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Background: Maternal malaria is associated with serious adverse pregnancy outcomes. One recommended means of preventing malaria during pregnancy is intermittent preventive therapy (IPTp) with sulfadoxine/pyrimethamine (SP). We sought to identify determinants of preventive use of SP during pregnancy among recently pregnant women in Uganda. Additionally, we characterized the timing of and indications for the administration of SP at antenatal care (ANC) visits and missed opportunities for SP administration. Methodology/Principal Findings: Utilizing a population-based random sample, we interviewed 500 women living in Jinja, Uganda who had been pregnant in the past year. Thirty-eight percent (192/500) of women received SP for the treatment of malaria and were excluded from the analysis of IPTp-SP. Of the remaining women, 275 (89.3%) reported at least two ANC visits after the first trimester and had an opportunity to receive IPTp-SP according to the Ugandan guidelines, but only 86 (31.3%) of these women received a full two-dose course of IPTp. The remaining 189 (68.7%) women missed one or more doses of IPTp-SP. Among the 168 women that were offered IPTp, 164 (97.6%) of them took the dose of SP. Conclusions/Significance: Use of IPTp in Uganda was found to be far below target levels. Our results suggest that women will take SP for IPTp if it is offered during an ANC visit. Missed opportunities to administer IPTp-SP during ANC were common in our study, suggesting provider-level improvements are needed. © 2010 Sangaré et al.
Between November, 2008 and January, 2009 a simple random sample of 500 female residents of Kibibi and Namizi parishes in Budondo-sub county of Jinja District, Uganda was invited to participate in a home-based interview to ascertain use of ITNs and SP during pregnancy, as well as possible factors associated with use. Interviews were conducted using a structured pre-tested questionnaire adapted from the conceptual framework proposed by Ribera et al. [20]. Women between the ages of 15 and 49 years who had a pregnancy within the past 12 months that lasted until at least the third trimester, regardless of pregnancy outcome, were eligible to participate. Due to the cross-sectional design of the study, current pregnancies were excluded to ensure equal opportunity among all participants to have received IPTp during their most recent pregnancy. Budondo-sub county of Jinja District was selected as the field site based on the availability of a recently completed census in November 2008, allowing for a population-based simple random sample to be selected. Namizi and Kibibi parishes are comprised of 16 rural and peri-urban villages, with a combined population of 21,681, of whom 4,654 were females aged 15–49 years, and 867 of these women reported having been pregnant in the previous 12 months. Jinja district is a peri-urban area where malaria is considered meso-endemic, with a relatively low transmission intensity; the average annual entomological inoculation rate is 6 infective bites per person per year [21]. Each parish has one public health center; Kibibi has a level II facility and Namizi a level IV facility. The administration policy of IPTp and the frequency of stock-outs of SP at the study clinics were assessed prior to the start of the study. Stock-outs of SP during the study period were uncommon (Namizi and Kibibi health centers, personal communication). While the Ugandan guidelines specify IPTp with SP should be taken as directly observed therapy (DOT), this is not consistently implemented in the study clinics due to lack of access to clean water and cups. For each ANC visit the woman attended, we ascertained if SP was offered or not and categorized her experience as 1) having received SP; 2) out of stock of SP, the woman was told to buy it on her own or return to ANC later to receive it; 3) asked to buy SP from the ANC; 4) the ANC never mentioned SP, or 5) SP was offered, but the woman declined to use it. To facilitate recall, a pregnancy history calendar was generated for each woman and used to record episodes of self-reported malaria, any use of SP or other antimalarials during pregnancy, and ANC visits. Additionally, women were shown photographs of SP packaging and the corresponding tablets for the most common formulations of SP available in the area. Self-reported SP use was compared with SP administration as recorded on antenatal cards for the subset of women who had retained the cards. IPTp with SP was defined as a complete 2-dose course of SP administered after the first trimester [9], [22], [23], [24], [25], if the participant believed the SP was used for the prevention of malaria. The analysis of IPTp was restricted to those participants with at least two qualifying ANC visits after the first trimester who had the opportunity to receive a complete course of IPTp. The indication for the use of SP (treatment or prevention) was based on self-report from the woman by asking her if she believed she was sick with malaria for each of the doses of SP that she received. Women who reported receiving SP for the treatment of malaria symptoms were excluded from the analysis of IPTp-SP for the following reasons: 1) determinants of use of treatment doses among women with symptoms suggestive of malaria are likely to be different than those of preventive doses among asymptomatic women; and 2) women who received a therapeutic dose of SP administered in concordance with the IPTp schedule would be unlikely to receive the recommended two or more preventive doses of SP. The Ugandan IPTp guidelines recommend that SP should not be given: during the first trimester of pregnancy, less than 4 weeks between doses, to women with a history of allergies to sulfa drugs, to women concurrently using cotrimoxazole, or to women with symptomatic malaria [26]. IPTp-SP was categorized as a full course: a complete 2-dose course of IPTp administered after the first trimester; partial course: only 1 dose after the first trimester; or none: a) 0 doses in the after the 1st trimester. Analyses were performed using Stata version 11.0 (College Station, Texas, USA). A 7-point composite variable was generated to summarize each woman’s knowledge of malaria, and a 4-point composite variable summarized her knowledge of SP safety. Principal components analysis was used to calculate the household wealth index, a standardized composite measure combining the cumulative living standard of a household and is based on a household’s ownership of selected assets, such as televisions and bicycles, materials used for housing construction, and types of water access and sanitation facilities [27]. Relative risk regression was used to determine the association between exposures of interest and receipt of a full-course of IPTp-SP [28], [29]. Risk estimates were adjusted for the number of ANC visits, however, small numbers precluded further adjustments. The study was approved by the Makerere University Research and Ethics Committee, the Uganda National Council for Science and Technology, and the University of Washington, Human Subjects Division. All participants provided written informed consent.
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