Perceptions of intermittent preventive treatment of malaria in pregnancy (IPTp) and barriers to adherence in Nasarawa and Cross River States in Nigeria

Accessibility of services was not a major problem, although distance to a secondary or tertiary health facility is longer and transportation is slightly more expensive in the peri-urban areas relative to the rural location. Though Cross River State should provide free primary health care for pregnant women and children under five, this is not the case in some facilities. Participants in men’s and women’s groups reported that poverty is a major barrier to seeking care at health facilities. Some participants argued that caught between hunger and illness, some people will chose food over anti-malarial drugs. This emphasizes the depths of poverty faced by many in this area.

When they cannot afford to go to the health facility, women would go to local drug shops (patent medicine vendors) for alternative or cheaper malaria drugs of possibly lower quality.

Among non-monetary reasons identified by FGDs as barriers to uptake of MiP services, rude health providers and long waiting times were noted most frequently. Patients get frustrated by delays they encounter at the public health facilities. Women generally waited for less than two hours in most primary health facilities, but waits could be as long as four hours at the secondary and tertiary health facilities. Many rural participants did not consider transportation to be a problem, but those in peri-urban areas complained about the difficulty of getting to a tertiary facility and the time taken by the trip. Some of them have to travel long distances to get to the facility only to be told that they have arrived too late in the day and cannot be attended to.

Participants expressed trust in public health care facilities and providers, yet some also complained about negative provider attitudes. Some participants expressed a reluctance to attend services and face provider disapproval if they were not complying with instructions about nutrition and self-care, or were using traditional medicines.

Both women and providers mentioned incentives for women to seek health care, or to return for a second IPTp dose. One powerful incentive is a positive experience of effective care, as described by this participant:

Women and providers described drugs and other commodities such as LLINs as motivating women to seek ANC.

However, the practice of giving material incentives has its own problems, particularly when many clinics have problems maintaining drug supplies.

Health providers at smaller facilities said they might see one to four cases of MiP per day, while those at secondary and tertiary facilities might see as many as 30 per week. Providers said that facilities charge for services. User fees at secondary and tertiary facilities ranged widely, from N350–2,000 (approximately USD2.20–12.60) in both States.

Community health workers generally knew more about linking ANC to IPTp than facility-based providers. Most health care providers interviewed correctly identified signs and symptoms of malaria, including headache, fever, loss of appetite, chills, general body weakness, vomiting, and abdominal discomfort. Nearly all agreed that malaria is dangerous for a pregnant woman and her foetus. Providers in Cross River seemed more knowledgeable about the effects of malaria on mother and foetus than their counterparts in Nasarawa.

According to the national protocol for IPTp, pregnant women may receive IPT with SP administered as directly observed therapy (DOT) regardless of symptoms, from 16 weeks of pregnancy for the first dose and one month later for the second dose. Pregnant women who have malaria may receive SP or another approved artemisinin-based combination therapy (ACT). All providers interviewed identified two or more anti-malarial drugs, including SP, ACT such as Coartem, and quinine. However, nearly all of them mentioned one or two incorrect drugs, including cholorquine, which has been discontinued and withdrawn from the market due to resistance. Despite its ban, many Nigerians are still using chloroquine [20]. Most listed ACT (or Coartem) as a preventive drug for pregnant women, though it is mainly used for treatment.

When asked to state how they administer SP for IPTp, none mentioned DOT or other approved steps. When asked directly if IPTp was administered by direct observation or during home visits, the reply was often negative. One noted that the practice of home visits had been discontinued.

Incorrect information on malaria case management and dosages was conveyed during interviews.

No provider interviewed mentioned obtaining rapid diagnostic tests. This suggests that malaria diagnosis is still presumptive based on non-clinical presentations. Health care providers do not appear to have received adequate training in correct dosage and case management of MiP. Many provider statements suggest that focused training is needed to improve malaria case management in health facilities.

Providers indicated they had attended training on at least one of the following areas: use of rapid diagnostic tests for malaria, IPTp with SP, malaria case management, and interpersonal communication. Though malaria prevention and control is a component of ANC, provider interviews suggest that this is not reflected in the training offered to providers. Many respondents said they heard of focused antenatal care (FANC) and knew of people who had been trained in this area, but few had been trained in it themselves. No provider in Nasarawa who had attended training on malaria prevention and case management had attended any training on FANC. Though one midwife said she had attended FANC training two years earlier, most had not attended such training, and several had not heard of FANC. Participants expressed considerable interest in attending FANC training.

While a few practitioners reported they had attended workshops led by experts on new modalities, many providers, especially in Nasarawa, said they had not received any recent training on MiP. Some referred to workshops and seminars they had attended, but most providers said they needed more training.

One of the components of the IPTp protocol is DOT, but DOT is not possible if the drugs are not available on site. In cases of stock-outs, providers write prescriptions, but they are unable to tell if the patient filled the prescription or took the medication correctly. Some participants were also unsure if they were adhering to the doctor’s instructions.

Providers in nearly all facilities in Nasarawa said they prescribed drugs that patients purchased outside the facility, mainly because of stock-outs. Providers reported that sometimes SP and other commodities might be freely available at their facilities, but ACT might be out of stock for two or three months. According to one of the physicians interviewed, such stock-outs were due to “the government’s lack of political will”.

Providers in only one health facility in Cross River reported that most of the required malaria commodities were available. (Some providers in large facilities were not sure, since these facilities keep drugs in pharmacies or stores.) Providers also indicated that malaria commodities were available only when supplied by international development partners.

While Cross River health facilities can sometimes alleviate supply problems by buying essential drugs on the open market and charging patients, facilities in Nasarawa either could not afford to buy drugs or their clients could not afford to buy drugs from them. As one midwife put it:

When asked to estimate the proportion of their clients who purchase the anti-malarial drugs that are prescribed, providers said they did not know, and it depended on whether they could afford them.

Most FGD participants demonstrated relatively good knowledge of malaria signs and symptoms and preventive methods, and nearly all knew that mosquitoes cause malaria. Many participants also reported causes of malaria other than mosquitoes, but some of these are simply misunderstandings of health information, and result in the correct preventive behaviour. For example, dirty surroundings will not cause malaria, but keeping one’s compound clean, without standing water, may reduce the population of mosquitoes breeding.

The sample was mostly recruited from women who had attended ANC services, so an overall positive view of ANC was expected and found, even among those who sometimes complained about specific aspects of ANC. Some women reported attending many more than the recommended four visits. Many of the studies in the systematic review [18] reported fear of side effects of SP including miscarriage or difficult deliveries as a result of babies growing too big. FGD participants in this study did not seem to fear that SP might harm the foetus; potential side effects described affected the woman, and were more unpleasant than dangerous.

Husbands are especially concerned about their wives’ health when they are pregnant, and anxious for them to comply with recommended treatment. In general, husbands, other relatives and community members support ANC, IPTp and malaria treatment for pregnant women, and encourage the women to attend. Women in the community seemed to motivate one another to seek routine care as well as treatment.

According to Ministry of Health policy, ANC includes malaria prevention and treatment, and there is a nationwide protocol for IPTp with SP. It is often not followed, particularly because of stock-outs and providers’ lack of specific knowledge, but the policy framework for IPTp is in place, and providers have basic knowledge and desire to learn more.

Table 4 summarizes the barriers to IPTp uptake found at each of the three levels of the conceptual framework. One star (*) indicates that a barrier may exist but does not have a very strong influence of lowering IPTp uptake. It may have been mentioned but only by a minority of participants, or participants did not consider it to be very important, or it may not be likely to influence IPTp in particular. For example, most women had a good understanding of the cause and symptoms of malaria, but there were also some misconceptions about causes. These barriers are relatively low priority. Two stars (**) indicate barrier considered to have a more important influence on IPTp uptake. Three stars (***) indicate a serious barrier to IPTp uptake that urgently needs to be addressed. The absence of stars indicates that a barrier of that type did not exist at that level. Table 4 summarizes and ranks the barriers to IPTp uptake identified in this study.

Most women in this study attended the number of ANC visits recommended or more, yet due to stock-outs they still did not receive two doses of IPTp. If the subset of women who are attending multiple ANC visits are not getting complete IPTp, it may mean that the problem resides at the health system or facility level.

Many women lack specific knowledge or have different perception of risks of MiP and the difference between prevention and treatment, and why prevention is necessary. Many FGD participants did not have correct information on medications that treat and prevent malaria, or on IPTp timing and dosage, even if they had previously received IPTp or malaria treatment while pregnant. Some considered traditional medicine as the appropriate first-line treatment for malaria.

The support of husbands and, to a lesser degree, extended family and friends, affects whether and where women seek care. When family and friends have differing perceptions of risk (severity and susceptibility) and the utility of IPTp, they can make it difficult for women to seek care. Some husbands and older family members indicate that other factors associated with ANC visits include cost, preference for traditional medicine, or because they see pregnancy as a normal occurrence that does not necessary require medical intervention.

For many families, lack of financial resources is a barrier, even if they are in favour of ANC. Even if ANC services are free, there are often costs associated with additional tests or services, prescriptions if there is no medication in stock, and transport. Inability to pay may prompt pregnant women who have malaria to seek treatment from traditional providers or other cheaper sources. However, this barrier is not specific to IPTp; rather, it is more likely to prevent women from accessing ANC services at all than to prevent them from receiving IPTp as part of ANC.

Providers need and want more training in early diagnosis, MiP case management and IPTp-SP, including dosage, spacing, timing, and DOT. ANC providers lacked the necessary knowledge to provide the recommended prevention and treatment interventions for MiP, or to correctly inform women about them. Community health workers tended to be better at linking IPTp to ANC than providers in facilities. Provision of more MiP training and post-training follow-up for ANC front-line workers, particularly facility-based providers, is essential for full implementation of the Nigerian government’s tripartite approach to MiP: use of LLINs, administration of IPTp-SP, and improved case management.

Many facilities selected for the study do not appear to offer focused ANC. Instead, women may attend many more visits without receiving the key elements of the focused ANC package, including IPTp. State malaria control programmes and federal reproductive health programmes need to coordinate to harmonize the ANC and malaria training work plans.

Some facilities, particularly secondary and tertiary level facilities, are located far away for rural communities and have very long waits, which discourages some women from attending ANC if they do not feel unwell. Similarly, some women may avoid care if they expect to be treated disrespectfully, particularly if they have not complied with previous advice.

The biggest barrier to receiving IPTp identified was the frequent stock-outs in facilities. In order for DOT to work, the facility must have the drug available on site. Even those women who do leave and fill a prescription at a local drug store or patent medicine vendor are not likely to come back to take the medication in front of the provider or to report that they took the medicine (nor would this be a desirable addition burden to place on the women). Thus, providers have no way of keeping track of who has taken IPTp and who still needs it, or who is taking it correctly. Given the low levels of specific knowledge about doses and timing among women, this is a particular problem.

The purpose of this study was to identify opportunities to improve uptake of IPTp. Information from women, husbands and providers agrees that a large proportion of the obstacles are structural and require remedies at the health system level, particularly improved supply chain management to reduce stock-outs, and better training and post training follow-up and supportive supervision for providers. A study of IPTp provision in Enugu state [21] using provider interviews and observations also found low levels of provider knowledge and adherence to IPTp. The authors concluded that the main barriers to IPTp were at the provider and facility level, rather than at the community level [22] and recommended improved training along with supervision and monitoring. Table 5 presents steps that programmes can take to improve MiP and particularly IPTp uptake, at each of the three levels.

Communication programmes can support training initiatives and improve provider competence in a number of ways. Job aids can help providers counsel women on prevention and treatment of MiP, and prescribe IPTp correctly. Providers are often reluctant to use job aids for fear of seeming to lack knowledge, but a patient brochure that can be used for counselling and given to the pregnant woman to take home may be more acceptable. Such a brochure could use clear pictorial instructions to explain how the woman should take IPTp, which is particularly important if most women have to buy SP from a pharmacy, and when she should return for her next dose. Women’s trust of providers affects their willingness to take unfamiliar medicines. Training providers on interpersonal communication and providing services in a respectful manner may increase the likelihood that women comply with their instructions to take SP, even if they find it unpleasant.

Community-level activities to reduce barriers or reinforce existing beliefs and behaviours that facilitate appropriate prevention and management of MiP must target not only pregnant women but also their husbands, families and influential community members. Though FGD participants indicated they had received information about malaria during ANC visits and from community health workers, they also had misconceptions about causes, signs and symptoms and particularly the risks of MiP. Studies have shown that when pregnant women do not perceive MiP as a serious illness, or they have misconceptions about its causes, they may be less willing to comply with recommended methods of prevention, such as IPTp or use of ITNs, or treatment with ACT [18]. Husbands play important roles in whether their wives access health care, but FGD participants in Cross River expressed a willingness to go against their husband’s wishes if necessary to benefit the health of their baby. Women and men suggested that husbands are more supportive of their wives’ health care when it protects the foetus. Community health workers (CHW) are trusted sources of information, and may effectively promote IPTp and prompt use of ACT for MiP in the context of protecting the foetus from the risks of malaria.

At their September 2012 meeting, the Malaria Policy Advisory Committee to the WHO decided to recommend that IPTp-SP protocols be changed from two doses to four doses [23]. One dose is to be given at each focused ANC visit, at least one month apart, beginning in the second trimester and up to delivery. In this context, it is more urgent than ever to address the barriers to the uptake of IPTp among pregnant women who are attending ANC.

The biggest limitation of this study is that it used purposive sampling and recruited primarily from among women who were already accessing services, and so does not adequately capture barriers for women who may not be attending ANC. However, the primary interest of the study was to learn more about the MiP care that women receive, which can be best accomplished by speaking to women who are already accessing care. The issues preventing women from accessing ANC may be very different from those preventing ANC patients from receiving IPTp. While only one-third of women receiving ANC are also receiving IPTp, there is a clear need to increase the quality of MiP care provided, as distinct from increasing the number who are accessing it.

An additional limitation relates to stock-outs. At the time of the study, many facilities had high levels of stock-outs. This problem may have been resolved post-study. Further, the existence of frequent stock-outs may have influenced provider adherence to protocols or even provider experience. For example, providers may rely on pharmacies to explain to women how to take the medication. Areas with greater drug security may not experience some of the barriers that we identified.