Background
Malaria contributes to 11% of maternal deaths in Nigeria [
1]. Parasite prevalence in pregnant women in Nigeria could be as high as 60-70% [
2]. These women are infected with
Plasmodium falciparum, the most virulent Plasmodium with serious health consequences including anaemia, impaired foetal growth, still birth, and premature delivery [
3,
4].
Intermittent-preventive treatment of malaria in pregnancy (IPTp) using sulphadoxine-pyrimethamine (SP) was approved by the World Health Organization (WHO) Expert Committee on Malaria for the control of malaria in pregnancy in areas of moderate to high transmission [
5]. This followed a number of studies documenting its effectiveness [
4,
6,
7]. SP was also found to be effective in increasing birth weight and reducing prevalence of preterm deliveries and maternal anaemia in Nigeria [
8].
In May 2000, African leaders in Abuja under the Roll Back Malaria (RBM) partnership set the target that by 2005 at least 60% of all pregnant women who are at risk of malaria, especially those in their first pregnancies should have access to chemoprophylaxis or IPT [
9]. The WHO reports that at the end of 2008, 35 of 45 sub-Saharan African countries had adopted IPTp as national policy [
10]. However, coverage has remained far from the target in many countries including Nigeria.
In 2001, Nigeria instituted intermittent preventive treatment using SP for pregnant women in the second and third trimesters of pregnancy. However, both first and second dose coverage remains low being 8.0% and 4.6% respectively in Nigeria and 9.9% and 5.4% in south-east Nigeria [
11]. The use of IPTp in Nigeria involves the administration of at least two curative doses of SP during pregnancy, regardless of whether the woman is infected [
12]. The first dose is taken after quickening (WHO 2004) and there should be at least one month between the two doses. However, although the WHO guideline allows the administration of IPTp all through the third trimester, the policy in Nigeria recommends otherwise, stating that
'the last dose should be given not later than one month before the expected date of delivery'[
12]. Direct observed treatment (DOT) by a qualified health worker was also incorporated to ensure compliance by pregnant women [
13]. Compliance is further enhanced by the single dose treatment of SP.
Successful deployment of IPTp is dependent on the utilization rates of antenatal care (ANC) services amongst pregnant women. Attendance at ANC is high in most sub-Saharan African countries [
5], but up to 25% of pregnant women pay the first visit in the 3 rd trimester [
14]. This may affect the impact of ANC and IPTp related services as delivery of the second dose of SP is substantially reduced and envisaged protection for mother and foetus is lost [
15].
A woman that attends ANC needs to do so at appropriate times for delivery of IPT, which is best given when the growth of the foetus is occurring at its highest velocity (16th - 24th week) as this helps to reduce placental parasitaemia, foetal growth reduction and the resultant low birth weight [
16]. Whether a woman starts early or late, each visit should count so that opportunities created by her attendance to ANC are not missed for the delivery of relevant interventions. However, studies have shown that missed opportunities abound and constitute a challenge for IPTp delivery [
17,
18].
Apart from failure to attend ANC clinics, other identified barriers to use of IPTp include poor acceptance of SP because of perceived association of SP with side effects, abortions and foetal deformities [
19‐
21]. However, clinical studies have shown such side effects are uncommon [
4,
6,
7,
22].
This study examined whether demand side factors constrain coverage of IPTp amongst pregnant women. This enabled the identification of opportunities to intervene to improve coverage. The study also examined the differences in coverage and demand side barriers between urban and rural dwellers. These are lacking for Nigeria where maternal mortality remains high[
11].
Results
The average age of respondents in the household survey was 28.3 years (Standard error = 0.11) (Table
2). Most of the women completed secondary education with the proportion slightly higher in the urban area. In both LGAs, most respondents were married. Similarly, the mean age of respondents for the exit interview was 28.4 years (SE = 0.83); most of them completed secondary school and were married.
Table 2
Socio-demographic characteristics of respondents
Age: mean (standard error)
| 28.4 (0.13) | 28.3(0.19) | 28.3 (0.11) | 28.4 (0.83) |
Highest Level of education reached
| | | | |
None | 0.4 | 1.0 | 0.6 | 0.7 |
Incomplete Primary | 0.7 | 2.0 | 1.2 | 2.1 |
Complete Primary | 8.3 | 10.2 | 9.0 | 9.6 |
Secondary + | 90.6 | 86.8 | 89.1 | 87.7 |
Current marital status
| | | | |
Single | 3.0 | 4.0 | 3.4 | 4.8 |
Married | 91.2 | 88.4 | 90.1 | 88.4 |
Widowed | 5.3 | 5.6 | 5.4 | 6.2 |
Divorced/separated | 0.5 | 2.0 | 1.1 | 0.7 |
Antenatal care attendance and coverage of IPTp amongst survey respondents
IPTp coverage amongst all respondents for the first dose was 13.7% (16.9% in urban areas and 8.6% in rural areas, p < 0.01) [Table
3]. Second dose coverage was 7.3% and higher as well for the urban area though not statistically significant. Most women interviewed in the household survey (96.1%) attended antenatal care at least once, with significantly higher attendance among urban dwellers (99.3%) than rural dwellers (91%) [p < 0.005]. The majority of women made five or more visits for ANC, though the share was higher for urban than rural areas (89.2% vs. 78.7%, p < 0.001). Amongst ANC attendees, 1
st dose coverage was 14.3% while 2
nd dose amongst 1235 respondents that made at least two ANC visits was 7.8%.
Table 3
Coverage of IPTp for malaria amongst respondents
IPTp Coverage and ANC attendance amongst all respondents
| | |
First dose | 136 (16.9) [15.2-18.7] | 43 (8.6) [5.3-13.4] | 179 (13.7) [12.0-15.5] | 0.009* | |
Second dose | 71 (8.8) [7.3-10.6] | 25 (5.0) [2.5-9.6] | 96 (7.3) [5.9-9.8] | 0.085 | |
Attended ANC at least once | 800 (99.3) [96.7-99.8] | 456 (91.0) [89.0-92.7] | 1256 (96.1) [95.1-96.9] | 0.001* | |
Attended ANC ≥ 2 times | 785 (97.4) [94.8-98.7] | 450 (89.8) [87.7-91.6] | 1235 (94.5) [92.9-95.8] | 0.002* | 132 (90.4) [79.3-95.9] |
Coverage amongst ANC recipients
|
First dose amongst those attending at least once
| | | | | |
- Offered dose | 136 (17.0) [15.3-18.8] | 43 (9.4) [6.0-14.6] | 179 (14.3) [12.6-16.1] | 0.015* | 17 (11.6)[5.3-25.6] |
- Took drug | 135 (98.9) [94.6-99.9] | 42 (97.7) [84.2-99.7] | 177 (98.9) [94.6-99.8] | 0.383 | 17 (100) |
Second dose amongst those attending
| | | | | |
- Offered dose | 71 (9.0) [7.6-10.7] | 25 (5.6) [2.8-10.8] | 96 (7.8) [6.3-9.6] | 0.134 | 4 (3.0) [0.9-9.3] |
- Took drug | 70 (98.6) [88.3-99.9] | 23 (92.0) [63.6-98.7] | 93 (96.9) [86.1-99.4] | 0.144 | 4 (100) |
Amongst all the women that received antenatal care, 97.3% and 91.5% paid timely visits for the first dose and up to two doses of IPTp respectively based on the national guidelines (Table
4). Of these women, 14.1% and 7.7% were offered the first and second doses respectively giving missed opportunities of 85.9% and 92.3%. More urban dwellers were offered the first dose (p < 0.01). Based on WHO guidelines, 99.5% and 95.8% paid timely visits for the first and up to two doses, respectively, while 14.3% and 7.5% were offered IPTp. Seven and seven respondents who attended at inappropriate times for IPTp were offered the first and second doses respectively based on the national guidelines. However, all sevens offered the first dose and one of those offered the second dose were eligible based on the WHO guidelines. Additional 28 and 54 women, for first and second doses, respectively, would have also been eligible for these doses based on the WHO guidelines.
Amongst ANC attendees offered first and second doses, 98.9% and 96.9% accepted the medicine (Table
3). The two respondents who did not take the first dose felt it would affect the baby while all the three that did not take the second dose felt that the time was too close to delivery for them to take it.
For the exit survey respondents, overall IPTp coverage amongst all ANC attendees was 11.6% for the first dose and 3.0% for the second dose amongst those attending at least two times (Table
3). Based on the national guidelines, the figures for timely attendance for the first and second doses were 93.8% and 76.5% respectively, and the coverage amongst them was 12.4% and 4.0%, giving a missed opportunity of 87.6% and 96.0% respectively (Table
4). All those that received the first and second doses took them.
Table 4
Coverage amongst ANC recipients that paid timely visits based on national and WHO guidelines
First dose
|
- Timely attendance | 776 (97.0) [95.4-98.1] | 446 (97.8) | 1222 (97.3) [95.7-98.3] | 0.593 | 137 (93.8) [88.9-96.6] |
- Offered dose | 131 (16.9) [15.4-18.5] | 41 (9.2) [6.0-13.8] | 172 (14.1) [12.6-15.7] | 0.009* | 17 (12.4) [5.6-25.2] |
- Missed opportunity | 645 (83.1) [81.5-84.6] | 405 (90.8) [86.3-94.0] | 1050 (85.9) [84.3-87.4] | | 120 (87.6) [74.8-94.4] |
Second dose
| | | | | |
- Timely attendance | 731 (91.4) [88.9-93.3] | 418 (91.7) [87.8-94.4] | 1149 (91.5) [89.5-93.1] | 0.865 | 101 (76.5) [69.2-82.6] |
- Offered dose | 67 (9.2) [7.9-10.6] | 22 (5.3) [2.9-9.5] | 89 (7.7) [6.4-9.3] | 0.066 | 4 (4.0) [1.2-12.4] |
- Missed opportunity | 664 (90.8) [89.4-92.2] | 396 (94.7) [90.5-97.2] | 1060 (92.3) [90.7-93.6] | | 97 (96.0) [87.6-98.8] |
Coverage amongst ANC recipients that paid timely visits based on WHO guidelines
| | |
First dose
|
- Timely attendance | 795 (99.4) [98.4-99.8] | 455 (99.8) [97.8-99.9] | 1250 (99.5) [98.9-99.8] | 0.334 | |
- Offered dose | 136 (17.1) [15.4-18.9] | 43 (9.5) [6.0-14.6] | 179 (14.3) [12.6-16.2] | 0.015* | |
- Missed opportunity | 659 (82.9) [81.1-84.6] | 412 (90.6) [85.4-94.0] | 1071 (85.7) [83.8-87.4] | | |
Second dose
|
- Timely attendance | 765 (95.6) [93.6-97.0] | 438 (96.1) [90.2-98.5] | 1203 (95.8) [93.7-97.2] | 0.817 | |
- Offered dose | 68 (8.9) [7.4-10.6] | 22 (5.0) [2.7-9.2] | 90 (7.5) [6.1-9.1] | 0.066 | |
- Missed opportunity | 697 (91.1) [89.4-92.6] | 416 (95.0) [90.8-97.3] | 1113 (92.5) [90.9-93.9] | | |
Source of drug for IPTp and practice of directly observed treatment amongst those who took the drug
Of the household survey respondents who took the drugs for IPTp, 62.7% and 58.1% obtained the first and second doses free at the health facility respectively (Table
5). Only 13.6% and 21.5% of these patients reported taking the first and second doses offered at the facility under direct observation. For the exit poll, 13 (76.5%) of the 17 respondents that took the first dose of SP obtained it free at the facility while the rest purchased it at the facility. However, 82.4% took it at home, while the rest took it in the facility under observation. Similarly, three out of the four that took the second dose did so at home while one took it at the facility under observation. Two of them obtained it at the facility while the rest purchased it at the facility.
Table 5
Source of drug for IPTp and practice of directly observed treatment amongst recipients
How drug was obtained
| | | | | | |
Received free at the health facility | 60.0 | 71.4 | 62.7 | 52.9 | 73.9 | 58.1 |
Bought drug at health facility | 38.5 | 26.2 | 35.6 | 44.3 | 26.1 | 39.8 |
Bought drug elsewhere | 1.5 | 2.4 | 1.7 | 2.9 | 0 | 2.2 |
Where drug was taken
| | | | | | |
In facility under observation | 9.6 | 26.2 | 13.6 | 17.1 | 34.8 | 21.5 |
In facility without observation | 1.5 | 2.4 | 1.7 | 1.4 | 0 | 1.1 |
At home | 88.9 | 71.4 | 84.7 | 81.4 | 65.2 | 77.4 |
Results of focus group discussions
Only two out of all participants had ever heard of IPTp. One (from the urban area) heard of it when some visitors to the facility she registered talked about it. The second woman (from the rural area) heard of it from a friend in school. Thus, no one heard of IPTp from health workers. The two who said they knew about it said it was 'something they do to prevent malaria' but had no idea what drug is used, how many doses a woman should take, when in pregnancy it should be given and how it should be given. The participant from the rural area however reported that a woman that books at the eight month of pregnancy should not receive two doses.
After IPTp was described to participants, some participants from one of the four discussion groups (rural area) recalled being given SP (in combination with other drugs) by health workers during pregnancy for prevention, but not for treatment. Two recalled being asked by the caregiver to take two tablets first and one later while another took three at a time and was given a second dose one month before delivery.
Concerning use of SP during pregnancy, participants did not see any cause for worry about use of the drug during pregnancy. Side effects could happen but 'this is seen in all drugs used for malaria.' Rather, women are worried when they do not know the drugs to take; but they take drugs health workers give them because 'they (the health workers) will only give the safe ones.' They also did not identify any existing cultural factor that hinders them from going for antenatal care or taking drugs given to them by health workers. The only concern expressed by participants in the rural area was that when women are taking herbal drugs given to them (usually by the TBA or mothers), they collect and keep the 'modern drug' and may have to wait to finish the herbal one before taking drugs given to them by antenatal care providers. Husbands, mothers of pregnant women and their mothers-in-law were mentioned as the only people who could influence the decision of a woman to take the drug or not. Even at that, participants did not consider their influence significant.
Discussion
The level of coverage of IPTp in the study area was low despite the fact that a policy has been in existence in the country for a decade. However, the first dose coverage that was found in this study (13.7%) was significantly higher than that reported in the DHS 2008 for the southeast region of the country (χ2 = 7.96, p < 0.05), suggesting that further improvements have been made in coverage in the region. However, there was no significant difference for the second dose coverage found when compared with 5.4% coverage documented in the DHS 2008 (χ2 = 3.8, p > 0.05).
It is worthy of note that first dose coverage was lower amongst women living in rural areas compared to their urban counterparts. Earlier reports found coverage levels of 12.6% and 6.0% amongst women living in urban and rural areas of the country, respectively [
11]. This unequal coverage indicates that access barriers still exist to higher degrees for those in the rural areas.
The overall low coverage occurs despite the finding that nearly all women receive antenatal care and most make enough visits. Higher IPTp coverage has been reported even in settings with lower ANC attendance rates [
24]. Other authors note that high attendance to ANC does not translate to high IPTp coverage [
15,
25]. This study shows that women pay enough visits for ANC and should be eligible to receive IPTp. Moreover, even though they do not know enough about IPTp to make informed demand for it, they make themselves available enough to receive interventions provided at the facility.
Apart from making the right number of visits, the visits should be appropriately timed. This study shows that not only did women go for ANC, most women attended at appropriate times for the delivery of two doses of IPTp irrespective of the guideline used for examining attendance. Attendance to ANC was timely for up to two doses to be offered even when they paid the first visit late in their pregnancy. Further still, geographic location did not affect timely attendance amongst ANC attendees. Yet, even amongst women who paid timely visits, the coverage was still very low. Similar observations have been made elsewhere [
26]. What abound are missed opportunities, which, if taken advantage of, provide enough opportunities for increase in coverage. This finding suggests that supply rather than demand side factors could be responsible for low coverage of IPTp and need to be examined. The problem of missed opportunities is further compounded by another supply related issue - the national guidelines - which make women ineligible for IPTp during the last month of pregnancy, even though such a practice is not supported by clinical evidence [
5].
A common concern that may affect use of IPTp is that women may be unwilling to take drugs given to them, usually because of side effects [
19]. This study however found that women take drugs given to them once it comes from the health workers, and do not have serious concerns about side effects which may affect them. Additionally, they do not think cultural barriers affect their demand for IPTp. This suggests that demand side concerns are unlikely to be responsible for low coverage and use of IPTp.
The study found that over three-quarter of those that took drugs reported that they were allowed to take the drug home, contrary to the guidelines for IPTp administration which stipulate the use of DOT. The findings of the exit interview corroborate those of the household survey and similar reports of poor experience of DOT elsewhere [
19,
27]. The implications for effectiveness of deployment of the intervention are significant - women are poorly covered with the intervention, and for the few who receive it, its effectiveness is likely to be further hampered by poor utilization practices which conflict with recommended guidelines. It would be useful to determine why limited use of DOT is reported by the women by exploring supply side practices.
A useful indicator for monitoring improvements in implementation of the IPTp policy could be the reduction in missed opportunities for coverage amongst those who could have received it. With the limited impact of demand side factors and the need to focus on the challenges with the primary delivery system, such an indicator may then reflect supply side constraints. However, research needs to be carried out to determine the usefulness of such an indicator and its sensitivity to demand and supply side changes.
In conclusion, this study found low coverage of IPTp in the study area which supported findings that high ANC attendance does not guarantee high IPTp coverage. Demand side factors such as attendance to antenatal care, appropriate timing of attendance, and perceptions about side effects were not significant constraining factors to increased coverage. The scenario is worsened by the reported low experience of directly observed treatment strategy amongst respondents. Further research is required to explore supply side influences to provide better understanding for the low coverage with IPTp.
Competing interests
The authors declare that they have no competing interests.
Authors' contributions
CO, KH and OO designed the study. CO and OO were involved in data collection and analysis. CO wrote the initial draft of the manuscript and all the authors participated in its finalization. All authors read and approved the final manuscript.