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Abstract

Background: The disease of malaria has remained a significant public health problem in endemic countries, especially in sub-Saharan Africa (SSA). The disease is even far more devastating among vulnerable and the most at-risk populations of pregnant women and children under five years. Existing interventions such as intermittent preventive therapy in pregnancy (IPTp) using sulfadoxine-pyrimethamine (SP) and the regular use of insecticide-treated bed nets (ITNs) are very effective against malaria, especially placental malaria. However, low uptake of these interventions is a challenge across SSA, often resulting in substantial malaria-related morbidities and mortalities of pregnant women, infants, low birth weights, as well as miscarriages. This study assessed the personal and the health system-related factors affecting the expected uptake of IPTp-SP and ITNs among pregnant women in Ghana. Objective: the study was conducted to address four main objectives as follows: 1. To estimate the distribution of IPTp-SP uptake and the ownership and usage of ITNs among pregnant women in urban and rural Ghana. 2. To determine the personal and health system factors that influence IPTp-SP and ITN use among pregnant women. 3. To measure the knowledge of pregnant women of the risks of malaria in pregnancy and the knowledge of the ANC providers on implementing the SP policy protocols in Ghana. 4. To assess the dosage of folic acid (FA) co-administered with the SP among pregnant women in Ghana. Materials and Methods: The study employed a mixed-methods design of a sequential-explanatory approach in Ghana's urban and rural districts. A multi-stage sampling technique was used to recruit 3rd-trimester pregnant women (n=740) and 74 health service providers from 37 primary healthcare facilities with antenatal care (ANC) services. Obstetric and gynaecological characteristics, as well as IPTp-SP history, were retrospectively assessed from the ANC records. In contrast, knowledge and personal characteristics were prospectively assessed. Quantitative data, including ITN data, was collected through a standard questionnaire from pregnant women and ANC service providers. Three focus group discussions (FGDs) were conducted in each district with pregnant women to collect information about the challenges in accessing and adhering to IPTp-SP and ITN interventions. The primary outcomes were the uptake of IPTp-SP during ANC visits and the co-administration of FA, and the regular use of ITNs. In addition, health system-related factors on the administration of SP and FA, as well as on ITN use, were assessed. Quantitative data for both the IPTp-SP and ITN interventions were first analysed through descriptive statistics, while the determinants of their uptake were analysed using Poisson and Binary logistic regressions, respectively. The qualitative data for IPTp-SP and ITNs were analysed using Microsoft Excel and QDA Miner Lite, respectively. Results: Responses from 697 and 664 pregnant women were analysed for the IPTp-SP and ITNs interventions, respectively. Of these, 184 (26.4%) had taken the third dose of SP (SP3) in line with international guidelines. About 78% reported regular use of ITNs. IPTp-SP uptake was significantly associated with the number of maternal ANC visits and their gestational age at 1st ANC visit. In contrast, ITN use was associated with maternal knowledge of malaria in pregnancy, more ANC visits, gestational age at first ANC, and ownership of ITN. Most pregnant women were regularly co-administered SP together with 5 mg of FA, in contrast to the international recommendations of 0.4mg FA. The main challenge to IPTp-SP uptake was frequent drug stockout, which was confirmed both by the ANC providers and the pregnant women. Further challenges reported were provider negligence, adverse drug reactions, and mobile residency of pregnant women. Challenges related to the access and use of ITNs include sleep discomfort, inability to mount the nets, poor knowledge of the importance of ITNs, and lack of motivation, among others. Conclusions and Recommendations: The uptake of IPTp-SP in the study area is deficient, partly explained by frequent drug stock-outs at health facilities. The high dosing of co-administered FA is against international recommendations. These observations need to be addressed urgently by the national public health authorities. Ownership of ITNs was comparably high among the pregnant women in the study area. However, regular use was still below the national and international targets. In both IPTp-SP and ITNs, health service providers need to formulate community and facility-level interventions that encourage early ANC bookings and regular attendance. There is also the need to focus on increasing specific maternal knowledge of malaria in pregnancy. The extent to which 5mg folic acid is co-administered with SP to pregnant women in Ghana and SSA and the exact motivation required by mothers to use ITNs, need to be further investigated.