Prospects, achievements, challenges and opportunities for scaling-up malaria chemoprevention in pregnancy in Tanzania: the perspective of national level officers

Abstract

ObjectivesTo describe the prospects, achievements, challenges and opportunities for implementing intermittent preventive treatment for malaria in pregnancy (IPTp) in Tanzania in light of national antenatal care (ANC) guidelines and ability of service providers to comply with them.MethodsIn-depth interviews were made with national level malaria control officers in 2006 and 2007. Data was analysed manually using a qualitative content analysis approach.ResultsIPTp has been under implementation countrywide since 2001 and the 2005 evaluation report showed increased coverage of women taking two doses of IPTp from 29% to 65% between 2001 and 2007. This achievement was acknowledged, however, several challenges were noted including (i) the national antenatal care (ANC) guidelines emphasizing two IPTp doses during a woman's pregnancy, while other agencies operating at district level were recommending three doses, this confuses frontline health workers (HWs); (ii) focused ANC guidelines have been revised, but printing and distribution to districts has often been delayed; (iii) reports from district management teams demonstrate constraints related to women's late booking, understaffing, inadequate skills of most HWs and their poor motivation. Other problems were unreliable supply of free SP at private clinics, clean and safe water shortage at many government ANC clinics limiting direct observation treatment and occasionally pregnant women asked to pay for ANC services. Finally, supervision of peripheral health facilities has been inadequate and national guidelines on district budgeting for health services have been inflexible. IPTp coverage is generally low partly because IPTp is not systematically enforced like programmes on immunization, tuberculosis, leprosy and other infectious diseases. Necessary concerted efforts towards fostering uptake and coverage of two IPTp doses were emphasized by the national level officers, who called for further action including operational health systems research to understand challenges and suggest ways forward for effective implementation and high coverage of IPTp.ConclusionThe benefit of IPTp is appreciated by national level officers who are encouraged by trends in the coverage of IPTp doses. However, their appeal for concerted efforts towards IPTp scaling-up through rectifying the systemic constraints and operational research is important and supported by suggestions by other authors.

Factors Affecting the Delivery, Access, and Use of Interventions to Prevent Malaria in Pregnancy in Sub-Saharan Africa: A Systematic Review and Meta-Analysis

“…General knowledge regarding the IPTp strategy among healthcare providers was considered poor [18],[37],[39],[55],[60],[61]. Confusion among healthcare providers over the timing and dosing of SP in relation to gestational age was commonly cited [18],[33],[37],[54],[55],[60],[61], in addition to imprecise estimation of gestational age leading to missed SP doses [62], or SP being given to women regardless of guidelines for gestational age [37],[44],[63]. Healthcare providers could not name the major side effects or contraindications of SP in Ghana or Nigeria [49],[53],[55],[64] and often gave SP and iron tablets to women without any explanations or instructions, or instructions were not given in the local language [44].…”

“…Evidence on the determinants of coverage and reasons for the failure in delivery and uptake of IPTp and ITNs from qualitative [15] and quantitative studies is currently disparate, in addition to which, many relevant reviews are now outdated [5],[16]–[18]. We therefore undertook a systematic review to update the evidence and to integrate findings from three separate syntheses of studies on (1) barriers to achieving high coverage, (2) determinants of uptake, and (3) interventions to increase coverage.…”

Assessing demand-side barriers to uptake of intermittent preventive treatment for malaria in pregnancy: a qualitative study in two regions of Uganda

“…While late attendance has been cited as a barrier to IPTp uptake in the literature [35, 36], it seems likely that this no longer plays a significant role. This research and several other recent studies did not find any evidence of late ANC attendance or a significant effect of the timing of ANC visits on IPTp [37–39].…”

Coverage and efficacy of intermittent preventive treatment with sulphadoxine pyrimethamine against malaria in pregnancy in Côte d¿Ivoire five years after its implementation

“…Additional factors can also contribute to low SP coverage including poor accessibility to health facilities and poor quality of antenatal service provided [14,[16][17][18].…”

“…Stock outs of SP, absence of cups and clean drinking water for taking SP by DOT [17], unclear guidelines [21] or confusion among health workers regarding the guidelines [24] and other related health facility factors [15,25] are factors which hamper delivery of IPTp.…”