Barriers in managing maternal schistosomiasis: a qualitative study of healthcare providers in Tanzania

Abstract

Background

Maternal schistosomiasis threatens the health of pregnant women and their foetuses in endemic regions. Although praziquantel is recommended for treatment, its utilization remains low. This study explored the experiences of healthcare providers (HCPs) with schistosomiasis, particularly maternal schistosomiasis, and their perceived management barriers in Tanzania.

Methods

This qualitative case study was conducted in October 2024 with nine purposefully selected HCPs. In-depth interviews guided by a semi-structured tool analysed HCPs’ experiences with schistosomiasis, maternal schistosomiasis and perceived management barriers. Interviews were audio recorded, transcribed verbatim and thematically analysed to identify key insights and barriers.

Results

Barriers to maternal schistosomiasis management were identified across three levels. At the policy level, the absence of guidance on diagnosis, treatment and prophylaxis in maternal health guidelines, along with the exclusion of pregnant women from mass drug administration programs, were prominent. Health system barriers included limited knowledge and training among HCPs and concerns about praziquantel safety in pregnancy. At the community level, inadequate health education, misconceptions, reliance on drug outlets and negative perceptions of praziquantel further impeded effective management.

Conclusions

Maternal schistosomiasis management in Tanzania is hindered by policy gaps, limited HCP training and community misconceptions. Integrating care into antenatal services, updating guidelines and strengthening community education are essential in endemic settings

Introduction

Schistosomiasis remains a significant public health concern, particularly in sub-Saharan Africa (SSA), where an estimated 10 million pregnant women are affected by the disease.¹ Maternal schistosomiasis is associated with a range of adverse pregnancy outcomes, including preterm labour, low birth weight (LBW) and anaemia.² Anaemia during pregnancy further increases the risk of intrauterine growth restriction, preterm delivery, LBW and even intrauterine foetal death,³ and can also contribute to complications during childbirth, leading to increased maternal morbidity and mortality.⁴ Beyond delivery, maternal anaemia is linked to poor developmental outcomes in infants, which may persist without timely intervention. LBW itself is a well-established risk factor for neonatal and infant mortality, with studies from SSA reporting that infants born with LBW face a threefold higher risk of death compared with those with normal birth weight.⁵ Moreover, maternal schistosomiasis has been associated with pro-inflammatory responses in maternal, foetal and placental tissues, potentially further compromising pregnancy outcomes.⁶

Efforts to control schistosomiasis have involved multiple strategies aimed at interrupting the parasite’s life cycle. These include the provision of clean water, improved sanitation, snail control, health education and mass drug administration (MDA).⁷ Since the late 1970s, the World Health Organization (WHO) has recommended praziquantel as a safe and effective drug for treating schistosomiasis.⁸ Although various population groups, including adolescents, preschool-age children, pregnant women, lactating mothers and adolescent girls, are vulnerable to schistosomiasis, MDA programs have historically prioritized school-age children. This exclusion was primarily due to limited safety data on praziquantel use in other groups, including pregnant women.⁸

However, studies including clinical trials have demonstrated that praziquantel is safe for use during pregnancy and lactation, with no evidence of reproductive toxicity or adverse maternal or neonatal outcomes.⁹ A 2002 a WHO informal consultation concluded that praziquantel does not pose reproductive risks when used in pregnant or breastfeeding women.¹⁰ Subsequently, in 2017, the WHO recommended the inclusion of women of reproductive age, including pregnant and lactating women, in praziquantel treatment programs in endemic areas, either through individual treatment at antenatal clinics or via MDA.⁸ Furthermore, discussions are ongoing between the WHO and the US Food and Drug Administration (FDA) to reclassify praziquantel from a category B to a category A drug, reflecting its established safety profile.⁹

Despite these progressions, the uptake of praziquantel for treating maternal schistosomiasis remains low in many endemic regions, including Tanzania.¹¹ Evidence shows that multilevel barriers constrain the implementation of maternal health interventions. These include healthcare system barriers such as limited prioritization, suboptimal quality of care, inadequate medicine supplies, weak infrastructure, high service costs, poor transportation and the absence of clear guidelines; healthcare provider (HCP)-related barriers, including staff shortages, limited knowledge and skills, low motivation, poor working conditions and resistance to change; community-level barriers such as sociocultural norms, stigma and gender-based inequities affecting women’s decision-making autonomy; and individual-level barriers, including low awareness, fear of treatment and financial constraints.^12–14 Understanding these barriers is critical for designing effective and context-specific interventions. Therefore, this study explored HCPs’ experiences with schistosomiasis, particularly maternal schistosomiasis, and their perceived management barriers in Tanzania.

Methods

Study design

This was an exploratory qualitative case study aimed at analysing the experiences of HCPs in managing maternal schistosomiasis in Tanzania. A qualitative case study explores a clearly bounded case within its real-life context to generate a rich, holistic understanding of a complex phenomenon. In this study, the case is the management of maternal schistosomiasis, and we specifically explored HCPs’ experiences in delivering care for pregnant women. These experiences were examined within their routine working environments, antenatal care (ANC) settings located in areas with a high burden of schistosomiasis, where maternal schistosomiasis is commonly encountered. The study was conducted in October 2024 and data were collected through in-depth interviews (IDIs) with selected HCPs.

Study area

The study was conducted in district hospitals within the Mwanza Region, located in the Lake Victoria basin on the Tanzanian side. The region has a high prevalence (>80%) of Schistosoma mansoni infections, followed by Schistosoma haematobium.^15,16 Three districts—Misungwi, Sengerema and Magu—were randomly selected for inclusion. In each district the study was carried out in the district hospital, specifically within the reproductive and child health (RCH) clinic.

Study population, sampling technique and sample size

The IDIs targeted medical doctors, pharmacists and nurses working in RCH clinics. A purposive sampling technique was used. Heads of RCH clinics were requested to identify medical doctors and nurses with substantial experience in maternal health services. These nominated individuals were then approached, informed about the study and invited to participate in interviews. For pharmacists, the study targeted the head of the pharmacy department in each hospital. This decision was based on the structural organization of Tanzania’s healthcare system, where RCH clinics do not have dedicated pharmacy units and the pharmacy profession is still in its early stages. Most district hospitals have a limited number of pharmacists, with the head of the pharmacy department typically being the most experienced. Principles of qualitative data saturation guided the data collection process. A total of nine IDIs were conducted across the three hospitals, comprising three medical doctors, three pharmacists and three nurses.

Data collection procedures

A semi-structured interview guide was developed to facilitate discussions during the interviews. The guide was initially prepared in English and then translated into Kiswahili, a language fluently spoken by both the investigators and participants. It included questions focusing on schistosomiasis, maternal schistosomiasis, treatment options during pregnancy and perceived barriers in the management of maternal schistosomiasis.

Two trained research assistants, each with a master’s degree and prior experience in qualitative research, were recruited to conduct the interviews. The principal investigator obtained the names of eligible participants from the head of the RCH clinic and contacted each participant to schedule a convenient time for the interview. All interviews were conducted in the participants’ respective offices. Before the start of each interview, participants were briefed on the purpose of the study, asked to complete a demographic information form and provided written informed consent. Interviews lasted 25–45 min and were audio recorded with participants’ permission.

Data analysis

All interviews were verbatim transcribed and analysis was carried out in Kiswahili to retain the original meaning. Only the codes and quotes were translated into English to present the findings. Three transcripts were randomly selected and cross-checked against the audio recordings for accuracy. We developed a preliminary codebook guided by our study objectives and interview guide before we started coding. The coding process was preceded by repeated reading of the full transcripts and field notes to familiarize ourselves with the content and context of the topic. Two researchers independently coded one transcript, after which they met to refine the codebook to incorporate emerging codes. Full analysis commenced once consensus on the codes and their descriptions was reached among the coders. Each researcher then proceeded to code his/her assigned transcripts independently. The generated codes were grouped according to the predefined codebook, with emerging codes either added as new entries or used to refine existing codes. Afterward, code abstraction was conducted through comparisons to identify similarities and differences. These abstracted codes were organized into subthemes, which were further abstracted into broader themes. Finally, we presented the findings with the support of concise quotes. Data analysis was conducted manually using Excel (Microsoft, Redmond, WA, USA).

Researcher reflexivity and positionality

The research team comprised a pharmacologist with a Bachelor of Pharmacy background, a health policy specialist who is a medical doctor and two implementation scientists affiliated with a leading medical university in Tanzania, all with extensive experience in the Tanzanian healthcare system. This multidisciplinary and contextually grounded expertise facilitated access to study sites and the establishment of rapport with participants. However, the investigators’ professional backgrounds may also have influenced participants’ responses and the interpretation of findings. To address this, reflexivity was practiced throughout the study through critical reflection on personal assumptions and professional perspectives during data collection and analysis. A semi-structured interview guide was used to ensure consistency in questioning and field notes were taken to capture key issues and contextual observations to complement interview transcripts. A preliminary codebook was developed based on the study objectives, transcripts and field notes prior to full analysis. The research team met regularly to discuss and interpret the data, refine codes and align themes and subthemes, thereby enhancing credibility and minimizing individual bias.

Results

Participants’ demographic characteristics

Of the nine participants, six were female. Eight held a bachelor’s degree, while one held a nursing certificate. In terms of professional experience, five participants had worked for ≥10 y, whereas four had <5 y of experience.

Summary of the findings

Using thematic analysis, barriers to the effective management of maternal schistosomiasis were categorized into three main themes: policy and guideline-related barriers, healthcare facility-related barriers and community-related barriers. A total of eight subthemes emerged from the data (Figure 1).

Figure 1.

Summary of the findings.

Barriers to the effective management of maternal schistosomiasis

Theme 1: Health policy and guidelines–related barriers

Guidelines are silent on maternal schistosomiasis

Participants reported that the current standard treatment guidelines (STGs) and ANC guidelines do not specifically address maternal schistosomiasis. While the STGs provide general information on schistosomiasis, they lacks guidance tailored to the diagnosis and treatment of schistosomiasis during pregnancy. Additionally, participants noted that praziquantel is not explicitly recommended in the ANC guidelines and there is no mention of preventive measures or prophylaxis for maternal schistosomiasis.

The current guideline does not mention maternal schistosomiasis.

— RCH nurse 3

Pregnant women are excluded from MDA programs

Participants explained that the MDA program for schistosomiasis primarily targets school-age children, who receive praziquantel through distribution at their respective schools. They noted that pregnant women are not included in the MDA campaigns.

Our long-running national campaign targets school children. I’m not aware of any similar campaign for pregnant women.

— Pharmacist 3

Theme 2: Healthcare facility-related barriers

Limited experiences with maternal schistosomiasis

Participants highlighted a general lack of awareness of maternal schistosomiasis among HCPs. They noted that the condition is rarely discussed during pre-service medical training and many HCPs had never received in-service training or continuing education on maternal schistosomiasis. Participants stated that maternal schistosomiasis is not commonly recognized or prioritized in clinical practice.

I’ve never received any training. We try to seek and gain knowledge during clinical practice, but even in pre-service training, topics like schistosomiasis in pregnancy are very rarely covered.

— Medical doctor 3

Fear of using praziquantel during pregnancy

Participants reported that many HCPs have limited familiarity with praziquantel. They noted that some HCPs are not well-informed about its potential side effects or its safety profile during pregnancy, which may contribute to hesitancy in prescribing the drug to pregnant women.

I’m not sure if pregnant women are treated with praziquantel. I don’t know its side effects during pregnancy.

— RCH nurse 2

Theme 3: Community-related barriers

Inadequate health education program on schistosomiasis

Participants explained that both pregnant women and the broader community lack awareness about schistosomiasis during pregnancy. Participants said that existing RCH programs provide education on conditions such as human immunodeficiency virus (HIV) and tuberculosis (TB), but they do not include information on maternal schistosomiasis. Participants further noted the absence of community-based campaigns aimed at raising awareness of the risks schistosomiasis poses to vulnerable groups, particularly pregnant women.

Awareness is low since it's rarely taught; people only learn about it when they get sick. Unlike HIV or TB, it’s not well known among pregnant women.

— Pharmacist 1

Misconceptions and poor health-seeking behaviours

Participants stated that misconceptions about schistosomiasis are common in the community. Some individuals mistakenly believe that schistosomiasis is a sexually transmitted infection (STI), leading to stigma and secrecy. As a result, patients may hide their condition and some avoid seeking healthcare services due to fear of being judged or labelled as having an STI.

Since this disease is seen as a secret, patients may say they feel fine after treatment. You should reassure them, advise on precautions, and protect their privacy to avoid stigma.

— Pharmacist 2

They can suffer for a long time, thinking it’s a urinary tract infection, until they start passing blood in their urine; that’s when they become alarmed.

— Medical doctor 1

Reliance on community drug outlets for treatment

Participants clarified that many community members, including pregnant women, often rely on community drug outlets as their primary source of healthcare. They tend to seek care from these outlets rather than visiting formal health facilities, especially during the early stages of illness.

Our people often assume it’s a urinary tract infection and go straight to a community drug outlet for treatment instead of visiting a health facility.

— Pharmacist 2

Patients and community negative perceptions of praziquantel

Participants noted that the community often perceives drugs distributed during MDA campaigns as part of promotional activities rather than essential public health interventions. They shared that during praziquantel MDA, community members frequently complain about the large tablet size, particularly when administered to children. Additionally, due to the messaging received during ANC at RCH clinics, many pregnant women believe that most medications are unsafe during pregnancy.

Firstly, people may perceive it as a campaign intended to destroy their pregnancies….

— Pharmacist 3

The tablets are quite large in size and shape, making users and caregivers feel very uncomfortable.

— Pharmacist 2

Discussion

This study aimed to explored HCPs’ experiences with schistosomiasis, particularly maternal schistosomiasis, and their perceived management barriers in Tanzania. The findings revealed policy, health system and community-level challenges. At the policy level, the absence of guidance on diagnosis, treatment and prophylaxis in maternal health guidelines, along with the exclusion of pregnant women from MDA programs, were key obstacles. Within the health system, limited knowledge and training on maternal schistosomiasis, coupled with concerns about the safety of praziquantel use during pregnancy, were prominent barriers. At the community level, insufficient health education, misconceptions, reliance on informal drug outlets and negative perceptions of praziquantel further hindered effective management.

National guidelines are the primary reference for most HCPs; however, both national and ANC guidelines lack recommendations on the prevention and treatment of maternal schistosomiasis. This gap reflects misalignment with national universal health coverage and neglected tropical disease (NTD) strategies, as well as WHO guidance on the safe use of praziquantel during pregnancy.^17,18 Schistosomiasis remains among the top three infectious diseases in Africa, with up to 65% of pregnant women in endemic areas at risk.^19,20 Participants further emphasized the exclusion of pregnant women and women of childbearing age from MDA programs. Such gaps are consistent with challenges reported across SSA.^1,20,21 Updating guidelines to recommend praziquantel for maternal schistosomiasis, similar to sulfadoxine–pyrimethamine for malaria and mebendazole for intestinal helminths, is therefore essential in endemic regions.^22,23

NTDs are included in medical and nursing curricula, but with far less emphasis than other common diseases.²⁴ Consequently, most HCPs gain knowledge and skills in NTD management mainly through clinical practice and mentorship from senior colleagues.²⁵ Our findings reflect this gap, showing limited experience among HCPs in managing maternal schistosomiasis. Similar evidence from Uganda and Nigeria highlights that inadequate knowledge and misconceptions about praziquantel teratogenicity contribute to its underuse during ANC.^20,26 Strengthening providers’ knowledge and skills is critical, as pregnant women often rely heavily on their guidance.²⁷ Therefore, medical and nursing curricula in endemic regions should allocate more time and provide adequate clinical exposure to NTDs, including schistosomiasis.

This study found that community members often perceive the distribution of praziquantel as a promotional exercise. Unlike high-profile diseases such as HIV and TB,^28,29 schistosomiasis receives little community-based education. As a result, some people mistake it for a sexually transmitted infection (STI), leading to stigma and reluctance to seek care.³⁰ Participants also noted that symptoms of urinary schistosomiasis are frequently confused with urinary tract infections, prompting self-medication with antibiotics from community drug outlets. This pattern reflects broader evidence that many people in low-resource settings rely on drug outlets as their main source of medicines due to accessibility and avoidance of additional costs such as transport, consultation and laboratory fees.³¹ Misconceptions about schistosomiasis and reliance on informal treatment often delay appropriate care and contribute to complications.³² Strengthening community awareness programs and ensuring the inclusion of pregnant women and women of childbearing age in MDA campaigns are essential. This is particularly important given that schistosomiasis increases women’s vulnerability to HIV infection and female genital schistosomiasis, which is associated with a higher risk of cervical cancer.³³

This study has several limitations. First, the sample size was small and the perspectives of pregnant women and their caregivers were not included. Second, as participants were HCPs working in facilities that provide ANC, their responses may have been influenced by social desirability bias. To mitigate this, we purposively sampled HCPs from different cadres (medical doctors, nurses and pharmacists) to capture multilevel perspectives and reduce bias. For future research, we recommend implementation studies to explore the perspectives of a broader range of stakeholders and to pilot the use of praziquantel in ANC or MDA programs.

Conclusions

This study highlights significant policy, health system and community-level barriers to managing maternal schistosomiasis in Tanzania. The absence of maternal-specific guidelines, inadequate health worker training, community misconceptions and the exclusion of pregnant women from MDA programs collectively hinder effective control efforts. Addressing these challenges requires integrating maternal schistosomiasis into ANC services, revising national guidelines and strengthening community health education. The findings have broader relevance for other low-resource, schistosomiasis-endemic settings facing similar structural and cultural barriers. Resource limitations further compound these challenges, as drug distribution and capacity-building initiatives often rely heavily on donor support. Moving forward, prioritizing maternal schistosomiasis within national NTD control programs and investing in operational research on effective integration models will be critical to reducing the disease burden and improving maternal health outcomes.

Authors’ contributions

All authors contributed meaningfully to the work, whether through conceptualization, study design, data collection, analysis, interpretation or a combination of these. They were involved in drafting, revising or critically reviewing the manuscript, approved the final version for publication, agreed on the target journal and take full responsibility for all aspects of the work.

Funding

This study was supported by the Royal Society of Tropical Medicine and Hygiene Small Grants Programme, 2021. The funder had no role in the design of the study, data collection, analysis, interpretation of the data or writing of the manuscript.

Competing interests

None declared.

Data availability

The data will be made available upon reasonable request to the corresponding author, subject to approval by the relevant ethics committees.

Ethical approval

Ethical clearance for this study was obtained from the Muhimbili University of Health and Allied Sciences Research and Ethics Committee (MUHAS-REC-12-2021-923). Permission to conduct data collection was granted by the Regional Administrative Secretary of Mwanza Region and the respective district executive directors. At the district hospital level, the study was formally introduced to the hospital administration and data collection activities were coordinated through the RCH clinics. Written informed consent was obtained from all participants before the start of the interviews. Throughout the data collection process, ethical principles were strictly observed in accordance with the Declaration of Helsinki.