Factors associated with use of malaria control interventions by pregnant women in Buwunga subcounty, Bugiri District

Malaria kills over a million people each year and causes 300–500 million clinical cases worldwide, with 80 % of the deaths and 91 % of the clinical cases occurring in sub-Saharan Africa [1]. More than half of the world’s population is at risk of contracting malaria [2]. Malaria disproportionately affects children and pregnant women, especially in resource-limited, developing countries [2]. During pregnancy, malaria may lead to several complications that include premature delivery or low birth weight, cerebral malaria with abnormal behaviour, impairment of consciousness, seizures, coma, or other neurological abnormalities [3].

The World Health Organization (WHO) recommends a package of intermittent preventive treatment in pregnancy (IPTp) with sulfadoxine–pyrimethamine (SP) and use of insecticide-treated bed nets (ITNs), together with effective case management of clinical malaria and anaemia in malaria-endemic areas, such as Africa [4, 5]. IPTp consists of two doses of SP taken one month apart commencing in the second trimester. With collaboration from malaria and reproductive health programmes in Uganda, both IPTp and ITNs are usually availed at the ANC clinics [6]. By 2010, the Roll back malaria partnership had aimed at ensuring that all pregnant women receive at least two doses of IPTp and 80.0 % of people at risk of suffering from malaria sleep under ITNs [7]. However the coverage of these preventive interventions among pregnant women remains low for many countries in sub-Saharan Africa [8]. The mean coverage of two doses of SP is 24.5 % despite having over 80 % of the women attending at least two ANC visits according to a survey in 27 countries [7]. This is an indication of substantial missed opportunities at the ANC clinics [6]. The same survey indicated that only 35.3 % of pregnant women slept under ITNs.

According to the 2009 Uganda Malaria Indicator Survey, 44 % of pregnant women had slept under an ITN the night before the survey and 32 % received two doses of IPTp [9]. This fell short of the Ministry of Health target of increasing IPTp2 (at least two doses) uptake to 80 % (Health Sector Strategic Plan II). The situation is worse in Bugiri District. According to Bugiri District STRIDES Baseline Needs Assessment, only 30.2 % of the pregnant women acquired more than one dose of IPTp and only 40 % slept under an ITN. This low coverage is said to have escalated the level of malaria morbidity and mortality among pregnant women and children under the age of 5 years.

High access and utilization of IPTp and ITNs by pregnant women is necessary to reduce the burden of malaria among pregnant women. The study examined the factors associated with the use of these malaria control interventions by pregnant women in Buwunga sub-county, Bugiri District.

The WHO recommendations emphasize that pregnant women should receive at least two doses of SP during pregnancy. The 42.0 % uptake of SP for IPTp2 in this study is lower than the targeted global coverage of 80 % in 2010 [2] and it is also lower than the national target of 85 % [11]. These findings are similar to those of a study conducted in Luweero which revealed that only 35.8 % of the mothers had received two or more doses of IPTp [12]. Lower uptake was reported in Nigeria where only 6.5 % of pregnant women had taken the recommended two doses of SP during pregnancy [13]. This low level of uptake of IPTp2 could be due to the reported regular stock-outs of SP tablets, which is one of the major barriers to the IPTp2 supply at health facilities in Uganda [14]. This finding implies that there is a need for regular supply of SP tablets in health facilities.

Bed net usage in this study was slightly higher than the national coverage of 47 % [15] and higher than the 44 % from the Uganda malaria indicator survey [9]. However, ITN use in this study was low compared to the national target of 85 % [16]. ITN utilization was low probably because most of the mothers said that it was hard to access ITNs. Although these nets are sometimes given out at health facilities, distribution centres are far from mothers, as reported by respondents.

In this study, about half of the respondents were knowledgeable about the use of IPTp tablets. Mothers who were knowledgeable about IPTp use were 2.48 times more likely to have received at least two doses of IPTp tablets (AOR 2.48, 95 % CI 1.53–4.02). These findings are in agreement with findings of a study conducted in Tanzania which showed that there was generally high knowledge of IPTp among pregnant women and that this high knowledge correlated well with IPTp coverage [17]. However, having knowledge alone is not enough to translate into IPTp uptake, as demonstrated in this study. Although 62.9 % of the respondents knew that SP should be taken at least twice, only 42.0 % actually received the recommended two doses.

The study findings also corroborated with findings of a study done in Korogwe District, northeastern Tanzania [18] which showed that although the majority recognized that SP prescribed at ANC facilities was for malaria preventive purposes, only 38.0 % received two doses of SP tablets. This clearly demonstrates the knowledge gap among ANC clients and it shows that interventions that can aid in transformation of knowledge into practice are needed.

It was revealed that women who had attained post-primary education level were two times more likely to have slept under ITNs than women of pre-secondary education level. This was probably because educated women had good knowledge about the dangers of malaria, so they developed the need to protect themselves by sleeping under mosquito nets. These study findings were not in agreement with study findings in Sudan which showed that although the level of education played a major role in access to curative and preventive health services, there was no significant association between the level of education and ITN usage [19], which was consistent with study findings by [20] in Tanzania where the level of education of the household heads significantly influenced the use of nets. The study findings therefore imply that there is need to package information use of ITNs to target those mothers who lack formal education.

Mothers who had had three to five pregnancies had increased chances of sleeping under ITNs (AOR 1.69, P < 0.05) than mothers who had had fewer than three and more than five pregnancies. This is probably because mothers who had fewer than three pregnancies had inadequate knowledge about the dangers of malaria, while those mothers with more than five pregnancies had a lower perceived need to visit ANC clinic because of their parity, and so they were less likely to go to ANC clinic, and subsequently had the reduced chance of accessing ITNs. This was in agreement with study findings in Sudan which showed that the increasing number of deliveries inversely related to the likelihood of ITN usage (AOR 0.1, P < 0.05), [19]. This implies that there is need to educate mothers and encourage them to attend ANC clinic and use bed nets no matter how many pregnancies they have had.

The study showed that the level of uptake of IPTp1 (at least one dose) was moderately high at 63.7 % while IPTp2 (at least two doses) was relatively low at 42.0 %. The IPTp2 coverage was far below the national target of 85 % in 2015. More than half, (58.6 %) of the respondents slept under an ITN the night before the survey. It was also shown that, about half of the respondents were knowledgeable about the use of IPTp tablets. The main factors that were associated with uptake of IPTp2 by pregnant women included education level of mothers and provision of free safe water at ANC clinics. The education level of mothers, ease of ITN access and parity of mothers were the main factors that were statistically significant for utilization of bed nets by pregnant women.

The district health team should consider intensifying health education campaigns about IPTp in the communities to improve the level of knowledge about IPTp among pregnant women. Emphasis should be put on explaining the purpose and the frequency of taking SP tablets for IPTp. Health workers should increase awareness and encourage mothers to continue sleeping under mosquito nets no matter how many pregnancies they have had. Health facilities should ensure that there is free safe water at ANC clinics at all times for mothers to swallow the SP tablets. The Ministry of Health should ensure that all ANC clinics are stocked with SP tablets at all times and that enough ITNs are available for distribution to health facilities.