Uptake of intermittent preventive treatment for malaria during pregnancy with Sulphadoxine-Pyrimethamine (IPTp-SP) among postpartum women in Zomba District, Malawi: a cross-sectional study

Malaria in pregnancy (MiP) is a significant cause of maternal morbidity and poor birth outcomes yet is preventable and treatable [1‐4]. Women are particularly predisposed to adverse effects of malaria during their first and second pregnancies [5]. Globally, it is estimated that 125 million pregnant women are at risk of malaria infection each year and 30 million come from sub-Saharan Africa [6]. Furthermore, 75,000–200,000 infants and 10, 000 women deaths are estimated annually and the deaths are attributed to MiP [6, 7]. Particularly, Plasmodium falciparum infections in pregnancy contributes to approximately 11% (100, 000) of neonatal deaths due to low birth weight in areas of Africa where malaria is endemic (LBW) [7‐9]. Infection with malaria in pregnancy predisposes women to increased risk of severe anaemia, intra-uterine growth retardation, intrauterine death, stillbirth, pre-term delivery, low birth weight (LBW), maternal death and placental malaria; and there is increased risk to unborn baby from miscarriage, stillbirth and LBW [10‐12].

World Health Organisation (WHO) recommends three-pronged approach in stable malaria transmission areas for malaria prevention and control in pregnancy, which are Intermittent Preventive Treatment of malaria during pregnancy with sulphadoxine-pyrimethamine (IPTp-SP), use of insecticides treated nets (ITNs), and prompt diagnosis and effective treatment. In the IPTp-SP interventional regimen, each dose contains three tablets of sulphadoxine/pyrimethamine and each tablet contains 500 mg/25 mg SP [13, 14]. Although in 2004, WHO recommended a minimum of two doses of IPTp-SP during pregnancy [15, 16], in October 2012 this policy was updated to “at least three doses during pregnancy and to be administered at least 1 month apart at each scheduled antenatal care (ANC) visit, beginning from second trimester under direct observational therapy” [17, 18]. Malawi adopted the updated policy in 2013 [19]. WHO envisage the policy would increase IPTp-SP uptake as it also recommends at least four ANC visits during the second and third trimesters of pregnancy under the Focused antenatal care (FANC) model [17, 20]. Roll Back Malaria set a target of 100% utilization of at least two doses of IPTp-SP by 2015 [21]. Antenatal Care is the main point of contact of pregnant women with the health system [7]. ANC clinics are used as a vehicle of coverage of health interventions against malaria and other adverse conditions. Thus, the uptake of IPTp-SP would depend on attendance of pregnant women and delivery of the intervention at a health facility [16, 22].

Studies that estimated proportions of uptake of at least three doses of IPTp-SP and identified factors associated with it among pregnant women are few since WHO updated the IPTp-SP policy. However, previous studies revealed that, successful uptake of at least two doses of IPTp-SP is determined by the number of ANC visits [4, 18, 23‐28], directly observed therapy (DOT) [4, 29, 30], residential area [18, 31], age of woman [31], education level and socioeconomic status [4, 32], parity [4, 31], timing of initial ANC visit [4, 33], knowledge about malaria/IPTp [4] and stockouts of the commodity [4]. This study envisages to contribute to identifying obstacles to completion of recommended doses of SP during pregnancy using the updated policy in order to develop a robust and multidisciplinary implementation approach for IPTp-SP intervention in resource limited settings. The aims of the study were to estimate the proportion of and identify factors determining the uptake of at least three doses of IPTp-SP among pregnant women in Zomba district, Malawi.

The WHO new recommended doses of IPTp-SP uptake was very low in the study population when comparing to Roll Back Malaria (RBM) benchmark target for all pregnant women in areas with moderate-to-high transmission in Africa [7]. Some of the factors associated with the low uptake that the study found were attending ANC clinic in rural area, three or less ANC visits, not taking SP under DOT.

Health facility location/women’s residential area setting has been found in this study to be related to uptake of IPTp-SP. Women who attended rural health facility were less likely to complete the recommended SP doses during pregnancy. This finding is similar to a study done in Geita district, Tanzania [18] and Nigeria [36]. To the best knowledge of the authors, the Geita-Tanzania study was the only study that evaluated uptake of IPTp-SP, categorised into less than three doses versus three or more doses of SP, at the time of writing this paper. This observation might either indicate that rural health facility had lower stock levels of SP than urban health facility because of poor supply chain from district health office (DHO) due to challenges in transportation of the commodity or understaffing [4] which leads to high client-to-staff ratios and subsequently long queues and waiting times. This could prompt some pregnant women not make further ANC visits. Kibusi et al. [31] reported that being a resident of Eastern Zone (urban) in Tanzania was associated with completing two or more doses of SP. This implies that Zomba District Health Office (ZDHO) should strive to strength the rural health systems and achieve equity. On the other hand, there is need for further investigation into the rural-urban differential to understand the real barriers and enablers of uptake in each context in order to improve the health of the community.

This study has shown that receipt of at least three doses of SP was higher among pregnant women making four or more ANC clinic visits than those making three or less visits. The finding is consistent with a study conducted in Tanzania [18, 24], in Ghana [27], in Burkina Faso [25], and in Mali [26, 28] in Cameroon, and in Benin [23]. ANC clinic is the vehicle that carries the intervention from the healthcare provider to the pregnant woman, hence the more visits a pregnant woman makes to ANC clinics the higher the number of SP doses she would receive as long as the visits are scheduled at least 1 month apart beginning from second trimester. Out of 426 women, 234 (55%) made at least four ANC visits but only 94 out of 234 (40%) received optimal doses of SP. This suggests a missed opportunity to provide the recommended doses of SP to women who attended WHO recommended number of at least four scheduled ANC visits, as two-thirds (284 out of 426) of the women commenced ANC clinic in the second trimester. The mismatch between percentage of four or more ANC visits and percentage of receipt of three or more doses could occur in part because of intermittent shortage of SP in the health facility, poor fidelity in implementation of IPTp-SP by individual healthcare providers as recommended in WHO policy brief [38], and women’s negative attitudes towards the use of the drug during pregnancy [4, 18, 26, 39]. This implies that health care providers and community leaders have to collaborate to aggressively promote optimal ANC attendance among pregnant women and make sure that every eligible pregnant woman who attends ANC at scheduled visit receives a dose of SP. This will maximise the opportunity of optimal SP uptake in the district for those who make four or more ANC visits.

In regards to direct observation therapy (DOT), the study has revealed that pregnant women who did not take doses of SP under DOT had less likelihood of completing the recommended number of doses. GM Mubyazi, P Magnussen, C Goodman, IC Bygbjerg, AY Kitua, OE Olsen, J Byskov, KS Hansen and P Bloch [40] observed that uptake of SP was low among the study participants especially when women were allowed to take the SP at home. There are many reasons why healthcare providers allowed women to take the drug home such as shortages of clean water and cups [40], high client-to-staff ratios which reduces consultation times resulting in poor or no observation [4, 30]. Taking doses of SP under direct observation therapy (DOT) of healthcare provider is one of the strategies in implementation of IPTp-SP with high fidelity [13]. This suggests that health care providers should strive to follow protocols in SP provision. Besides, health facilities’ management has to strengthen their efforts in supervising ANC providers and learn about challenges they face in order find solutions of strengthening DOT, which would work in their context. Considering that resources, such as cups and clean drinking water, will never be sufficient, ZDHO and health facility management ought to be pragmatic in overcoming this challenge. One solution might be engaging community leaders to encourage pregnant women to bring with them a cup when on a scheduled ANC visit.

The odds of completing at least three doses of SP was more than 1.72 times higher among pregnant women between age group 25 to 34 than those aged between 15 to 24 years old. This result indicates that young pregnant women were under utilizing the intervention, which is similar result that Kibusi’s study revealed [31]. Therefore, there is need to increase awareness of importance of completing recommended doses of IPTp-SP among pregnant women aged between 15 to 24 years as well pregnant women older than 34 years. The study has shown that poor uptake is affected by differentially on women born at different times, which might reflect women’s culture of health care utilization at different ages. For instant, teen pregnancies are usually unplanned therefore are less likely to consistently utilize ANC services and subsequently miss out on receiving optimal doses of SP.

Lastly, spouse escort to health facility has shown to be positively associated with good uptake of several interventions offered at ANC [41]. However, pregnant women in the study population who had a problem with spouse escort were more likely to complete the recommended doses of SP. Mostly, these women were either divorced or windowed or on separation, hence they were socially vulnerable and probably took their situation positively by attending ANC clinics and took the recommended SP doses to avoid MiP and its adverse effects. The other possible explanation would be that they had more autonomy in relation to the use of ANC than married women [42]. This might imply that pregnant women with more autonomy are in a position to have confidence in prioritization of health care services.

This study had the following limitations. First, the study participants were recruited from health facility maternity wings and antenatal clinics. In Malawi, according to National Statistical Office (NSO) [Malawi] and ICF Macro [34], 20% of births occur at home and 80% of women who received no antenatal care services deliver at home. Therefore, it would not be representative of the wider population of postpartum women in Zomba district. However, the researcher minimised the limitation by including women who delivered at home and visited the health facility within 48 h for check-up. Only 14% of women age 15–49 giving birth outside health facility received a postnatal check in the first 2 days after delivery [43]. Second, the health systems factors (time and patient flow challenges, integration of services into ANC); Policy and guidance environment, human resource factors, and supply chain factors (SP availability at the facility) also play an important role in the coverage of the intervention. However, this study did not study them because the focus was primarily on pregnant women’s perceptive. This limitation would under-or-overestimate the problem understudy when viewed holistically. Third, the study focused on determinants of IPTp-SP uptake in postpartum women from catchment areas of selected Health facilities in Zomba district. Hence, the results would not be generalised to all districts in Malawi because the participating district was purposively sampled because of its low uptake. However, the results could be related to other districts with similar characteristics as the sampled one. Finally, recall bias is an inherent limitation of the survey design. There was a possibility of women reporting past exposures/experiences with varying degree of accuracy. However, some of these recall biases were minimised by using records such as ANC cards and interviewing the women immediately after delivering.

Malaria in pregnancy continues to pose a major public health problem in sub-Saharan Africa and particularly in Malawi. However, there are a number of evidenced-based interventions for preventing MiP and one of them is IPTp-SP. This study was conducted to identify the enablers and barriers of a pregnant woman completing at least three doses of IPTp-SP and estimate the uptake levels in Zomba district. The study demonstrated that there is low utilisation of SP in this population and this seems to be associated with the number of ANC visits, use of DOTs and health facility location. Therefore, community-based health promotion on optimal ANC attendance should be encouraged and antenatal care clinics should strengthen IPTp messages particularly on younger pregnant women. Zomba District Health Office in collaboration with health facilities’ management have to strengthen their efforts in supervising ANC providers to enhance DOT. Further research needs to be carry out to understand factors affecting the rural-urban differential IPTp uptake to provide evidence that would address the variance.