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Background: Intermittent Preventive Treatment (IPTp) and insecticide treated nets (ITNs) are recommended malaria in pregnancy preventive interventions in sub-Saharan Africa. Despite their cost-effectiveness and seemingly straight-forward delivery mechanism, their uptake remains low. We aimed at describing perceptions of pregnant women regarding malaria and the recommended prevention interventions to understand barriers to uptake and help to improve their effectiveness. Methods and findings: We used mixed methods to collect data among 85 pregnant women from a rural area of Southern Mozambique. Information was obtained through observations, in-depth interviews, and focused ethnographic exercises (Free-listing and Pairwise comparisons). Thematic analysis was performed on qualitative data. Data from focused ethnographic exercises were summarized into frequency distribution tables and matrices. Malaria was not viewed as a threat to pregnancy. Participants were not fully aware of malaria- associated adverse maternal and birth outcomes. ITNs were the most preferred and used malaria preventive intervention, while IPTp fell between second and third. Indoor Residual Spraying (IRS) was the least preferred intervention. Conclusions: Low awareness of the risks and adverse consequences of malaria in pregnancy did not seem to affect acceptability or uptake to the different malaria preventive interventions in the same manner. Perceived convenience, the delivery approach, and type of provider were the key factors. Pregnant women, through antenatal care (ANC) services, can be the vehicles of ITN distribution in the communities to maximise overall ITN coverage. There is a need to improve knowledge about neonatal health and malaria to improve uptake of interventions delivered through channels other than the health facility. © 2014 Boene et al.
The study was conducted in Manhiça, southern Mozambique, located 80 Km north of Maputo city. The district covers an area of 2,360 Km2 and its population in 2007 was around 160,000 inhabitants, of which 23% comprised women of reproductive age [12]. Malaria transmission is perennial, with moderate seasonality that peaks during the rainy season (from November to March), and mainly due to Plasmodium falciparum [13]. The prevalence of HIV in women attending the ANC clinic was 29.4% in 2010 [14]. The population of Manhiça belongs mainly to the Changana ethnic group. They are mostly subsistence farmers, informal traders, employees of two local sugar estates, and migrant labours in South Africa [15]. Adult illiteracy rate is 71%, being more prevalent among women [15]. Around 92.000 inhabitants are under continuous follow-up through a Demographic Surveillance System (DSS), which covers an area of around 500 Km2 (also known as the Demographic Surveillance Area) and routinely registers pregnancies, births, deaths, and migrations. During 2009, the DSS registered 2,539 new pregnancies (unpublished data, Manhiça DSS 2009), and around 2,000 women attended ANC visits (unpublished data, MDH 2009). The ANC clinic at the Manhiça District Hospital (MDH) offers maternal and child health treatment and preventive services that include screening and treatment of syphilis, anaemia, and urinary tract infections, IPTp with SP (administered 3 times during pregnancy), ITNs distribution, antihelmintic, ferrous sulphate and folate tablets, tetanus toxoid vaccination, and prevention of mother to child transmission (PMTCT) of HIV with administration of antiretrovirals [16]. For malaria prevention, in addition, indoor residual spraying (IRS) is carried out in yearly rounds in the community. This was a mixed method study, generating qualitative and quantitative data. Specifically, standard qualitative data collection approaches namely observation of ANC clinic activities and in-depth interviews (IDIs) with pregnant women were combined with focused ethnographic study (FES) data collection approaches [17], [18]. Focused ethnographic studies address some of the limitations of the classic ethnographic design, by making use of a package of exercises that can be applied during the course of individual or group interviews [18], [19]. The exercises used in this study were Free-listing and Pairwise comparison. The exercises help to swiftly generate, organize and categorize insights regarding local perceptions and behaviours and how these are shaped by cultural norms. Data was collected by a trained female Mozambican social scientist with experience in conducting qualitative studies (HB) assisted by a local female interviewer (RP), who was specifically trained for this study. Both of them are fluent in Portuguese and Changana languages. The majority of interviews and FES exercises were conducted in Changana and very few were conducted in Portuguese. Choice of language was determined by participants’ convenience. Through in-depth interviews (Form S1), perceptions about malaria in pregnancy, and the use and acceptability of conventional and traditional malaria preventive interventions were explored. The interviews targeted both women attending ANC and women who had not attended any ANC visit during their current pregnancy. Participants not attending ANC were involved in a single interview at home, while ANC attendants were expected to be involved in three interviews. The first interview with ANC attendants was conducted at the health facility immediately after the administration of the first IPTp dose. For the second and third interviews women were followed up at home, up to two weeks after administration of the second IPTp dose, and up to 24 weeks after the end of the pregnancy respectively. While the first and second interviews focused on aspects related to pregnant women’s perceptions and experiences with the different interventions offered to them during ANC, the third interview dealt, in addition, with their overall degree of satisfaction with regards to such interventions in the light of the pregnancy outcome, and any other issues that the interviewer had not managed to address during the previous interviews. Interviewing the participants several times and outside the health facility environment allowed rapport building between the interviewer and the participant. During the IDIs with ANC attendants, Free-listing and Pairwise comparison exercises were conducted as part of the Focused Ethnographic Study component. Through the Free-listing exercise (Form S2), a list of perceived and experienced health problems and complaints during pregnancy was generated, through an open-ended question, at the start of each IDI. The interviewer then probed about perceived causes and consequences of each of the identified health problems both for the mother and the foetus. The exercise ended by the interviewer revisiting each of the mentioned complaints and discussing the perceived severity and the perceived risk of contracting the illness. Pairwise comparison consisted in the use of pictorial vignettes representing malaria preventive interventions and other interventions delivered through ANC. First, the vignettes were presented to the participants all at once, and an agreement was reached between the participant and the interviewer as to which intervention each vignette represented. The participant was asked to organize the vignettes from the most preferred to the least preferred intervention. The interviewer used a data extraction form to register the preferences (Form S3). Secondly, the vignettes were presented to the participant in pairs, i.e., each vignette was matched one-on-one with another vignette at a time, encouraging the participant to think about the relative advantages and disadvantages of each of the presented interventions. For each pair, the participant was asked to elect the favourite one, and a discussion followed regarding the reasons for the choice. Lastly, observations were carried out at the ANC clinics, both in the waiting and consultation rooms. The latter generated information about the participants’ interaction with health care providers, as well as on their reactions to the procedures offered to them. It also provided insights about the possible contextual factors impeding or facilitating the implementation and acceptability of the interventions. This study took place from September 2010 to November 2011. Two groups of participants were recruited. One group comprised pregnant women attending the first ANC visit and willing to participate in the qualitative study. Every day, the ANC nurse recruited the first two patients who fulfilled the inclusion criteria. The social scientist then asked for consent and arranged for the appropriate time and place for an initial interview. To capture the views and opinions of those who had not had access to ANC services, a second group of participants was recruited, consisting of randomly selected pregnant women identified through the DSS. Every day, two women were recruited by the DSS fieldworker who annotated the directions of the household and possible dates for an initial interview. A minimum sample size of 20 per group was foreseen in order to fulfil the study objectives. A final sample size of 85 women was obtained based on the saturation point, which is reached when the inclusion of new participants is suspended due to redundancy in the data being generated [20]. The number of observations was also determined by saturation, giving a total of 30 observations conducted at the ANC clinic over a period of six months. Ethical approval for this study was granted by the National Health Bioethics Committee in Mozambique (IRB nr. 00002657). Written informed consent was sought from all participants. Among the participants of this study we included a subgroup of 11 pregnant women between the ages of 15 and 18, reflecting the range of ages of pregnant women at risk of malaria in the study area. Regarding participation of these women in the study, a waiver for parental consent was given by the IRB because they are considered to be mature minors who make autonomous decisions regarding their pregnancy and foetus. In fact, the majority of them were either married or not living with their parents. Moreover, culturally, the likelihood of an undisclosed pregnancy in the first trimester is high, therefore parental permission, which implied disclosure of pregnancy status, would pose more social harm to the participants than the participation in the study without parental permission. Participation of this group of women was crucial because they are the group most at risk of malaria-related pregnancy adverse consequences. Exclusion of this group from studies like this may deny benefits to this group on the long run. All data analysis was performed using MS Excel [21] and Paired Comparison Worksheet [22]. For the data generated through the Free-listing exercise, all the illnesses that were identified by the participants were sorted in decreasing order of frequency of being mentioned. Further, for each illness, the perceived symptoms, preventive measures, and known treatment options were tabulated according to the frequency of being mentioned [17], [18], [23]. Analysis of Pairwise comparisons was performed in two steps. First, for the component of the Pairwise comparison whereby each participant was asked to rank their preference among the seven interventions presented to them all at once, the interventions were tabulated according to the frequency in which these interventions were elected as 1st, 2nd, …nth choice (n = 7). Secondly, for the component of the Pairwise comparison whereby participants were asked to choose their preference between interventions that were presented in pairs, each intervention obtained one to three points according to the difference in the frequency mentioned compared to the alternative, and zero points for a tie. Interventions were then ranked according to the total number of points obtained after the scores of all possible comparison pairs were added [24]. The in-depth interviews and the discussions held during the FES exercises were digitally recorded and transcribed verbatim and field notes were taken during observations. Transcriptions and field notes were read and data were extracted and tabulated according to three key themes: (i) perceptions and knowledge of malaria in pregnancy; (ii) knowledge and acceptability of ANC services; (iii) acceptability and use of malaria preventive interventions in general and IPTp in particular.
