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Background: The level of access to intermittent preventive treatment for malaria in pregnancy (IPTp) in Nigeria is still low despite relatively high antenatal care coverage in the study area. This paper presents information on provider factors that affect the delivery of IPTp in Nigeria. Methods. Data were collected from heads of maternal health units of 28 public and six private health facilities offering antenatal care (ANC) services in two districts in Enugu State, south-east Nigeria. Provider knowledge of guidelines for IPTp was assessed with regard to four components: the drug used for IPTp, time of first dose administration, of second dose administration, and the strategy for sulphadoxine-pyrimethamine (SP) administration (directly observed treatment, DOT). Provider practices regarding IPTp and facility-related factors that may explain observations such as availability of SP and water were also examined. Results: Only five (14.7%) of all 34 providers had correct knowledge of all four recommendations for provision of IPTp. None of them was a private provider. DOT strategy was practiced in only one and six private and public providers respectively. Overall, 22 providers supplied women with SP in the facility and women were allowed to take it at home. The most common reason for doing so amongst public providers was that women were required to come for antenatal care on empty stomachs to enhance the validity of manual fundal height estimation. Two private providers did not think it was necessary to use the DOT strategy because they assumed that women would take their drugs at home. Availability of SP and water in the facility, and concerns about side effects were not considered impediments to delivery of IPTp. Conclusion: There was low level of knowledge of the guidelines for implementation of IPTp by all providers, especially those in the private sector. This had negative effects such as non-practice of DOT strategy by most of the providers, which can lead to low levels of adherence to IPTp and ineffectiveness of IPTp. Capacity development and regular supportive supervisory visits by programme managers could help improve the provision of IPTp. © 2012 Onoka et al.; licensee BioMed Central Ltd.
The study was conducted in Enugu North and South local government areas (LGA) and Udi LGA in Enugu State, south-east Nigeria, in 2010. Udi LGA (rural) has a population of 244,852, and Enugu North and South (urban) have a combined population of 443,575 [16]. The public health care delivery system in the state is organized in three levels based on a District Health System with primary level facilities being the entry point for health care utilization. This level also serves as the primary point of delivery of ANC services. In Udi and Enugu, 17 and 11 of such public health facilities, respectively, offer ANC services. In addition, there are several private health facilities in Enugu while six major ones exist in Udi. Each health facility has an ANC/maternity unit that has responsibility for providing ANC, family planning and delivery services. An ANC/maternity unit is headed by staff of the facility with relevant skills for maternal health service delivery, and ANC clinics are held twice a week. Malaria is highly endemic in Enugu [17]. In line with the policy of the Federal Ministry of Health (FMOH) [1], the state implements IPTp delivery. Implementation of IPTp involves use of SP for IPTp, delivery of the first dose after the 16th week of pregnancy, and provision of two doses for pregnant women at least four weeks apart, and three for HIV-positive pregnant women. Health workers are not to give SP within the four-week period preceding a woman’s expected date of delivery, quite unlike the WHO regulation which allows IPTp to be offered at this time [7], and it must not be offered within the first trimester of pregnancy. The strategy also stipulates that the health providers should give SP under direct observation at the health facility. Healthcare providers that provide ANC services receive training through workshops organized by the state Ministry of Health, and other non-governmental organizations involved in malaria control. These organizations also distribute posters and leaflets that specify the guidelines for delivery of IPTp to both public and private health care facilities [18]. Data were collected using an in-depth interview guide and a checklist. The interview guide was used to collect data from the heads of the ANC/maternity units in all the 28 public primary health facilities offering ANC services in Enugu and Udi, and from an additional six purposely selected private hospitals (three from each district). The information obtained included health workers’ knowledge of the existence of a policy on IPTp, the procedures for delivery of IPTp, as well as the reasons underlying observed practices. In-depth interviews were recorded using a digital voice recorder. A facility checklist was also used to obtain information on availability of SP and water for ANC on the day that the facility was visited. In addition the number of ANC clients, and the skilled attendants as defined by WHO [8] that ran the ANC clinics for the week preceding the facility visit were obtained from the facility staff register to enable determination of the ratio of ANC client/skilled attendant per clinic day. The number of unskilled staff (such as community health extension workers (CHEWs) who do not receive midwifery training) providing assistance, or fully manning, a unit was obtained. Recorded interviews were transcribed following each interview. The transcripts were coded based on predetermined themes corresponding to the main categories of interest. Information given by each provider was compared with the FMOH implementation guidelines for IPTp delivery in order to determine whether the provider had correct or incorrect knowledge of any of the components, and the number of providers that knew the four components that served as criteria for assessment of knowledge. These were: correct knowledge of the drug used, time of first dose administration, of second dose administration, and knowledge of the strategy for administration (DOT). Emphasis was then laid on describing deviations from the guidelines with regard to provider knowledge and behaviour, and the facility-related factors that may help explain observations. Apart from description of providers’ behaviour, summary statistics were obtained from the data and presented based on facility characteristics, such as urban and rural location and whether they were private or public providers. Summary statistics were also obtained from the facility checklists and categorized based on the above characteristics and the data generated were related to data from the qualitative data analysis to enhance the understanding and interpretation of the study findings. The information obtained from the study was further confirmed by participants that attended a results dissemination workshop organized at the end of the study for the health care providers, as well as state Ministry of Health officials and non-governmental organizations involved in malaria control in the state. Approval for this study was obtained from the Research Ethics Committee of the University of Nigeria Teaching Hospital Enugu and the London School of Hygiene and Tropical Medicine. The primary health care (PHC) coordinators for the LGAs used and the heads of primary health facilities and private hospitals gave permission for the use of facilities. Written and signed consent forms were obtained from all individuals interviewed.
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