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

Background Malaria remains a significant health problem in Mozambique, particularly to pregnant women and children less than five years old. Intermittent preventive treatment is recommended for malaria prevention in pregnancy (IPTp). Despite the widespread use and cost-effectiveness of this intervention, the coverage remains low. In this study, we aimed to explore the factors limiting the access and use of IPTp-SP in Chókwè district. Methods and findings We used qualitative research methods through semi-structured interviews to collect data from 46 pregnant women and four health care staff from Chókwè, a rural area of southern Mozambique. Data were transcribed, manually coded and analysed using content and thematic method. Participants were not aware of pregnancy-related risks of malaria infection or the benefit of malaria prevention in pregnancy. Late and infrequently antenatal care (ANC) attendance, concerns about the long waiting time at ANC consultations,plus reluctance to disclose the pregnancy early, emerged as driving factors for inadequate IPTp delivery. Conclusions Pregnant women experience substantial barriers to receive adequate IPTp-SP dosing for malaria prevention. Poor awareness, non-compliance with ANC attendance and poor attitude of health care staff were main barriers to IPTp-SP delivery. There is a need to strengthen actions that improve awareness about malaria and prevention among pregnant women, as well as quality services across the ANC services in order to increase IPTp-SP uptake.


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Pregnant women are at high risk of malaria and its adverse consequences. It is 35 estimated that 5.5 million pregnancies occur annually in endemic areas, where malaria can be 36 attributable of 10,000 maternal deaths [1,2]. Malaria infections during pregnancy are often 37 asymptomatic, but can still cause adverse consequences for both the mother and her child, 38 including maternal anemia, impaired fetal growth, premature and still-birth, low birth weight, 39 or congenital malaria, which have been associated with a high risk for infant mortality and ITNs is delivered during antenatal care (ANC) visits. Even though many countries in sub- 48 Saharan Africa (SSA) have adopted IPTp-SP for malaria prevention in pregnancy, the 49 coverage of the recommended three or more doses is still unacceptably low, despite a modest 50 increase in ANC attendance among pregnant women [5], limiting the beneficial effect of this 51 strategy on maternal and child outcomes [6,7]. 52 Quantitative data collection approaches have been widely used to explore factors 53 affecting access and use of IPTp-SP. In this regard, several factors such as limited access to 54 ANC services, health professionals attitudes and practices, low awareness of malaria 55 consequences during pregnancy, low patient adherence, or community attitudes towards 56 preventive interventions have been associated with low IPTp-SP coverage [7][8][9][10]. However, 57 quantitative data collection often lacks inclusion of sociocultural data, such as individual and 58 community's sociocultural beliefs, that may be affecting pregnant women's access and use of 59 malaria control intervention [10][11][12][13]. 60 In Mozambique, policies to improve maternal and neonatal health, such as those 61 targeting anemia and malnutrition, the prevention of MiP, increased institutional deliveries,   Within the selected primary health facilities, women who were pregnant and aged ≥15 106 years old were invited to participate in the study. To have additional information on the IPTp 107 delivery from the provider side, health care staff were also included in the study. This was 108 represented by one nurse at each health centre, who had been responsible for the ante-natal 109 consultation for at least one year preceding the date of interview.   Reporting of the study methods and results follow the consolidated criteria for reporting 128 qualitative research [19].

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Characteristics of study respondents 140 In this study, a total of 50 participants were interviewed: 46 pregnant women attending 141 ANC services, and four health care staff (nurses) trained for maternal and child health care  and high blood pressure. According to local belief "Xitsongua tsonguana" is something that 158 can pass from the mother to the baby, and in case this happens, the baby can be born with the 159 "moon disease" described as a set of symptoms such as body pain, convulsions, fevers, 160 constipation or cough, that the baby can manifest every time the full moon appears. Other 161 diseases cited by participants were "Dzedzedze" (fever), stress, and diabetes.         When the health providers were questioned about the way in which the users were 260 offered the anti-malarial drugs, they acknowledged that they could do counselling about 261 malaria and its prevention during ANC consultations and the benefits of the drugs during 262 pregnancy. However, they recognized that in most cases they only provide the pills without 263 explaining the purpose and its benefits because the burden and number of patients seeking 264 care is huge, and as a mechanism to manage such pressure, health providers are "forced" to 265 perform a quick consultation.  The results indicate that women recognized malaria as an important disease that affects 281 the population and mainly pregnant women in the study area, particularly in the hot and rainy 14 | P a g e 305 Although most women mentioned having never heard about IPTp-SP, they remembered 306 to have been given a drug during antenatal consultations. However, some could not 307 remember the name of the drug given neither wether this was given to prevent malaria, but 308 they were able to describe the three white tablets that were taken in front of the nurse.

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Previous studies in Africa identified perceived adverse reactions to the drugs as an important 310 determinant factor for adherence [10,11,22]. In this study, there were no indications that  Our findings on pregnant women attitudes towards IPTp-SP use showed that ANC 318 attendance was likely to constitute barrier for an adequate IPTp-SP uptake. Nurses of 319 maternal and health services interviewed in this study reported that pregnant women do not 320 complete the recommended doses for the gestational period. This was mainly linked to late 321 and infrequent ANC attendance, which led to missed opportunities for the provision of the 322 recommended IPTp-SP dosage. This is in agreement with our previously reported results in 323 the study on IPTp-SP coverage among delivering women conducted in the same setting [17]. with pregnant women's cultural beliefs. For example, reluctance to disclose their pregnancy 330 early, the tendency to only starting to attend ANC when the tummy is visible, which in most 331 of the cases happens after the fifth month and a trend to only seek help when sick [10,23,24].

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Although the hospital is viewed as an entity of trust and obedience towards the health

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Our study findings should be interpreted taking into account the following limitations: