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Background: Few women in Uganda access intermittent preventive treatment of malaria in pregnancy (IPTp) with sulfadoxine-pyrimethamine (SP). Previous studies have shown that high costs, frequent stock-out of drugs, supplies and poor quality of care are the greatest hindrance for women to access health services. In order to increase adherence to IPTp, we conceptualised an intervention that offset delivery care costs through providing a mama kit, created awareness on health benefits of IPTp and built trust between the provider and the client.Methods: The new strategy was conceived along four constructs namely: 1) creating awareness by training midwives to explain the benefits of SP and the importance of adhering to the two doses of SP as IPTp to all pregnant women who attended ANC and consented to the study. Midwives were trained for two days in customer care and to provide a friendly environment. The pregnant women were also informed of the benefits of attending ANC and delivering at health facilities. 2) Each woman was promised a mama kit during ANC; 3) trust was built by showing the mama kit to each woman and branding it with her name; 4) keeping the promise by providing the mama kit when women came to deliver. The strategy to increase adherence to two doses of SP and encourage women to deliver at health facilities was implemented at two health facilities in Mukono district (Kawolo hospital and Mukono health centre IV). The inclusion criteria were women who: i) consented to the study and ii) were in the second trimester of pregnancy. All pregnant women in the second trimester (4-6 months gestation) who attended ANC and consented to participate in the study were informed of the benefits of SP, the importance of delivering at health facilities, were advised to attend the scheduled visits, promised a mama kit and ensured the kit was available at delivery. The primary outcome was the proportion of pregnant women adhering to a two dose SP regimen.Results: A total of 2,276 women received the first dose of SP and 1,656 (72.8%) came back for the second dose. 1,069 women were involved in the evaluation (384 had participated in the intervention while 685 had not). The main reasons that enabled those who participated in the intervention to adhere to the two doses of IPTp and deliver at the study facilities were: an explanation provided on the benefits of IPTp and delivering at health facilities (25.1%), availability of a mama kit at delivery (24.6%), kind midwives (19.8%) and fearing complications of pregnancy (8.5%). Overall, 78.0% of these women reported that they were influenced to adhere to IPTp by the intervention. In a multivariable regression, nearby facility, P = 0. 007, promising a mama kit, P = 0.002, kind midwives, P = 0.0001 and husbands’ encouragement, P = 0.0001 were the significant factors influencing adherence to IPTp with SP.Conclusion: The new strategy was a good incentive for women to attend scheduled ANC visits, adhere to IPTp and deliver at the study facilities. Policy implications include the urgent need for developing a motivation package based on the Health-Trust Model to increase access and adherence to IPTp. © 2013 Mbonye et al.; licensee BioMed Central Ltd.
The study was conducted in a malaria endemic district of Mukono in central Uganda. The total population of the district is 850,900 with an annual growth rate of 2.3% and consists predominantly of subsistence farmers of the Baganda ethnic group. The majority of the population, 88%, lives in rural areas. Access to health services is poor and adherence to the two doses of IPTp is currently estimated at 25.9% in the central region where Mukono district is situated. Despite this, ANC attendance for the first visit is high, 94% and women who attend the 4 recommend visits in the central region is 69.1% [2]. Although drugs and supplies in maternity units are supplied free in public facilities as government policy, frequent stock-outs due limited funding and delivery constraints compromise the quality of services. The new strategy was conceived along four constructs of a model (Health-Trust Model) we have constructed, namely: 1) creating awareness by explaining the benefits of SP and the importance of adhering to the two doses of IPTp. 2) Each pregnant woman attending routine ANC was promised a mama kit; 3) trust was built by showing the mama kit to each woman and branding it with her name; 4) keeping the promise by providing the mama kit when women came to deliver. The mama kit contained 1 metre of a polyethylene sheet, four pairs of gloves, cotton wool, gauze, surgical blade, soap and tetracycline eye ointment. The primary outcome was the proportion of pregnant women who adhered to the two doses of SP. The strategy was evaluated by interviewing women exiting maternity units after delivery from January to December 2011. The evaluation used a quasi-experimental design to assess factors that encouraged women to adhere to IPTp with SP. The evaluation of this intervention was based on a quasi-experimental study design comparing a sample of women who participated in the intervention and those who did not. Selection of respondents was based on the following criteria: i) any woman who had just delivered at either of the two centres and II) consent to participate in the evaluation. Sample size calculation was based on the proportion of women who completed two doses of SP as IPTp in Uganda estimated at 25% [1]. In order to detect a difference of 6% in this proportion at 80% power and 5% level of significance, a minimum sample of 357 women in each group was required. We aimed to measure the impact of the intervention by asking exiting clients what factors enabled them to adhere to the two doses SP as IPTp and deliver at the health facilities. The client exit interviews were conducted from January to December 2011. A structured questionnaire was administered to all consenting women exiting the maternity units over a period of 12 month. The client exit questionnaire captured data on demographic characteristics, access to IPTp, delivery experience, client satisfaction, reasons that compelled women to adhere to IPTp and recommendations to attract other women to access essential maternal care. Twelve midwives working at the two maternity units at Kawolo hospital and Mukono health centre IV conducted the interviews. They were trained for 2 days on study procedures and participated in the pre-testing and revision of the questionnaire before the study. The questionnaire was initially developed in English and translated into the local language (Luganda). The field coordinator and the research team supervised all aspects of data collection. Data were entered and verified using Microsoft Access 2007 (Microsoft Inc., Redmond, Washington) and analysed using STATA version 11.0 (STATA Corporation, College Station, Texas). Qualitative data was coded and entered. Univariate and bivariate analyses were performed to assess factors that enabled women to adhere to two doses of IPTp with SP, deliver at health facilities and client satisfaction. A binary logistic regression was constructed to analyse factors that enabled women to adhere to IPTp. Variables with a P-value less than 0.05 on Univariate analyses were entered into the model using a stepwise procedure. Odds ratios and 95% confidence intervals were calculated. Comparisons between women who participated in the study and those who did not, were made by a chi-square test and a two-sample proportion test. For all calculations, statistical significance was a P-value less than 0.05. Ethical approval for the research was granted from review boards at the Uganda Virus Research Institute and Uganda National Council of Science and Technology (Reference HS. 747). Written consent was obtained from all participating women.
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