Background
Malaria is an infectious disease transmitted by specific mosquitoes, a public health problem facing many tropical and sub-tropical countries, and associated with substantial risks to the mother, foetus and newborn [
1,
2]. National, bilateral and multilateral organizations as well as other development stakeholders/partners have been working hard toward achieving a significant reduction of the occurrence and burden of this disease. Despite many health programmes having been instituted and others still being recommended, besides the advances in the newly recommended control methods, malaria in pregnancy (MiP) and in children under five years remains one of topmost public health problems calling for attention to be paid to in tropical and sub-tropical countries. This is due to the persisting epidemiological, systemic and operational challenges, and tropical sub-Saharan Africa (SSA) is the region mainly hit [
2,
3]. That is why the World Health Organization (WHO) has urged ministries of health (MoH) in malaria endemic countries to ensure that they prioritize identification, institutionalizing and strengthening of all measures aimed at promoting effective control of MiP and in under-five children who are most vulnerable to malaria infections and their morbidity and mortality consequences [
2,
4].
One of the advocated approaches for effective control of diseases in general is to ensure that basic preventive services as well as curative services are in place in the health care system [
5]. Where possible, attempt to achieve universal coverage by offering the basic (primary) health care services free of charge to all people in need irrespective of their incomes is highly recommended. However, there has been a prolonged research and policy debate on whether this policy ambition is realistic and, if so, would lead to the anticipated universal service coverage within and outside Africa [
6‐
8].
Intermittent preventive treatment of malaria during pregnancy (IPTp) using sulphadoxine-pyrimethamine (SP) is a strategy for malaria control in pregnant women that became officially recommended by the WHO in 2000. Since then, this strategy has become an integral package of national health care systems in SSA, particularly for protecting the targeted women and their pregnancies in areas with moderate to high malaria transmission. This strategy requires each pregnant woman in malaria endemic countries to receive a full therapeutic standard dose of SP at defined period, particularly allowing a one month period apart between one dose and the next one [
2,
4]. The IPTp guidelines recommend that the administration of the first dose (abbreviated as IPTp-1) should be done during the first trimester of pregnancy, but immediately after quickening while the second dose (IPTp-2) and, possibly, a third dose (IPTp-3) should be administered during the third trimester. That is to say that more than two doses are allowed for the women who manage to complete at least four scheduled ANC clinic visits. Meanwhile, it is suggested that pregnant women eligible for taking these doses have to be supervised by qualified health service providers under the directly observed therapy (DOT) procedure [
5]. When the SP is administered together with other supplementary medicines such as ferrous/iron and folic acid tablets, it is recommended that care should be taken to follow the official guidelines. In fact, a dose of 30-60 mg of iron and 0.4 mg of folic acid should be given daily to supplement SP per pregnant woman to reduce the risk of low birth weight in infants, maternal anaemia, and iron deficiency term. Moreover, SP can be administered to a pregnant woman with an empty stomach (hungry clients) or who not hungry for IPTp, but where it is noted that the client concerned is presents symptoms of malaria and get confirmed to be parasitemic, then she should not receive IPTp and instead should be treated with the appropriate drug recommended in the existing WHO/National guidelines [
5].
In Tanzania, MiP sustains high levels of morbidities and mortalities among pregnant women and newborn babies [
9,
10], and it accounts for at least 20% of all maternal deaths in some districts [
11]. In this country, maternal deaths have remained as high as over 500 per 100,000 live births for almost the past two decades without remarkable decline [
12]. Therefore, the latest records showing that maternal mortality ratio (MMR) caused by a combination of malaria, HIV/AIDS and other conditions has declined to 454 deaths per 100,000 live births, the infant mortality rate caused by malaria and other conditions being estimated at 51 per 1,000 population [
13], and under five mortality rate attributable to malaria and anaemia being estimated to be 23% [
12], are subject to further and review if possible debate. In Tanzania, the IPTp-SP strategy was put into operation in 2001 [
13,
14]. Initially, the Ministry of Health and Social Welfare (MoHSW)’s aimed to achive at least 60% coverage of all pregnant women with at least two doses of IPTp-SP by 2005 in line with the Abuja Declaration of 2000. However, the target was later on increased to a coverage rate of 85% pregnant women attending ANC clinics by 2010 [
15]. The latter decision was in line with the Roll Back Malaria Partnership’s aim that emphasized countries to target covering at least 80% of all the pregnant women living in areas with stable or high intensity of malaria with IPTp doses. The same projection was made about targeting to cover pregnant women using ITNs by 2010. Discouragingly, most countries did not succeed attaining this target due to a number of demand and supply barriers [
16].
The issue of administration of IPTp-SP following the existing national guidelines in Tanzania has remained precipitating debates. As reported before, at least a number of frontline HWs interviewed at various health care facilities (HFs) have criticised the ambiguities existing in the existing national guidelines in Tanzania. They pointed out the guidelines emphasizing the IPTp-1 dose to be administered in the 20-24 weeks of gestational age of pregnancy and IPTp-2 during the 28
th - 32
nd weeks gestational age. To them, this seemed contrary to WHO guidelines recommending IPTp-SP administration immediately after quickening and even at late stages of pregnancy including the time close to delivery [
5]. The national guidelines to which reference was made by the reporting workers have for a long time guiding the service provider not to administer SP after the 36
th week of their pregnancy because of the anticipated risks [
14]. From the perspective of other critics, this HW’s feeling cannot be counted as the failure of such individuals to comply with the requirements if they strictly adhered to giving SP not later than the stated period, and instead it is a reflection of a policy weakness in the first place [
17].
IPTp implementation in Tanzania has a wider chance of being widely implemented at the HFs owned by both the private and public authorities. So, it is a matter of where the client(s) seeks the services and the availability of the institutional environments that are supportive for the services needed to be accessed and utilised. Records indicate that nearly all public and many private (for-profit and not-for-profit) HFs in Tanzania provide ANC services or have ANC clinics, and over half of the Tanzanian population live within 5km of a nearby HF. Meanwhile, critics argue that despite the official records indicating that over 80% of the pregnant women in Tanzania are noted of having physical access to ANC services, they may not all and always utilise the services available at the existing facilities due to various physical, financial and process barriers [
18]. That is why it is important for the national malaria control program (NMCP) and officers to note that achieving higher ANC (including IPTp-SP) coverage rates is already constrained. They should recognize that high service coverage would depend on conditions related to the availability of essential medicines and other supplies, HWs’ and users’ compliance with guidelines as well as affordability of the services, and real or perceived quality of the services at the existing HFs [
17,
19]. The available evidence indicates that so far generally the proportion of pregnant women completing four ANC visits in Tanzania is low. Records reveal that the overall coverage is 43% for both urban and rural areas, while specifically it is 55% for urban areas only and only 39% for rural areas [
20].
In a nutshell, technical research reports, journal-based publications and official working papers/documents indicate the numerous factors constraining the delivery and uptake of IPTp to include the following categories: (i) psychosocial and cultural; (ii) economic (iii) systemic [
3,
21,
22]; (iv) biomedical; and (v) political. Issues that have received substantial attention include (a) how to provide optimal IPTp services to HIV positive clients [
5,
23]; (b) how to optimise, balance and combine advocacy and health communication on IPTp, insecticide-treated nets (ITNs) and indoor residual spraying (IRS) [
24]; and (c) how to optimise administration of IPTp-SP in areas with low and moderate malaria transmission intensity [
1]. Meanwhile, given the diverse nature of the challenges experienced at national and local levels, suggestions have been given that more studies are required to evaluate the status of IPTp implementation and provide recommendations for optimising the coverage and quality of services [
21,
25].
In Tanzania, documented psychosocial challenges are mainly related to negative social perceptions on SP’s safety and treatment benefits [
25‐
27]. Economic challenges are related to the availability/supply of SP at HF level [
3,
17,
18], how to provide IPTp-SP and ITNs free of charge to all eligible clients [
28], and costs/affordability of SP to the clients using the private and public HFs [
29,
30].
Within the framework of the National Package of Essential Reproductive and Child Health (RCH) Interventions, the Ministry of Health and Social Welfare (MoHSW) of Tanzania launched the focused ANC (fANC) programme in 2004. This programme was revised in 2007 [
12]. Frontline HWs were expected to use the fANC guidelines as reference material when administering IPTp-SP to pregnant women at ANC clinic levels. The fANC service package identifies a range of services which are essential for every ANC client. These include, among others, physical and clinical examination, laboratory screening for haemoglobin levels, HIV testing, syphilis testing, urine analysis, blood grouping and cross-matching, IPTp-SP through DOT, and administration of ferrous/folic acid tablets. Other elements include history taking, health education, health counseling (including counseling for HIV/AIDS), and basic vaccination/immunization. Furthermore, the frontline service providers are required to collect, keep and report on specific records of their clients related to delivered services and observed health status. This should be part of the essential national health information system to facilitate local and national decision-making including health service planning [
15,
31]. Since the fANC was introduced, its operational effectiveness (its real practicability potential) has not been systematically evaluated. That is why little information is so far available regarding the acceptability, accessibility, practicability and quality of fANC services [
21,
27]. As suggested earlier, a proper evaluation should have included insights or analysis and experience of frontline HWs who are responsible for implementing it [
2], and this is important because the HWs may be challenged by inadequate supplies, logistics and manpower [
32‐
34] on one hand and by socio-cultural, cost-related, and provider-client interaction factors on the other hand. All these factors either in singularity or in combination have a major lowering impact on the quality and uptake of services [
27,
35].
This paper, therefore, is relevant as it reports on a study that assessed the psychosocial, cultural, behavioural and systemic determinants of pregnant women’s attendance to ANC clinics and their ability to access and use IPTp-SP services. The data presented and analysis made on them help to narrow the current evidence gap and identify other potential areas needing further systematic research. Thus, the present paper presents the perspectives of HWs who have been dealing with ANC services directly as service providers or service managers at HF levels in two districts in Tanzania. It adds on the previous report from the same study districts on the equivalent perspectives of ANC users [
18], partly the service providers [
29], and of higher level stakeholders at district and national level [
17,
36,
37]. These findings provide additional evidence in support of the reports from a previous survey in Korogwe district also in Tanzania [
26] and the reviewed literature on previous studies in the same country and abroad [
27].
Acknowledgements
Funding for the study was obtained from The Bill and Melinda Gates Foundation through the Gates Malaria Partnership (GMP) coordinated by the London School of Hygiene and Tropical Medicine (LSHTM). Thanks to the GMP Director (Prof. Brian Greenwood, his Deputy Prof. Geoff Targett, Dr Hazel McCullough, Dr. Amit Bhazin, Karen Slater and Dalia Iskander, on behalf of GMP at the LSHTM) for their support in collaboration with DBL Centre for Health Research and Development and Centre for Malaria Parasitology (CMP) at the University of Copenhagen, Denmark. Prof. Ib C. Bygbjerg, Prof. Pascal Magnussen, Dr Jens Byskov (all from University of Copenhagen), Dr Kristian S. Hansen (University of Aarhus, Denmark) and Dr. Ǿystein E. Olsen (University of Bergen, Norway) commented on the respective PhD thesis chapter as during his leadership of GMM PhD study supervision in cooperation with Dr. PB. Libent Bankobeza, Paul Kiluwa, Nyangoma Mubyazi, Eli Mashauri, George Kambanga, Dorcas (Dorica) B. Mujwauzi-Mubyazi and Abdulatif Rashid for assisting in data collection. Data cleaning and preliminary analysis was done with help from Dr Bruno P. Mmbando, a biostatistician of NIMR working at Tanga Medical Research Centre, Tanzania. Administrative support from Local and Central Government Authorities in and cooperation from the study respondents Tanzania. Tanzania’s Government through the MoHSW and NIMR Director General approved GMM’s study leave and study publications.
Competing interests
The authors declare to have no competing interests.
Authors’ contributions
GMM conceived the study from which the data presented were collected as part of his PhD training. He has, therefore, participated in all stages of the study from after its conception, drafted first and final versions of the manuscript (MS). PB was one of the two principal supervisors of GMM PhD in health sciences study programme; also having reviewed and commented on this MS. All authors read and approved the final manuscript.