was no significant relationship between maternal age, gestational age at registration for ANC and the use of SP-IPTp in our study.
Our study findings should be interpreted in light of the following limitations: self-reported use SP-IPTp by the women and our inability to follow-up with the women till delivery to estimate compliance with the recommended total dose of SP-IPTp according to the national guidelines. We were unable to collect facility-level data on other barriers to the use of SP-IPTp in the PHC facilities.
Conclusions
Our study findings underscore the importance of assessing and addressing individual, household and facility factors that may impede the use of SP-IPTp. In particular, levels of awareness and non-compliance of PHC facilities to treatment guidelines may hamper efforts to reduce maternal and child morbidity and mortality associated with malaria. Health education programmes on the prevention of malaria are needed. These programmes should target mothers, heads of households and a wide range of health providers. In addition, programmes are needed to enhance the capacity of PHC facilities to implement the SP-IPTp guidelines.
Ethics approval and consent to participate
Ethics approval for this research was granted by the Cross River State Research Ethics Committee. Permission to conduct the study was received from the nurse-in-charge of the selected PHC facilities. Written informed consent was obtained before enrolling the women to participate in the study.
Consent for publication
Written informed consent to publish the findings of this research was obtained from the study participants. However, we did not obtain consent to publish individual person’s data.
Availability of data and materials
The dataset on which the conclusions of this manuscript rely will not be made available given the conditions stated in the written informed consent form to protect the identity of the patients and health facilities in which the study was conducted.
Competing interests
The authors declare that they have no competing interests.
Authors’ contributions
SA and EO developed the study protocol. Statistical analysis and interpretation were done by SA. SA, EO, AO, CWK, OEOA, AE, OE, and NE critically reviewed the manuscript and approved the final version.