Background
Malaria in pregnancy (MiP) is a major health concern in Nigeria. Malaria infection is more dangerous during pregnancy, and adverse effects are more serious for the pregnant woman as well as the foetus and newborn. In endemic areas such as Nigeria, women have high levels of immunity so may not experience fever or other malaria symptoms. During pregnancy, however, their immunity is altered and they are more vulnerable to complicated and severe malaria. Meta-analysis of intervention trials in sub-Saharan Africa [
1] suggests that in endemic areas, MiP is largely undetected and untreated, and leads to 100,000 infant deaths per year due to malaria-associated, low birth weight. Malaria-related anaemia may cause up to 10,000 maternal deaths per year [
2]. Malaria also increases high blood pressure in babies [
1,
3‐
5]. In Nigeria, a large proportion of pregnant women do not go to a health facility even when they have malaria symptoms. This is especially true in States where many Muslim women are in seclusion and do not make their own decisions about attending a health facility.
Intermittent preventive treatment of malaria in pregnancy (IPTp) is a strategy where all pregnant women are given a full curative dose of sulphadoxine-pyrimethamine (SP) at least twice during pregnancy, regardless of whether they have malaria. Starting as early as possible in the second trimester, IPTp-SP is recommended by the World Health Organization (WHO) [
6] for all pregnant women at each scheduled antenatal care (ANC) visit until the time of delivery, provided that the doses are given at least one month apart. Sulphadoxine-pyrimethamine should not be given during the first trimester of pregnancy; however, the last dose of IPTp-SP can be administered up to the time of delivery without safety concerns. The effectiveness of IPTp-SP in improving birth weight and reducing prevalence of pre-term deliveries and maternal anaemia in Nigeria has been documented [
1]. IPTp is part of Nigeria’s three-pronged approach to MiP: 1) prompt and effective case management of malaria; 2) use of IPTp with at least two doses of SP; and, 3) consistent and correct use of long-lasting insecticide-treated nets (LLINs).
Nigeria adopted IPTp as a national strategy in 2005, replacing weekly prophylaxis [
7‐
9]. IPTp with SP should be offered as part of focused ANC. Focused ANC is a WHO-recommended approach that consists of a minimum of four goal-oriented ANC visits during a pregnancy. Focused ANC is part of the Federal Ministry of Health (FMoH) policy, but has not yet been scaled-up in most of the country. National protocols stipulate that SP is given free of charge through ANC services at public health facilities and non-governmental organization (NGO) facilities, using directly observed therapy (DOT).
The Government of Nigeria, development partners, and funding organizations have initiated several strategies and programmes to mitigate the impact of malaria on pregnant women and their children, but Nigeria has a long way to go in achieving targets set for IPTp. Recent studies revealed that few pregnant women adhere to the recommended two-dose course [
10‐
12]. The 2010 Nigeria Malaria Indicator Survey reported that only 15% of women who had given birth in the two years preceding the survey had received even one dose of SP during their ANC visits, less than a third of the number who attended ANC with a skilled provider.
A number of quantitative studies have documented low level of IPTp adherence and identified knowledge gaps [
13‐
16], but little is known about social and cultural barriers operating at individual, community and health facility levels that influence IPTp uptake and adherence among pregnant women. This study was designed to gather evidence on real and perceived barriers to IPTp-SP adherence from the perspectives of pregnant women and ANC providers.
Objectives
The study objectives were to identify pregnant women’s and providers’ perceptions of IPTp, and barriers to adherence to the protocol of at least two doses. The objective of focus groups with women was to understand:
a)
Real and perceived logistical, social and cultural barriers to correct IPTp use/adherence
b)
Women’s ability to act and access appropriate care
c)
Perceptions of risk of MiP
The objective of provider interviews was to understand:
d)
Provider knowledge of MiP and IPTp
e)
Perceptions of their role in ensuring adherence to IPTp
f)
Institutional-level barriers
Qualitative data from pregnant and post-partum women and front-line ANC providers in tertiary, secondary and primary health facilities can not only help to fill knowledge gaps, but also inform and support the development of strategies and interventions that improve IPTp uptake and adherence.
First level of influence: individual
Perceptions of malaria and prevention methods
FGD participants were asked what causes malaria and how it is transmitted, since such degrees of perceptions often determine what steps are taken to prevent illness and decisions to seek care [
20,
21]. In both States, most participants referred to mosquito transmission and cited appropriate signs and symptoms, such as headache, fever, lack of appetite, weakness of joints, and vomiting.
Participants also reported additional causes of malaria. A few noted that malaria may result from an attack (“witchcraft”) by somebody. More frequently, participants linked malaria to a virus, exposure to the sun, infection from toilets, or drinking bad (impure) water and connected the presence of mosquitoes to unclean or dirty environments:
“Leaving dirty things around the house causes malaria; leaving the toilet dirty, not washing and leaving dirty water around the house can cause malaria. Leaving unwashed plates or clothes can cause malaria; some people don’t tidy up their rooms”.
With the exception of one FGD in Cross River, all participants could name one or two proven malaria prevention methods such as use of LLINs, though use of LLINs was not mentioned in four of the 36 FGD sessions. In both States, participants cited insecticide spray and screened environments. No respondent mentioned indoor residual spraying.
Many participants believed in prevention methods that were not related to mosquitoes, such as washing hands after toilet use, cutting grass, staying out of the sun, and keeping premises clean. To repel mosquitoes, participants mentioned using a local rat poison called otapiapia and burning fragrant or “scenting” leaves:
“I keep our environment clean, because sometimes it’s not even about the nets. You may sit outside resting and the mosquito will come and bite you. You keep your compound clean and all the grasses around you, you clear it, so that mosquito will not come to your compound because it is the neat one. When you go to toilet, you wash your hands and you keep your toilet clean. That will prevent you not to have malaria”.
Perceptions of risk and care-seeking for MiP
While some women could not identify any danger to the foetus from MiP, most perceived dangers such as anaemia, jaundice, miscarriage, pre-term birth, and stunted growth. Some participants referred to malaria as a cause of death and to community perceptions of its dangers.
“Malaria kills faster than AIDS, so most of them are scared”.
“[The foetus] could die inside [the mother]. Because of the high temperature, the foetus will try to get out [and the mother] could suffer a miscarriage”.
When asked about their motivation for visiting a government health facility for pregnancy-related care, most participants mentioned the need to maintain their health and particularly that of their unborn babies. Some said that going to a government health facility was their way of ensuring their baby’s safety. As one rural FGD participant put it,
“If we don’t have transport, we often walk to the health facility, no matter how far away we live”.
Most FGD participants said that if they had malaria, they would go to a hospital and take prescribed medications, if they could afford it. Nearly all participants said they would advise a pregnant woman to go to a health centre for malaria medication and indicated they know women or girls who have had malaria. Other barriers to accessing MiP care from health facilities mentioned included individual choice, ignorance, lack of money, lack of time, fear of surgery, dislike for oral medication, and reliance on prayer.
Traditional therapy was also highly acknowledged as a good cure for MiP. Many participants confirmed that seeking treatment in modern health facilities is generally viewed as a last resort, usually when the disease poses a major threat to life. A few participants reported that some traditional healers warned against mixing traditional and hospital medicines, and they admonished pregnant clients not go to a hospital for preventive care. Local herbs in Cross River, called okon-a-tekor and yabulikponben, are used to treat malaria, along with lemon grass and the leaves of dongoyaro (Neem), pawpaw, mango, and lime trees. Advantages that participants cited were that traditional medicine works faster and is cheaper and more conveniently accessed, in comparison to anti-malarial medicines that smelled bad, caused nausea, side effects and allergic reactions, and were “very big to swallow”.
“My friend here dislikes oral medicine, so when she collects the medicine she will hide it under a pillow and later throw it away”.
“Some if they take it (anti-malarial drugs) they vomit, so they don’t take it”.
Side effects of modern anti-malarials mentioned tended to be transient, affecting the woman, rather than potential harm to the foetus. A few participants noted that traditional herbs involved unreliable dosages and regimens. Respondents also referred to the potential danger of patronizing “chemists” instead of getting approved anti-malarial medicines from government health facilities.
Understanding of IPTp
Some participants perceived malaria prevention as a component of ANC, but most did not. Very few participants in rural areas referred to receiving anti-malarial drugs, LLINs, or rapid diagnostic testing of malaria with ANC services. Participants did not appear to clearly understand the difference between chemoprophylaxis (prevention of malaria through medication) and the specific treatment they have to take in the event of an episode of malaria. In nearly all FGDs, participants correctly identified the appropriate anti-malarial drugs used during pregnancy, including the SP brand names Laridox and AntiMal. Some participants mentioned chloroquine, which was frequently used as prophylaxis in the past, but has since been withdrawn due to resistance. All participants in one FGD in Cross River identified Coartem rather than SP as the drug of choice for pregnant women. Most women trusted their health facilities and said they attempted to follow instructions given to them by the doctors, nurses or midwives regarding the dosage of malaria medication, but the dosage and the spacing of the two doses are not clearly understood.
Some participants referred to the need to take two doses while pregnant, but the majority of women in nearly all the FGD sessions demonstrated inadequate knowledge, such as incorrectly describing the dosage of SP or the recommended interval between doses. Only a few women knew how many tablets constituted the recommended dose or that the requisite number of tablets were to be swallowed at the same time under the direct observation of a health provider (DOT).
“I wanted to take the three tablets at once but somebody told me that I should not take the three tablets at once, that I should take one per day, so that was how I took my own”
“They instruct us to take the medicine in the morning, afternoon and in the evening, every day for the number of days they will tell us”.
“Well, we do not know when to take this medicine. Whenever we come to the clinic and they prescribed medicine for us they only tell us to take 3 times or 2 times. Since we have never been diagnosed with malaria, we don’t really know when”.
“The women who are registered here are given the drugs upon registration and again when they are six months pregnant, so that you are supposed to take two doses before childbirth”.
Family support for seeking MiP care
Community or social factors affecting women’s health-seeking behaviour include the support they receive from husbands, friends and other relatives. Male partners’ influence on the uptake of maternal health services has been well documented [
22]. Men play an important economic role, including paying for transportation to and from health facilities, hospital services, prescriptions, and recommended foods.
Husband’s role – from women’s perspective
Fewer women under 20 years acknowledged the importance of husbands’ support, but women over 20 years in both States referred to it frequently.
“Our husbands are very supportive if they notice any sign of malaria in pregnancy. They are aware that we can only get good treatment in hospitals, and they will not be able to concentrate on other things if our health is in trouble. He will always encourage me to go to the hospital to confirm the health of both the baby and the mother. They always support us with money for treatment so that we can give anytime such is required”.
FGDs with both women and men suggested that a pregnant woman has no alternative if her husband wants her to seek care in a health facility. One of the main types of support husbands provide is money for services and transport.
“Sometimes they offer advice; sometimes they offer support by giving transport money”.
Beyond paying for services, some women said their husbands encouraged them to take their medications, reminded them of scheduled visits, and monitored their health. Some husbands accompany their wives to the ANC facilities, and others asked a female relative (often a sister) to accompany their wives.
More FGDs in Nasarawa reported that husbands were very supportive of them seeking modern, medical care for MiP; only a few reported otherwise. Views from Cross River were more varied, ranging from support to ambivalence, indifference or hostility toward modern medicine. In Cross River and Nasarawa States, poverty or lack of money was considered the main, but not the only reason some men did not encourage their wives to go to the health facility.
Religion and traditional beliefs were considered barriers for some in both States. In Cross River, a preference for traditional healers was cited, along with the belief in adhering to practices of parents and older generations who did not go to ANC facilities.
“Some, like my husband's tribe, dislike medicine; most of them do not like hospital. When they are sick, they patronize [a traditional medicine practitioner]. I had an experience three months ago and I was bleeding during pregnancy, my husband and his family took me [there]”.
“They (some husbands) are very greedy, they don’t want to spend money, they say the traditional way is faster and refuse to bring the money to allow them to come”.
Only rarely was sickness in pregnancy described as being caused by witchcraft and therefore only curable by traditional medicine. More often, traditional medicine consisted of herbal remedies or tonics of uncertain mixtures and dosages to alleviate common ailments. Not all participants had confidence in herbalists, but they are cheap and accessible compared to modern medicine.
In Nasarawa, men who “practice these conservative religions” reportedly did not allow their wives to go to hospitals because they might be under the care of male health providers.
“Some of my friends will tell you that … their husbands will not allow them to go to hospital, especially these people that practice these conservative religions. They believe that when they (the wives) go to hospitals, men (male health providers) will attend to them, so they don’t want men to “look” at them, understand? So they don’t want men to “look” at their wives. These are some of the reasons why traditions affect some people”.
Husband’s role – from men’s perspective
FGDs with husbands in Nasarawa State corroborated the range of attitudes and behaviours that facilitate or present barriers to uptake. Many discussions referenced cost of drugs and of transportation to access care that husbands were expected to cover.
“It depends on the money for that medicine, even if it is one million naira provided you have the money, you just pay”.
Husbands also considered it their duty to ensure that their wives take prescription medication. It was implicit in many of the discussions that there is a belief that women in Nasarawa needed to be “forced”, or husbands needed to “make sure” women “went out” to seek health care. There were also suggestions that some husbands threaten physical violence against their wives to ensure that the women seek care for protection against malaria and comply with the prescriptions.
“Yes, you have to, because you have to force her before she takes the medication”.
Some husbands mentioned other kinds of support provided for their pregnant wives, such as assisting with household chores and ensuring they eat foods thought to be healthy.
“
You know whenever a woman becomes pregnant, there are two to three things which the husband is supposed to be doing for her… Difficult work must be stopped, because anything that will touch her and what she is carrying inside her stomach; secondly she must take additional supplements”.
“Encouragement—you have to encourage her in one way or the other, maybe you have to pay for the transport money to take her, make sure you remind her of the appointment even she forgot to take her drugs regularly”.
Apart from encouraging, advising and providing financial support, there was ample evidence from the discussions to support the belief that men constitute an extremely important support mechanism for women seeking medical care during pregnancy. The tone of both male and female discussions suggested that if a man wants his wife to seek medical care in a health facility, the woman virtually has no other alternative. Male and female participants variously portrayed men as the initiator, financier, advisor and enforcer of hospital attendance and compliance with prescriptions by women.
“I will make sure I collect the card for her then I will leave her with the doctors; I have done my part.
“The help is that we force them to come for antenatal”.
Second level of influence: community
Extended family members and peers often influence the choice of place of treatment. Respondents reported receiving support and encouragement from some family members such as their parents or a trusted neighbor or friend when they seek health care during pregnancy. Some women might not go to a clinic unless such a person encouraged them to do so. Friends or neighbors might pressure pregnant women not to skip appointments and to seek medical help when ill.
“A friend came to visit me. She saw how terribly ill I was. After two days, she came to visit me and she saw my condition had not improved. Therefore, she told me to seek medical attention or she will never visit me again. So, to me she was caring; that was why she advised me”.
Women also reported that friends shared good experiences about medical care and instigated companionable trips to medical facilities.
“If my friend wants to go to the hospital, she normally calls me and we go together”.
Other women attending ANC facilities provided significant collective support.
“Each time we come for antenatal care, we make new friends. Sometimes we talk about the facilities and the drugs; sometimes we encourage ourselves to take our drugs. A woman may say ah! They gave me malaria drug and I have not taken it, and another woman may say why have you not been taking it? Somebody might say I have not been taking my traditional herbs, and another person will say try to take them because they will help you. We encourage one another”.
As with husbands, some parents do not encourage their daughters to go to a hospital during pregnancy because of their traditional beliefs and recommend traditional birth attendants, herbalists or native doctors rather than health care providers in government health facilities.
Competing interests
The authors declare that they have no competing interests.
Authors’ contributions
CD and TP conceived the paper, designed the analysis and wrote the first draft of the manuscript. CM contributed substantially to the analysis and writing. CM and BK contributed to editing the manuscript. All authors have read and approved the final version of this paper.