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Background: Malaria during pregnancy is dangerous to both mother and foetus. Intermittent preventive treatment of malaria in pregnancy (IPTp) is a strategy where pregnant women in malaria-endemic countries receive full doses of sulphadoxine-pyrimethamine (SP), whether or not they have malaria. The Nigerian government adopted IPTp as a national strategy in 2005; however, major gaps affecting perception, uptake, adherence, and scale-up remain. Methods. A cross-sectional study was conducted in peri-urban and rural communities in Nasarawa and Cross River States in Nigeria. Study instruments were based on the socio-ecological model and its multiple levels of influences, taking into account individual, community, societal, and environmental contexts of behaviour and social change. Women of reproductive age, their front-line care providers, and (in Nasarawa only) their spouses participated in focus group discussions and in-depth individual interviews. Facility sampling was purposive to include tertiary, secondary and primary health facilities. Results: The study found that systems-based challenges (stockouts; lack of provider knowledge of IPTp protocols) coupled with individual women’s beliefs and lack of understanding of IPT contribute to low uptake and adherence. Many pregnant women are reluctant to seek care for an illness they do not have. Those with malaria often prefer to self-medicate through drug shops or herbs, though those who seek clinic-based treatment trust their providers and willingly accept medicine prescribed. Conclusions: Failing to deliver complete IPTp to women attending antenatal care is a missed opportunity. While many obstacles are structural, programmes can target women, their communities and the health environment with specific interventions to increase IPTp uptake and adherence. © 2013 Diala et al.; licensee BioMed Central Ltd.
Cross River and Nasarawa States have very different climatic, cultural and socio-economic indicators, but they share similar demographic and health indicators and a high malaria burden. As Table 1 shows, uptake of maternal health care is higher in Cross River than in Nasarawa State, and IPTp uptake in both states is higher than the national average, but still very low [17]. In 2010, the proportion of Nigerian women who received ANC from a skilled provider was estimated at 58% (66% in the North Central region, where Nassarawa is located and 74% in South-South, where Cross River is located) [17]. Table 1 describes the demographic and health indicators for study respondents and contrasts national with state-specific health indicators. Demographic and health indicators *Source: National Population Commission and ICF Macro 2009; ** Source: National Population Commission and ICF Macro 2011. The cross-sectional study was conducted in peri-urban and rural communities in Cross River and Nasarawa States in July and August 2012. Study instruments were based on a socio-ecological model and the multiple levels that influence or present obstacles to change are shown in Figure 1[18]. The model takes into account the individual, community, societal, and environmental contexts of behaviour and social change, including cultural norms, traditions and gender roles personal, societal, and religious beliefs; and, systemic, institutional and environmental factors. The socio-ecological model is adapted as the conceptual framework for this study. Focus group discussions (FGDs) were conducted with women aged 20–40 years who were pregnant, post-partum, or had given birth in the previous two years; adolescents aged 14–19 years who accessed ANC and given birth in the previous two years; and in Nasarawa State, a “men-only” FGD was conducted with husbands of women who fitted the recruitment criteria and had also accompanied their wives to ANC facilities. Adolescents were included as a separate group because they often have age-specific concerns about health care, and stigma regarding teenage pregnancy may prevent them from seeking health care at government facilities. It was important to gather the views of male partners in a State such as Nasarawa, which has a large Muslim population, in light of the dominant role of men in women’s use of health facilities [19]. In-depth interviews (IDIs) were conducted with community-based and facility-based health care providers who offer routine ANC and treat pregnant women with malaria. Interviews with health care providers were designed to elicit the following information: ● knowledge of how malaria affects pregnant women and malaria signs and symptoms ● whether treatment for malaria during pregnancy is a part of focused ANC services ● detailed knowledge of IPTp, including the names of medicines, dosages, availability, and cost ● evidence on institutional-level barriers to adherence, including stock-outs and insufficient training ● incentives for pregnant women to return for the second IPTp-SP dose Ten study facilities that provide ANC services were purposively selected in each State: one tertiary facility, three secondary facilities and six primary health facilities. Fieldwork took place in two local government areas (LGAs) in Cross River (Calabar and Yakurr) and in three LGAs in Nasarawa (Keffi, Karu and Nasarawa Eggon). After a flood damaged one of the selected primary health facilities in Nasarawa, it was replaced by a district hospital, bringing the number of secondary facilities in Nasarawa to four. Three interviews were conducted in each facility with physicians, nurses, midwives or community health extension workers who deal directly with pregnant and post-partum women. The number of FGDs depended on participant availability (Table 2). Most focus group discussions were conducted in available meeting rooms in the selected health facilities. Other FGDs were held in community centres, recreation halls, and schools. Focus group discussions in Cross River State and Nasarawa State Table 2 describes the characteristics of the study population and the number and location of FGD conducted with each group. ANC clients at the selected facilities who met the age criteria were recruited to participate in the FGDs. Husbands of women who met study criteria were recruited into two “men only” FGDs in (rural and peri-urban) Nasarawa State. Initially, the study recruited women who had accessed ANC services because that is where IPTp is most often provided. The study was later expanded to include women who had not received ANC because large numbers of women were not attending ANC. These participants were recruited from communities; local leaders and chiefs assisted with recruitment, using town criers to announce the study and invite participation. FGD facilitators were of the same gender as participants and spoke the same languages. Field workers attended a two-day training that covered subject selection and recruitment, instruments and techniques, facilitation and note-taking skills. The pre-tested discussion guide and other survey instruments were translated into local languages: Efik, Lokarr and Pidgin in Cross River and Hausa in Nasarawa, then back-translated to English. Just before the FGDs, a short questionnaire covering basic demographic information including occupation, estimated household income, marital status, number of pregnancies and attendance at ANC was administered to about half of the participants. Audiotaped FGD sessions were transcribed and translated into English in the field to enable verification and first-level corrections. The data were then cleaned and imported into Atlas ti software for analysis. Data were coded according to a framework based on the conceptual model in Figure 1. Additional codes were created for themes that emerged from the data and transcripts were re-coded. Figure 1 is a modified socio-ecological model (SEM) with cross-cutting factors that identify the three levels (individual, community and environment) that impact women’s ability to make healthcare-seeking decisions. Modifying the SEM for change, the study examined factors that may motivate or impede the ability of pregnant women to act promptly and decisively to prevent and treat malaria at three levels (individual, community and environment). 1. Individual: factors related to individual personality and autonomy, including beliefs about malaria and the efficacy of modern medications. This includes women’s knowledge of MiP and understanding of IPTp. Women do not act alone, but are also heavily influenced by their families: husbands, significant others, mothers-in-law and other social circles play a role in women’s access to care. In the conceptual framework, the individual level consists of the woman (the centre of the SEM) and her immediate family, particularly her partner, from the “interpersonal” level of the model. 2. Community: The framework further expanded the interpersonal to include other community level factors that encompass the influence of in-laws, preferences for home births, preferences for traditional birth attendants and other relatives, friends, neighbours, peers and others in the community, those in the “interpersonal” level of the model but outside the immediate family unit. Other community factors relate to the culture and norms of the community, for example with regard to whether pregnant women are expected to seek care in health facilities, with traditional providers, or a combination of the two. Issues of spirituality and witchcraft play important roles in women’s beliefs and actions. 3. Environment: The third framework level is the “environment” as most factors are institutional or systemic and the term “environment” encompassed the two outer circles of the model. From the women’s perspective, this includes economic factors, women’s willingness to follow provider advice, and systemic factors at ANC facilities, such as waiting times and attitudes of providers. From the providers’ perspective, this includes MiP knowledge, training on MiP and focused ANC, and stock-outs. In addition, poor attitudes, a lack of professional commitment for quality and inappropriate charges for hospital forms on the part of providers hinder women’s abilities to seek and adhere to ANC services. Factors at the first two levels — individual and community — primarily relate to decisions to seek care (both routine ANC where IPTp should be provided and treatment for malaria if needed), accessing care at facilities and complying with provider instructions. Decisions to seek care are influenced by an understanding of MiP and its risks, perceptions of the effectiveness and quality of care, and support from family and community. Family and community support also influences women’s ability or motivation to access services and comply with instructions and adhere to medication regimen. Many factors at the environmental or institutional level relate to the kind of care pregnant women receive and are more specific to whether and how IPTp is provided.
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