Access to and use of preventive intermittent treatment for Malaria during pregnancy: A qualitative study in the Chókwè district, Southern Mozambique

Background Malaria remains a significant health problem in Mozambique, particularly in the case of pregnant women and children less than five years old. Intermittent preventive treatment with sulfadoxine-pyrimethamine (IPT-SP) is recommended for preventing malaria in pregnancy (MiP). Despite the widespread use and cost-effectiveness of IPTp-SP, coverage remains low. In this study, we explored factors limiting access to and use of IPTp-SP in a rural part of Mozambique. Methods and findings We performed a qualitative study using semi-structured interviews to collect data from 46 pregnant women and four health workers in Chókwè, a rural area of southern Mozambique. Data were transcribed, translated where appropriate, manually coded, and the content analyzed according to key themes. The women interviewed were not aware of the risks of MiP or the benefits of its prevention. Delays in accessing antenatal care, irregular attendance of visits, and insufficient time for proper antenatal care counselling by health workers were driving factors for inadequate IPTp delivery. Conclusions Pregnant women face substantial barriers in terms of optimal IPTp-SP uptake. Health system barriers and poor awareness of the risks and consequences of MiP and of the measures available for its prevention were identified as the main factors influencing access to and use of IPTp-SP. Implementation of MiP prevention strategies must be improved through intensive community health education and increased access to other sources of information. Better communication between health workers and ANC clients and better knowledge of national ANC and IPTp policies are important. The study was conducted in the health and demographic surveillance system (HDSS) catchment area of the Chókwè district, Gaza Province, Mozambique. Chókwè is a rural district is situated on the Limpopo River and most of its population belongs to the Changana ethnic group, whose main economic activities are subsistence farming, large-scale rice production, livestock keeping, small business and migrant labour in South Africa. Around 135,000 habitants are under continuous follow-up through the HDSS. This system covers an area of approximately 600Km2 within a 25Km radius of Chókwè City. The HDSS is run by the “Centro de Investigação e Treino em Saúde de Chókwè” (CITSC), a clinical research center affiliated with the Instituto Nacional de Saúde, which is overseen by the country’s Ministry of Health. The HDSS routinely registers pregnancies, births, deaths, and migrations [Bonzela et al, in preparation]. There are two seasons: a hot, rainy season that runs from November to April and a cool, dry season that runs from May to October. Malaria transmission is perennial and occurs year-round, although it is more intense during the rainy season. Plasmodium falciparum is the predominant malaria parasite species in the area [19]. At the time of data collection, the country had adopted the new WHO policy recommendation that calls for monthly SP administration and a minimum of three doses during the course of pregnancy [20]. Within the HDSS catchment area the official health Network is comprised by nine health centres. The referral district hospital is Chókwè Rural hospital with 125 beds and the Carmelo hospital which is specialized in TB and HIV management. Most of the government medical services are provided free of charge except for drugs prescribed at the outpatient department, which are available for purchase at subsidized prices. The other seven health centres provide maternal and child health care and preventive services, screening and treatment of syphilis, anemia, and urinary tract infections, administration of anthelmintic treatments, ferrous sulphate supplementation, folate tablets, and tetanus toxoid vaccines, and prevention of mother to child transmission of HIV [15]. The prevalence of HIV in Mozambican women aged 15–49 years in 2015 was 28.2% in 2015 [17]. This was a descriptive qualitative study undertaken between March and April 2015 in the context of a study conducted in the same area designed to evaluate IPTp-SP uptake and pregnancy outcomes in order to explore barriers to IPTp for preventing MiP. Four primary health facilities were selected for data collection. To qualify for participation in the study, the health center had to be located in the study area and offer maternal and child health care and preventive services. Therefore, the Chókwè Health Center, Terceiro Bairro Health Center, Lionde Health Center and Conhane Health Center were selected into the study. At each of the four facilities, interviews were held with a sample of health service users, represented by pregnant women aged ≥15 years old, and health workers, represented by nurses. Pregnant women were randomly selected from those who visited the health facilities for prenatal consultations and provided their written informed consent to participate in the study. One nurse was selected at each of the health facilities. To qualify for participation in the study, the nurse had to have been delivering ANC for at least 1 year before the interview. Interviews were held in a private room at the healthy facility and conducted by an experienced male social scientist assisted by a female research officer specifically trained for this study. Sessions ran for approximately 45 minutes and were conducted in Portuguese and/or in Changana (local language) depending on the participants’ preferences. All interviews were digitally recorded. Interview guides were developed to explore factors limiting access to IPTp during pregnancy from the perspectives of both the pregnant women and the nurses. The Pregnant women were interviewed using a semi-structured questionnaire focusing on (a) general perception of diseases in the study area, (b) perceptions of malaria and IPTp-SP, and (c) experiences with ANC and perceptions of the quality of service (S1 Form). The nurses were asked about (d) women’s attitudes towards IPTp and challenges for IPTp-SP delivery (S2 Form). The full content of the interview recordings in the local language (Changana) was transcribed verbatim and translated into Portuguese. All transcripts were read for accuracy before the analysis. Data were coded separately according to the original research questions and the data collection guides. They were coded using pre-defined themes based on the research questions and analyzed manually using a content data analysis method, which involved familiarization with data through reading and re-reading of transcripts and refining of themes by comparing codes with research questions. The headings used in the results and discussion sections of this paper reflect the codes used for the analysis. The study was approved by the National Health Bioethics Committee (CNBS) (IRB 00002657). Administrative approval to conduct the study was obtained from the local health facilities and the Ministry of Health of Mozambique. With participants’ prior agreement, written informed consent was obtained prior to the interview. Women under 18 years of age provided informed assent and their husbands, mothers, or representatives provided informed consent. During transcription, names were replaced with codes to ensure anonymity and digital recordings were deleted once the transcription and translation had been completed and checked for quality.