Factors associated with uptake of optimal dose of IPTP-SP among pregnant women attending antenatal clinics of Soroti district, Uganda

Abstract

Malaria in pregnancy is a major Public Health problem globally especially in low- and middle-income countries, because it contributes significantly to maternal, foetal, and perinatal morbidity and mortality. Uptake of up to three doses (optimal dose) of intermittent preventive treatment using sulfadoxine pyrimethamine (IPTp-SP) has been shown to prevent malaria in pregnancy and placental malaria. We aimed to determine the factors associated with the uptake of optimal dose of IPTp-SP among pregnant women attending antenatal care in Soroti District. A cross-sectional study was conducted at selected health facilities in Soroti District between March and June 2023. Three hundred and forty-three pregnant women at 36 weeks gestation or more were enrolled into the study. Sociodemographic, obstetric, knowledge on malaria and health care service delivery factors were collected from the women to determine the factors associated with uptake of optimal dose of IPTpSP. Uptake of optimal dose of IPTp-SP was 86.6%. Factors associated with uptake of optimal dose of IPTp-SP were: knowledge about dangers of malaria in pregnancy (aOR: 2.42, 95%CI: 1.19–4.91), knowledge about IPTp-SP benefits (aOR: 4.15, 95%CI: 2.10–8.23) and having enough clean cups at the ANC clinic to facilitate directly observed therapy (DOT) (aOR 5.43, 95% CI: 2.44–12.1). Uptake of optimal dose of IPTp-SP was high. Knowledge about dangers of malaria in pregnancy, IPTp-SP benefits and, always having enough clean cups at the ANC to implement DOT were associated with optimal IPTp-SP uptake. There is need to increase awareness among pregnant women and facilitate Directly Observed Therapy in antenatal clinics as these will improve IPTp-SP uptake.

Introduction

Worldwide, malaria is a Public Health problem because it significantly contributes to maternal and perinatal morbidity and mortality. In 2020, approximately 241 million malaria cases occurred globally resulting in about 627,000 deaths¹. The morbidity and mortality occurred in 85 malaria endemic countries, with the highest burden reported in the WHO African Region countries². About 96% of these global malaria cases and death occurred in 29 countries where Uganda was ranked third^1,2. In 2020, 11.6 million of the 33.8 million pregnancies in the WHO African Region, were exposed to malaria infection. This contributed to approximately 819,000 low birth weight children being born^1,3 which predispose them to neonatal and infant mortality.

In Africa, malaria in pregnancy causes approximately 75,000-200,000 infant deaths and 10,000 maternal deaths yearly⁴. It has been estimated that low birth weight from Plasmodium falciparum infection leads to100,000 neonatal death annually^5,6. Other complications attributed to malaria infection include, anemia, spontaneous abortion, placental malaria, hemorrhage, still birth^7–9 congenital and childhood malaria¹⁰.

Over 95% of the malaria cases seen on the African continent are caused by Plasmodium falciparum parasite species with the remaining four parasites causing the rest of infections¹¹. Plasmodium falciparum infection in pregnancy has been associated with an increased risk of developing hypertensive disorders in pregnancy¹² especially when the preventive interventions are inadequate^13,14.

In Uganda, 40% of outpatient consultations, 20% of hospital admissions and 10% deaths in pregnant women and children are attributed to malaria^9,15 This has a great impact on the life of children and women due health complications, loss of productive time and healthcare costs. As such many strategies have been adopted to reduce the burden of malaria especially in pregnancy. These include the use of the insecticide treated mosquito nets, Intermittent Presumptive Treatment using sulfadoxine pyrimethamine (ITPp-SP) and prompt case management¹⁶. According to WHO and Ugandan Ministry of Health guidelines for prevention of malaria in pregnancy, Sulfadoxine Pyrimethamine (1500/75 mg) is given at monthly intervals from 13 weeks gestation up to 36 weeks^2,6,15. This dose is given irrespective of the women’s parastaemia status, however, HIV positive pregnant women who are on cotrimoxazole prophylaxis are excluded from this regimen¹⁷. This intervention reduces the incidence of malaria in pregnancy, placental malaria, neonatal death¹⁸ and increases maternal haemoglobin and, birth weight¹⁹.

Some studies have reported factors associated with optimal uptake of IPTp-SP. The factors include the women’s income^20,21 being a farmer and businesswoman²² having a formal education^23–25 living less than 5 km from the health facility²³ and maternal age^24,26. Other factors are early ANC initiation^23,27–29 number of ANC contacts^24,28,30 knowledge about fansidar^20,27 and knowledge about malaria²⁹. Decreased uptake of optimal doses of IPTp-SP has been due to drug stock outs^28,31 poor adherence to directly observed therapy^28,32 and knowledge of midwives on the IPTp-SP protocol^25,33.

The optimal dose IPTp-SP involves administration of at least three doses of sulfadoxine pyrimethamine in pregnancy starting after the first trimester. In the 33 WHO African Region, the uptake of optimal dose of IPTp-SP has remained at 32%, below the target of 80%^2,34. Uganda Ministry of Health has set a national target of an optimal dose of IPTp-SP among pregnant women to be 93% for IPT2 and 80% for IPT3¹⁵. Despite the fact that antenatal care services are free in Uganda, up to 73% of women delay their first antenatal clinic attendance and fail to take the optimal dose of SP³⁵. Studies have shown that the uptake of optimal dose of IPTp-SP has remained as low as 18% and below in Uganda^22,24. This leaves a shortfall of 62% to reach the national target. However, previous studies were based on secondary data³⁶. Therefore, the purpose of this study was to determine the factors associated with uptake of optimal dose of IPTp-SP among pregnant mothers attending ANC in Eastern Uganda.

Methods

Study design

This was a Multi Centre Institutional based Cross-sectional study where four high volume health facilities which handle at least 80 mothers per week with gestation of 36 weeks and above attending antenatal clinics were selected (Sororti Regional Referral Hospital, Tirir Health Center IV, Asuret Health Center III, and Gweri Health Center III).

Study setting

The study was conducted at antenatal clinics of selected health facilities in Soroti District. The district is located in eastern Uganda about 324 km from of Kampala, the capital city of Uganda. It serves a catchment population of about 3.4 million people. It is served by about 18 Public Health Facilities, of which 7 are Health Centre II, 8 Health Center III and 2 Health Center IV and one Regional Referral Hospital. Four high volume facilities which attend to at least 80 mothers per week were selected. (Sororti Regional Referral Hospital, Tirir HCIV, Asuret HCIII, and Gweri HCIII). This area has a high burden of malaria among pregnant women standing at 23.3% of admitted cases in 2021³⁷. These facilities run antenatal clinics from Monday to Friday. It is an urban setting (it serves both urban and rural population) and the residents are formally employed (e.g. teachers) and informally employed (e.g. farmers, market vendors and fishermen). About 300 pregnant mothers of gestational age of 36 weeks and above attend antenatal clinics monthly³⁸.

Study population

The study population consisted of pregnant women with gestational ages of 36 weeks and above attending antenatal clinic at the selected health facilities. Pregnant women were sampled from March to June 2023. According to the Ugandan Demographic and Health survey most women by 36 weeks of gestation have attended at least 4 antenatal clinic contacts and have had at least three doses of IPTp-SP³⁹. Pregnant women were excluded if they were HIV positive and were on cotrimoxazole or dapsone prophylaxis or women who were sensitive to sulphur. The women were attending antenatal care at Soroti hospital, Tirir Health center IV, Gweri health center III, and Asuret health center III.

Sample size determination

Fleiss formula (1981) for comparing two proportions was used. Using a study conducted in Ghana in which 55.1% of women who started ANC in first trimester took at least 3 doses of IPTp-SP, with the power of 80% and confidence interval of 95%, a sample size of 343 women was obtained.

Sampling procedure

Proportionate sampling to size was used to determine the number of pregnant women to recruit per health facility. This was based on the average number of pregnant women above 36 weeks of gestation who attended each of the selected health facility monthly. Accordingly, the women were recruited as follows: Soroti hospital-100 mothers per month: 165 women, Tirir HCIV-40 mothers per month: 66 women, Gweri HCIII-36 mothers per month:59women and Asuret HCIII-32 mothers per month :53women giving a total of 343 women.

Study procedure

The research assistants used the antenatal clinic register and the antenatal cards to identify women who were eligible for the study. The eligible women were given information about the study. The gestational age was estimated using the last normal menstrual period, the first trimester ultra sound scan and syphisio-fundal height measurements. Those who accepted to join the study were recruited using systematic sampling in which every third woman was selected until the sample size was achieved. The women were taken through the informed consent procedure to obtain informed consent.

Data collection technique

Information was obtained from the women using an interviewer administered structured questionnaire. The questionnaire was both in English and Ateso which is a local language spoken by women in that area. Uptake of IPT-SP was collected from the maternal record book. Information on sociodemographic characteristics (age, education level both the men and women, marital status, residence, religion, tribe, distance from facility). socioeconomic factors (occupation of woman, occupation of men, distance from facility, level of income of men, level of income of women), obstetrics factors (parity, gestational age, frequency of ANC visit, experience of SP side effects, gestation age at 1 st ANC), knowledge factors: dangers of malaria (miscarriage, foetal death, cerebral malaria, maternal death, anaemia), malaria prevention(ITN, ITP, correct dose of IPT, schedule of IPT), IPTp-SP benefits(not sure, prevents malaria in pregnancy) when to start IPTp-SP(< 13 weeks, > 13 weeks, at 13 weeks),, knowledge of side effects (difficulty in breathing, headache, nausea, vomiting, rash, dizziness), optimal IPTp-SP dose (one dose, two doses, three doses, at least three doses).

Common principles used to assess knowledge about malaria were used in this study as has been used previously⁴⁰. Multiple choice questions were generated in which a correct response was assigned one and zero to an incorrect one. The correct responses in each domain were added and a score was generated. The women were classified as having low/inadequate knowledge and moderate/adequate knowledge. The other information collected from the women was about health care delivery factors (cups at the clinic, SP administration and clinic waiting time).

Data Analysis double data entry was done using EpiDtata (version 4.4.1) software and exported to STATA/IC version16.0 (STATA CORP, TEXAS USA) for analysis. Continuous variables were summarized as means and medians. Categorical variables are summarized as frequencies and percentages. The uptake of optimal dose of IPTp-SP was computed as the proportion of pregnant women at 36 weeks of gestation or more who had taken at least 3 doses of SP over the total number of pregnant women recruited in the study and expressed as a percentage. Bivariate analysis was performed using logistic regression between each independent variable and optimal dose of IPTP-SP. All variables with p value ≤ 0.2 and those that were known apriori to be associated with the outcome of interest were considered for multivariate analysis. Backward elimination method was used until a stable model was achieved. Results are presented as adjusted odds ratios with 95% confident intervals.

Ethical considerations

Permission to conduct this study was sought from the Research and Ethics Committee of the School of Medicine, Makerere University College of Health Sciences (Mak- SOMREC − 2022 − 495) and administrative approval was obtained from Soroti regional referral hospital and the District Health Officer Soroti District. Informed consent was obtained from all the participants and anonymity was ensured by using numbers instead of names and no names were entered into the data base. All methods were performed in accordance with the relevant guidelines and regulations.

Results

Socio demographic chracteristics and obstetrical characteristics of pregnant women attending atenatal clinic in selected Helath facilities in Soroti district

The mean age of participants was 26.2 years (SD: 6.7). Most of the participants were residing in rural areas, were married, had primary level of education or less, were housewives. The majority of mothers were Catholics, had their monthly income of 100,000 shs or less and were of Ateso tribe. Most husbands were farmers, earning 100,000 Uganda shillings or less per month and were of Ateso tribe (Table 1). The majority of mothers were 37 weeks gestation or more, had their first antenatal visit in the second trimester (13–25 weeks) and had had 4 or more antenatal contacts Table 1.

Table 1.

Socio-Demographic characteristics and obstetric factors of 343 pregnant mothers attending ANC in Soroti district selected health facilities between March and June 2023.

Characteristic	Frequency (n)	Percentage (%)
Age, mean (SD)	26.2 (6.7)
Distance in km to ANC clinic; Median (IQR)	5 (2–8)
Religion
Catholic	143	41.7
Protestant	113	32.9
Born again	55	16.0
Muslim	22	6.4
Other	10	2.9
Marital status
Single/Never married	18	5.2
Married/cohabiting	325	94.8
Residence
Rural area	248	72.3
Urban area	95	27.7
Education level
None/Primary	213	62.1
Secondary and above	130	37.9
Ethnic group
Atesot	242	70.5
Kumam	57	16.6
Others	44	12.8
Occupation
Housewife	169	49.3
Formal employment	44	12.8
Merchant/Businessman	44	12.8
Farmer	85	24.8
Other	1	0.3
Monthly income
≤ 100,000	263	76.7
> 100,000	80	23.3
Husband’s Education
None/Primary	180	52.5
Secondary and above	163	47.5
Husband’s occupation
Does not work	1	0.29
Formal employment	65	19.01
Merchant/Businessman	72	21.05
Farmer	192	56.14
Other	12	3.51
Husband’s Monthly income
≤ 100,000	179	52.2
> 100,000	164	47.8
gestational age
= 36 weeks	112	32.7
≥ 37 weeks	231	67.3
Gestational age at first ANC
≤ 12 weeks	29	8.5
13–24 weeks	224	65.3
≥ 25	90	26.2
Frequency of ANC visits
≤ 3 visits	111	32.7
≥ 4 visits	232	67.6

Knowledge and health related factors of pregnant women attending antenatal clinics at selected health facilies in Soroti district

As shown in Table 2, the uptake of optimal dose of IPT-SP was 86.6%.

Table 2.

Knowledge and health related factors of study participants.

Knowledge about dangers of malaria in pregnancy	Frequency( n )	Percentage (%)
Low/Unknowledgeable	204	59.5
Moderate/Adequate knowledge	139	40.5
Knowledge about prevention of malaria in pregnancy
Low/Unknowledgeable	184	53.6
Moderate/Adequate knowledge	159	46.4
Knowledge about IPTp-SP benefits
Low/Unknowledgeable	77	22.4
Moderate/adequate	266	77.6
Knowledge about when to start IPTp-SP dose
Low/No knowledge (don’t know)	237	69.1
Moderate knowledge (> 13 weeks)	106	30.9
What is Optimal SP dose?
< 3 doses	74	21.6
≥ 3 doses	269	78.4
Knowledge regarding side effects/dangers of SP
Low/No knowledge	207	60.3
Moderate/adequate knowledge	136	39.7
Ever experienced any side effects of SP
No	141	41.1
Yes	202	58.9
Side effects experiences
Dizziness	85	42.1
Nausea	73	36.1
Headache	62	30.7
Others	2	0.01
Enough cups at ANC clinic
Never	39	11.4
Sometimes	135	39.3
Always	169	49.3
SP administration at ANC clinic
Never missed	336	98.0
Ever missed	7	2.0
Average waiting time
< 2 h	127	37.0
2–3 h	100``	29.1
¬ 3 h	116	33.8
Uptake of IPT-SP
< 3 doses	46	13.4
≥ 3 doses	297	86.6

Most mothers had little or no knowledge about dangers of malaria in pregnancy, about prevention of malaria in pregnancy, when to start IPTp-SP dose. While most mothers had good knowledge about IPTp-SP benefits, optimal dose of IPTp-SP and most mothers had experienced side effects of SP. About half the mothers reported that there was always clean drinking water and clean cups available at the ANC clinic and a few had had ever missed administration of SP due to stock out.

Unadjusted and adjusted association of factors associated with uptake of optimal dose of IPT-SP among pregnant women attending antenatal clinics at selected health facilities in Soroti district

From the bivariate analysis, factors found to be associated with uptake of optimal IPTp-SP were: Urban residence (OR = 10.03, 95%CI = 2.38–42.25), Mother’s education level (OR = 4.9, 95%CI = 1.10–18.34), Husband’s education level (OR = 3.94, 95%CI = 1.89–15.59), Gestation age at first ANC (OR = 4.38, 95%CI = 2.28–8.44), Knowledge about dangers of malaria in pregnancy (OR = 4.49, 95%CI = 2.54–11.92), Knowledge about prevention of malaria in pregnancy (OR = 11.96, 95%CI = 1.40–19.71), Good knowledge about IPTp-SP benefits (OR = 4.5, 95%CI = 2.35–8.61), Knowledge about when to start IPTp-SP dose (OR = 11.3, 95%CI = 1.49–18.58), Ever experienced any side effects of SP (OR = 2.82, 95%CI = 1.48–5.36), Enough cups at ANC clinic (OR = 3.78, 95%CI = 1.71–8.32), as shown in Table 3.

Table 3.

Unadjusted and adjusted association between social demographic factors, obstetric factors, knowledge related factors and health services-related factors and uptake of optimal IPTp-SP for 343 pregnant women attending antenatal clinic at selected health facilities at Soroti District.

Variable	OR (95% CI)	aOR (95% CI)
Age	1.23(0.97–1.08)
Marital status
Single	1
Married/cohabiting	2.73(0.36–21.04)
Religion
Catholic	1
Protestant	0.48(0.67–1.48)
Born again	0.69(0.45–1.36)
Other	1.05(0.12–8.91)
Muslim	3.35(1.21–9.24)
Residence
Rural area	1
Urban area	10.03(2.38–42.25)
Mother’s education level
None/Primary	1
Secondary/Tertiary	4.5(1.10–18.34)
Husband’s education level
None/Primary	1
Secondary/Tertiary	3.94(1.89–15.59)
Mother’s occupation
Housewife	1
Formal employment	3.19(0.93–10.96)
Merchant/Businessman	4.90(1.13–21.32)
Farmer	2.25(0.99–5.12)
Gestation age at first ANC visit
≥ 25 weeks	1
13–24 weeks	4.38(2.28–8.44)
≤ 12 weeks	11.37(1.47–88.01)
Knowledge about dangers of malaria in pregnancy
Low/Unknowledgeable	1	1
Moderate/adequate knowledge	4.94(2.06–11.84)	2.42(1.19–4.91)
Knowledge about prevention of malaria in pregnancy
Low/Unknowledgeable	1
Moderate/adequate knowledge	11.96(1.40–19.71)
Knowledge about IPTp-SP benefits
Poor (Not sure)	1	1
Good (Prevents malaria in pregnancy)	4.5(2.35–8.61)	4.15(2.1–8.23)
Knowledge about when to start IPTp-SP dose
Low/No knowledge	1
Adequate/Moderate knowledge	11.30(1.49–18.58)
Knowledge regarding side effects/dangers of SP
Low/No knowledge	1
Adequate/Moderate knowledge	9.43(2.15–21.51)
Ever experienced any side effects of SP
No	1
Yes	2.82(1.48–5.36)
Enough cups at ANC clinic
Never	1	1
Sometimes	3.78(1.71–8.32)	2.68(0.80–6.32)
Always	12.37(4.90–31.23)	5.43(2.44–12.10)

Factors found statistically significant were: knowledge about dangers of malaria in pregnancy, aOR;2.42 (95%CI: 1.19–4.91), good knowledge about IPTp-SP benefits aOR 4.15; (95%CI: 2.10–8.23) and always having enough clean cups at the ANC aOR; 5.43, (95% CI: 2.44–12.10) see Table 3.

Discussion

In this study, we assessed the prevalence and factors associated with uptake of optimal dose of IPTp-SP among pregnant women attending antenatal clinic in selected health facilities in Soroti District, Eastern Uganda. Three factors were found to be associated with receiving optimal doses of IPTp-SP among pregnant mothers, these were knowledge about dangers of malaria in pregnancy, good knowledge about IPTp-SP benefits and always having enough clean cups at the ANC clinic.

We found the uptake of optimal dose of IPTp-SP among pregnant mothers was 86.6%. This is similar to what was found in other studies in Sierra Leone⁴¹ (93.4%), in Kenya⁴² (79.6%) and Ghana⁴³ (75.5%). However, it was higher than in other studies in Ghana⁴⁴ (46%), in Nigeria⁴⁵ (16.8%), and other studies in Uganda⁴⁶ (22.3%) and⁴⁷ (23%). The high uptake of optimal dose of IPTp-SP among pregnant mothers in this study might be attributed to awareness through government policies, community sensitization and media campaigns, health worker training and improved access to ANC services through the provision of free services at public health facilities. The utilization of the IPTp-SP found in this study was higher than the target of 80% that was set to be achieved by 2015 in Uganda¹⁵. Uptake of at least three doses of SP is known to be effective in reducing malaria in pregnancy, maternal anemia, low birth weight and neonatal mortality⁴⁸.

In this study, mothers who had knowledge about the dangers of malaria to pregnancy were associated with increased odds of uptake of optimal doses of IPTp-SP, when compared to mothers who had no knowledge. These findings are in line with findings from similar settings in Africa^24,44,45. The level of knowledge about dangers of Malaria in pregnancy may translate to their level of trust in the efficacy and safety of IPTp-SP for malaria prevention. It has been found that knowledge of mothers about Malaria in pregnancy increased the uptake of optimal doses of IPTp-SP. Studies have reported that mothers who were educated on IPTp-SP had belief in its effectiveness against malaria infection⁴⁴.

In this study we found that women with knowledge of benefits of IPTp-SP were more likely to take optimal doses of IPTp-SP. This agrees with studies elsewhere which have reported that ladies who had knowledge of the benefits of IPTp-SP were more likely to take more doses of the medication^32,49. Knowledge of the use of SP, including its benefits and any possible side effects could improve women’s decision-making on the uptake of the medication during pregnancy²⁴.

Our study found that health facilities that always had clean cups for ladies to take their IPTp-SP medication at the health facility were more likely to take more doses of it. Having clean cups at the antenatal clinic ensured Directly observed therapy (DOT) of IPTp-SP for mothers. This has been echoed in a recent study in Ghana reported in which DOT, a highly recommended practice in the administration of IPTp-SP, is the reason why the majority of the women had 3 or more doses, despite having poor perception. DOT is known to increase the likelihood of pregnant women receiving 3 or more doses⁵⁰. It has been observed that pregnant mothers who did not take SP under direct observation therapy were less likely to complete the recommended number of doses³². This has been confirmed by a study in Tanzania which followed the DOT protocol to ensure that the mothers took their IPTp-SP doses at the ANC clinic and this practice increased uptake among mothers⁵¹.

The weaknesses of this study is its cross-sectional nature of its design which is prone to recall bias. In addition, the prevalence used in the sample size calculation was lower than the atual sample size which could have underpowerd our study and readers should interpret these results with caution. However, it has a number of strengths, being a multi–Centre Institutional Based study and clinics in Soroti district served a big proportion of rural residents, helped us to recruit a broad variety of patients which are makes it representative to the study population. In addition, we used primary data, which gave us reliable and up to date information.

Conclusion

The uptake of optimal dose of IPTp-SP among pregnant mothers in Soroti was high. Knowledge about dangers of malaria in pregnancy, IPTp-SP benefits and, always having enough clean cups at the ANC to implement DOT were associated with optimal IPTp-SP uptake. There is need to raise awareness among pregnant women, their families, and communities about the benefits of IPTp-SP in preventing malaria during pregnancy and to facilitate Directly Observed Therapy of SP as this will increase uptake of optimal dose of IPTp-SP. This will reduce the burden of malaria in pregnancy and hence improve maternal and child health outcomes. Another study with a prospective design is recommended to study the cause effect relationship.

Author contributions

JA, IN and PK contributed to the conception of the study; JA, IN and MM contributed to the design of the study; JA, PK and JW contributed to acquisition and analysis of the data; JA, IN, PK, MM and JW interpreted the data; JA, IN, PK made the first draft; IN, PK, MM, JW revised the manuscript; JA, IN, PK, MM and JW approved the submitted version; All authors are accountable to their contributions.

Funding

there was no funding for this study. It was a dissertation for Angwec, Jackline Aporo as requirement for the award of the Masters degree in obstetrics and Gynaecology of Makerere University.

Data availability

The data can be available from the corresponding author at reasonable request.

Declarations

Competing interests

The authors declare no competing interests.

Disclosure

This paper was uploaded on the Makerere University repository as a dissertation in October 2023. http://hdl.handle.net/10570/12337.