An ethnographic study of how health system, socio-cultural and individual factors influence uptake of intermittent preventive treatment of malaria in pregnancy with sulfadoxine-pyrimethamine in a Ghanaian context

Social determinants of malaria in low- and middle-income countries: a mixed-methods systematic review

BACKGROUND

Malaria remains a leading cause of morbidity and mortality in many low- and middle-income countries (LMICs). Factors outside the health sector, including social determinants, such as economic status remain important drivers of malaria in these settings. However, social determinants of malaria generally remain unaddressed in preventing the disease, with the limited existing evidence overly descriptive and fragmented.

METHODS

A mixed-methods systematic review was conducted to thematically synthesize the current evidence on the social determinants of malaria in LMICs. PubMed, Web of Science, and Scopus were searched to identify English articles on the social determinants of malaria published between January 2013 and December 2023. Search terms such as social determinant, socio-cultural, and socioeconomic factors were used. Articles that did not meaningfully engage with the social determinants were excluded.

RESULTS

The 39 articles included in the review were mostly cross-sectional and qualitative studies of moderate quality, in general. Findings indicate a range of social determinants of malaria related to the following overarching themes: environmental factors, access to and use of treatment, preventive interventions use, housing, stakeholder influence, livelihoods and economic development, and poverty. The various social determinants influenced malaria in different ways, including limiting access and use of preventive and treatment interventions and increased exposure to mosquitoes. Poverty and gender intersected with other social determinants such as housing and livelihoods.

CONCLUSION

Different social determinants of malaria are key drivers of malaria in LMICs. The findings emphasize the need for malaria control efforts to consider social determinants at all levels, including funding, implementation, and evaluation.

Enhancing IPTp-SP uptake: Community and stakeholder recommendations for improving access and utilisation - insights from a study in Bayelsa-Nigeria

Background

Malaria remains a major global health challenge, disproportionately affecting pregnant women and children. In Nigeria, malaria in pregnancy contributes to 70.5% of maternal morbidity and 41.1% of maternal mortality. Recognising these risks, the World Health Organization recommends intermittent preventive treatment with sulfadoxine-pyrimethamine (IPTp-SP) as a key strategy for malaria in pregnancy prevention. However, despite its proven effectiveness, pregnant women's uptake of IPTp-SP remains unacceptably low. This study presents participant-driven recommendations to enhance IPTp-SP uptake, structured within the socio-ecological framework.

Materials and Methods

This study employed an exploratory descriptive qualitative approach to examine the community-level contextual factors influencing IPTp-SP uptake. Data were collected from 53 participants in two communities in Bayelsa, Nigeria. Individual interviews were conducted with 17 key stakeholders (spouses, mothers-in-law, religious leaders, community leaders, and traditional birth attendants) and 6 focus group discussions with 36 pregnant women. Data management and coding were conducted using NVivo 14 QSR International software, following an inductive-deductive thematic analysis approach.

Results

Participants proposed multi-level interventions to address barriers to IPTp-SP uptake at the individual, interpersonal, community, and healthcare system levels. Key recommendations include: Community-wide education campaigns to raise awareness of IPTp-SP's benefits; comprehensive training for healthcare providers to enhance their knowledge and prescription of IPTp-SP; integration of traditional birth attendants into the formal healthcare system; community-level distribution of IPTp-SP to improve access for pregnant women who do not attend antenatal care; government intervention to ensure the functionality of health centers; addressing workforce shortages, and guaranteeing a consistent supply of IPTp-SP.

Conclusion

These evidence-based, participant-driven recommendations offer a holistic and scalable strategy to improve pregnant women's uptake of IPTp-SP in Nigeria and other malaria-endemic regions. Implementing these recommendations can strengthen malaria prevention efforts, improve maternal and child health outcomes, and support broader public health initiatives.

Sex of household head and trends in uptake of sulfadoxine-pyrimethamine intermittent preventive treatment for malaria during pregnancy: insights from secondary data in sub-Saharan Africa

Background

Malaria in pregnancy remains a serious public health concern in sub-Saharan Africa. The household head as a primary decision-maker plays a major role in women's utilization of maternal health services. This study aimed to examine the trends, and the association between the sex of household head and the uptake of intermittent preventive treatment of malaria in pregnancy using sulfadoxine-pyrimethamine (IPTp-SP) in six sub-Saharan African countries. The findings provide insight into the progress, status and gender-specific barriers to IPTp-SP uptake.

Methods

Secondary data from the most recent Malaria Indicator Surveys for the six countries were analysed. A total of 15,452 (weighted) women aged 15-49 years from the six countries were included in this study. Both descriptive and inferential statistics were computed, including a chi-square test and binary logistic regression.

Results

The pooled data showed that 77% of the participants took at least one dose of IPTp-SP and 37% took ≥ 3 doses. The trend analysis showed that the uptake of IPTp-SP has increased over time. Women with a female household head (AOR = 1.21, 95% CI 1.08-1.38) had higher odds of taking ≥ 3 doses of IPTp-SP compared to those with a male household head.

Conclusion

The findings suggest that promoting women's participation in decision-making and leadership at the household level may help increase the uptake of IPTp-SP in sub-Saharan Africa.

"If they take it without knowing, they will default…": perceptions of targeted information transfer to promote adherence to intermittent preventive treatment with dihydroartemisinin-piperaquine for the prevention of malaria in pregnancy in western Kenya

BACKGROUND

Increasing resistance to sulfadoxine-pyrimethamine (SP) threatens the effectiveness of intermittent preventive treatment (IPTp) to prevent malaria in pregnancy. Dihydroartemisinin-piperaquine (DP) is the most promising candidate to emerge from clinical trials, but requires a multi-day regimen. Despite being a single-dose regimen, coverage of IPTp-SP remains low, fuelling concerns about adherence to multi-day drug options. An implementation feasibility trial in routine antenatal care settings in western Kenya demonstrated that adherence to the multi-day DP regimen was improved when IPTp-DP was delivered with a targeted information transfer intervention that comprised healthcare provider training and communication tools to support delivery and uptake. This study explored healthcare provider and pregnant women perspectives to understand (1) how the targeted information transfer improved adherence to IPTp-DP and (2) if improved adherence to IPTp-DP influenced provider perceptions towards implementation feasibility of multi-day drug regimens for IPTp.

METHODS

In-depth interviews were conducted with 64 healthcare providers and 64 pregnant women, selected using a convenience sampling approach from across the three trial arms: IPTp-DP+ (with intervention), IPTp-DP, and current standard of care IPTp-SP. Transcripts from healthcare providers and pregnant women were coded in Nvivo-12 using separate a priori frameworks that included components of the consolidated framework for implementation research. Thematic analysis was used to understand how the targeted information transfer affected adherence to IPTp-DP and how concerns about adherence might influence provider perceptions towards multi-day drug regimens for IPTp.

RESULTS

Adherence to IPTp-DP doses taken at home was compromised when women experienced unpleasant side effects. Pregnant women valued being given information about IPTp-DP, including potential side effects and how to manage them. Among providers in the IPTp-DP + arm, confidence in advising women on how to manage side effects increased, and they believed this guidance improved adherence. When concerns about adherence were reduced, providers in the IPTp-DP + arm were positive about implementation feasibility, whereas providers in the IPTp-SP arm remained focused on the dosing complexities and were less convinced of the feasibility of implementing IPTp-DP.

CONCLUSIONS

Healthcare provider confidence in advising women on how to minimize side effects was boosted through targeted information transfer, which was perceived to improve adherence to IPTp-DP. Policy makers are encouraged to consider supportive interventions that enhance provider confidence around adherence should they shift to multi-day drug regimens for IPTp.

Perspectives of postpartum women on intermittent presumptive treatment in Uganda: implications for malaria prevention: a qualitative study

BACKGROUND

Malaria during pregnancy leads to many deaths in Africa. COVID-19 contributed to more malaria cases due to interruptions in prevention efforts. Intermittent presumptive treatment (IPTP) is an effective malaria prevention strategy for pregnant women, but adoption barriers still exist. The study aim was to explore barriers to the adoption of IPTP at Kawempe National Referral Hospital (KNRH) Uganda.

METHODS

In a qualitative study design, data was collected using focus group discussions. A total of 37 postpartum mothers were interviewed in six focus group discussions. The interviews were conducted using a structured guide to explore barriers to IPTP implementation at KNRH. The data was transcribed, coded, and analysed using NVivo 10.

RESULTS

The study found that mothers lacked adequate knowledge about IPTP, faced socioeconomic and cultural constraints, fear of side effects, a high pill burden, and experience of health system challenges as major themes of barriers to optimal IPTP use.

CONCLUSIONS AND RECOMMENDATIONS

Challenges in the service delivery and inadequate information in regard to importance and expected side effects were identified by the users as the major barriers to IPTP delivery in public health care setting. Improving delivery of focused health education talks and health work attitude and delivery chain for IPTP in the health facilities are recommended to increase its uptake.

Uptake and Effectiveness of Intermittent Preventive Treatment with Sulfadoxine-Pyrimethamine during Pregnancy in Africa: A Scoping Review

Malaria poses a significant threat to pregnant women in sub-Saharan Africa, necessitating effective interventions like the intermittent preventive treatment of malaria in pregnancy with sulfadoxine-pyrimethamine (IPTp-SP). However, challenges persist in the uptake and effectiveness of this intervention. This scoping review aims to explore IPTp-SP uptake in African countries, identify influencing factors, and assess its effectiveness in preventing malaria and adverse outcomes in pregnancy. This scoping review follows Arksey and O'Malley's framework, employing the PRISMA-ScR guidelines for reporting. Searches were conducted in PubMed, Embase, Scopus, JSTOR, Web of Science, Google Scholar, and ProQuest, focusing on studies post-2000 published in the English language. The search produced 15,153 records, of which 104 full-text records were eligible and 101 papers were included in this review. The findings suggest varying IPTp-SP uptake rates, spanning from 5.3% to 98.9%, with their effectiveness supported by longitudinal studies, randomised controlled-trials (RCTs), cross-sectional surveys, and mixed-method studies. IPTp-SP demonstrates efficacy in reducing malaria during pregnancy, placental parasitaemia, and anaemia episodes, alongside improved birth outcomes. Common adverse effects of IPTp-SP include prematurity and low birth weight. Facilitators of IPTp-SP uptake include education and ANC attendance, while commonly reported barriers included inadequate knowledge and healthcare system challenges. The findings also suggest adverse effects such as prematurity, low birth weight, and maternal and perinatal mortality associated with IPTp-SP uptake. It is vital to strengthen antenatal care services by integrating comprehensive counselling on IPTp-SP and address healthcare system challenges. Community engagement, women's empowerment, and context-specific interventions are necessary for promoting IPTp-SP uptake and improving maternal and neonatal health outcomes in Africa.

The readiness of malaria services and uptake of intermittent preventive treatment in pregnancy in six sub-Saharan countries

Background

Malaria infection during pregnancy is associated with an increased risk of maternal death, as well as adverse birth outcomes. Intermittent preventive treatment in pregnancy with sulfadoxine-pyrimethamine (IPTp-SP) is known to improve pregnancy outcomes. However, the coverage of IPTp-SP in antenatal care (ANC) in sub-Saharan Africa remains well below the target. This study aims to estimate to what extent malaria service readiness affects the uptake of IPTp-SP during ANC visits in sub-Saharan African countries.

Methods

This study included 3267 pregnant women attending ANC for the first time and 2797 pregnant women who had attended ANC more than a month ago in six sub-Saharan African countries. The readiness of malaria services at each institution includes four indicators: the presence of IPTp-SP guidelines, SP availability, integration of IPTp-SP service into ANC, and provider training on IPTp-SP. The outcome variable indicates whether a pregnant woman received IPTp-SP at her current ANC visit. A modified Poisson regression model estimated the associations between malaria service readiness and IPTp-SP uptake for women eligible for the first and subsequent doses.

Results

For women eligible for their first dose, visiting an institution with available SP was associated with an increased probability of receiving IPTp-SP (risk ratio (RR) = 1.43; 95% confidence interval (CI) = 1.22 to 1.67, P < 0.001). For women who were eligible for their next dose, the availability of SP (RR = 1.17; 95% CI = 1.04 to 1.32, P = 0.008) and integration of IPTp-SP service into ANC (RR = 1.82; 95% CI = 1.21 to 2.74, P = 0.004) in the institution were associated with increased likelihood of IPTp-SP uptake. Counterfactual predictions indicated that enhanced provider training could boost IPTp-SP uptake in high-uptake countries, while better SP availability and IPTp-SP integration into ANC would significantly impact low-uptake countries.

Conclusions

For better IPTp-SP coverage, strategies should be customised. High uptake countries should focus on provider training, while low uptake ones should ensure IPTp-SP availability and service integration.

Spatial distribution and determinants of intermittent preventive treatment for malaria during pregnancy: a secondary data analysis of the 2019 Ghana malaria indicators survey

BACKGROUND

Malaria during pregnancy is associated with poor maternal, foetal, and neonatal outcomes. To prevent malaria infection during pregnancy, the World Health Organization recommended the use of intermittent preventive therapy with sulfadoxine-pyrimethamine (IPTp-SP) in addition to vector control strategies. Although Ghana's target is to ensure that all pregnant women receive at least three (optimal) doses of SP, the uptake of SP has remained low; between 2020 and 2022, only 60% of pregnant women received optimal SP during their most recent pregnancy. This study sought to map the geospatial distribution and identify factors associated with SP uptake during pregnancy in Ghana.

METHODS

Secondary data analysis was conducted using the 2019 Ghana Malaria Indicator Survey dataset. The data analysed were restricted to women aged 15-49 years who reported having a live birth within the two years preceding the survey. A modified Poisson regression model was used to determine factors associated with SP uptake during pregnancy. Geospatial analysis was employed to map the spatial distribution of optimal SP uptake across the ten regions of Ghana using R software.

RESULTS

The likelihood that pregnant women received optimal SP correlated with early initiation of first antenatal care (ANC), number of ANC contacts, woman's age, region of residence, and family size. Overall, the greater the number of ANC contacts, the more likely for pregnant women to receive optimal SP. Women with four or more ANC contacts were 2 times (aPR: 2.16; 95% CI: [1.34-3.25]) more likely to receive optimal SP than pregnant women with fewer than four ANC contacts. In addition, early initiation and a high number of ANC contacts were associated with a high number of times a pregnant woman received SP. Regarding spatial distribution, a high uptake of optimal SP was significantly observed in the Upper East and Upper West Regions, whereas the lowest was observed in the Eastern Region of Ghana.

CONCLUSIONS

In Ghana, there were regional disparities in the uptake of SP during pregnancy, with the uptake mainly correlated with the provision of ANC services. To achieve the country's target for malaria control during pregnancy, there is a need to strengthen intermittent preventive treatment for malaria during pregnancy by prioritizing comprehensive ANC services.

Provider and User Acceptability of Integrated Treatment for the Control of Malaria and Helminths in Saraya, South-Eastern Senegal

Integration of vertical programs for the control of malaria, schistosomiasis, and soil-transmitted helminthiasis has been recommended to achieve elimination of malaria and neglected tropical diseases (NTD) by 2030. This qualitative study was conducted within the context of a randomized controlled trial to explore the perceptions and views of parents/caregivers of at-risk children and healthcare providers to determine their acceptability of the integrated malaria-helminth treatment approach. Randomly selected parents/caregivers of children enrolled in the trial, healthcare providers, trial staff, malaria, and NTD program managers were interviewed using purpose-designed topic guides. Transcripts obtained from the interviews were coded and common themes identified using content analysis were triangulated. Fifty-seven study participants comprising 26 parents/caregivers, 10 study children aged ≥ 10 years, 15 trial staff, four healthcare providers, and two managers from the Senegal Ministry of Health were interviewed. Thirty-eight of the participants (66.7%) were males, and their ages ranged from 10 to 65 years. Overall, the integrated malaria-helminth treatment approach was considered acceptable, but the study participants expressed concerns about the taste, smell, and side effects associated with amodiaquine and praziquantel in the combination package. Reluctance to accept the medications was also observed among children aged 10 to 14 years due to peer influence and gender-sensitive cultural beliefs. Addressing concerns about the taste and smell of amodiaquine and praziquantel is needed to optimize the uptake of the integrated treatment program. Also, culturally appropriate strategies need to be put in place to cater for the inclusion of children aged 10 to 14 years in this approach.

Social determination of malaria in pregnancy in Colombia: a critical ethnographic study

BACKGROUND

The meanings and experiences related to malaria in pregnancy (MiP) and its processes of social determination of health (PSDH) have not been reported in the world scientific literature. The objective was to understand the meanings and experiences of MiP, and to explain their PSDH in an endemic area from Colombia, 2022.

METHODS

Critical ethnography with 46 pregnant women and 31 healthcare workers. In-depth and semi-structured interviews, focus group discussions, participant and non-participant observations, and field diaries were applied. A phenomenological-hermeneutic analysis, saturation and triangulation was carried out. The methodological rigor criteria were reflexivity, credibility, auditability, and transferability.

RESULTS

At the singular level, participants indicated different problems in antenatal care and malaria control programmes, pregnant women were lacking knowledge about MiP, and malaria care was restricted to cases with high obstetric risk. Three additional levels that explain the PSDH of MiP were identified: (i) limitations of malaria control policies, and health-system, geographic, cultural and economic barriers by MiP diagnosis and treatment; (ii) problems of public health programmes and antenatal care; (iii) structural problems such as monetary poverty, scarcity of resources for public health and inefficiency in their use, lacking community commitment to preventive actions, and breach of institutional responsibilities of health promoter entity, municipalities and health services provider institutions.

CONCLUSION

Initiatives for MiP control are concentrated at the singular level, PDSH identified in this research show the need to broaden the field of action, increase health resources, and improve public health programmes and antenatal care. It is also necessary to impact the reciprocal relationships of MiP with economic and cultural dimensions, although these aspects are increasingly diminished with the predominance and naturalization of neoliberal logic in health.

Interventions for malaria prevention in pregnancy; factors influencing uptake and their effect on pregnancy outcomes among post-natal women in a tertiary facility in the Volta Region of Ghana

Objectives

Malaria in pregnancy is associated with adverse pregnancy outcomes including maternal anaemia and low birthweight. Uptake of preventive interventions is sub-optimal in sub-Saharan Africa including Ghana. Understanding local-level factors that influence uptake of these interventions can enhance control. The study assessed uptake of intermittent preventive treatment of malaria during pregnancy using sulphadoxine-pyrimethamine (IPTp-SP) and insecticide-treated net (ITN) use, their determinants and effects on pregnancy outcomes.

Methods

A cross-sectional study involving 349 post-partum women was conducted from 25 August 2022 to 9 October 2022 at the Ho Teaching Hospital. A structured questionnaire was used to collect data on participant socio-demographics, ITN use, number of doses of sulphadoxine-pyrimethamine received, knowledge of malaria in pregnancy, haemoglobin levels and birth weight among others. Summary statistics were reported as frequencies, percentages and means. Associations between exposure and outcome variables were assessed using logistic regression methods and odds ratios reported with 95% confidence intervals. Statistical significance was concluded at p < 0.05.

Results

More than 80% (291) of respondents received ⩾3 doses of intermittent preventive treatment using sulphadoxine-pyrimethamine and 64.8% (226) slept under ITNs the night before the survey. Age >25 years, employment, good knowledge of malaria in pregnancy, parity ⩾2 and initiating antenatal care visits in the first trimester facilitated the uptake of these interventions. Receiving ⩾3 doses of sulphadoxine-pyrimethamine was associated with having normal-weight babies (adjusted odds ratio 2.80, 95% CI: 1.07, 7.34; p = 0.036) while ITN use was associated with having term babies (adjusted odds ratio 2.72, 95% CI: 1.24, 5.90; p = 0.013) and normal maternal haemoglobin concentration at term (adjusted odds ratio 1.57, 95% CI: 1.01, 2.47; p = 0.044).

Conclusions

The interventions were beneficial against low birthweight and preterm births which predispose to neonatal deaths and poor cognitive function in children. Malaria in pregnancy health campaigns should be intensified, especially among younger-aged primigravidae, to increase their knowledge of the condition as a way to further improve uptake of these preventive interventions.

Intermittent preventive treatment with Sulfadoxine pyrimethamine for malaria: a global overview and challenges affecting optimal drug uptake in pregnant women

Malaria in Pregnancy (MiP) leading to morbidity and mortality is a major public health problem that poses significant risk to pregnant women and their fetus. To cope with this alarming situation, administration of Sulfadoxine-pyrimethamine (SP) drugs to pregnant women as an intermittent preventive treatment (IPT) from 16 weeks of gestation is recommended by the World Health Organization (WHO) guidelines. We conducted a comprehensive search of published articles related to MiP in last 10 years with predefined keywords or their synonyms. The mapping of malaria in pregnant women showed a prevalence rate up to 35% in many countries. Although IPTp-SP has been implemented in endemic regions since several years but the IPTp-SP coverage percentage vary from country to country and continue to remain below the target of 80%. Major reasons for low IPTp-SP involve gestational age at first prenatal visit, level of education, place of residence, knowledge of IPTp-SP benefits, and use of antenatal services. Several challenges including the emergence of septuple and octuple SP-resistant parasites is reported from many countries which make the prophylactic use of IPTp-SP currently debatable. This narrative review addresses the barriers for optimal use of IPTp-SP and discusses alternative approaches to increase the use and effectiveness of SP intervention for preventing MiP. The COVID pandemic has drastically affected the public health disrupting the management of diseases worldwide. In view of this, a brief summary of COVID impact on MiP situation is also included.

Synthesis of Qualitative Evidence on Malaria in Pregnancy, 2005-2022: A Systematic Review

Qualitative research on malaria in pregnancy (MiP) is incipient, therefore its contextual, experiential and symbolic associated factors are unknown. This study systematizes the qualitative research on MiP, describes knowledge, perceptions and behaviors about MiP, and compiles individual, socioeconomic, cultural and health system determinants of MiP through a meta-synthesis in 10 databases. A total of 48 studies were included with 2600 pregnant women, 1300 healthcare workers, and 2200 relatives or community members. Extensive knowledge was demonstrated on ITN and case management, but it was lacking on SP-IPTp, risks and consequences of MiP. Attitudes were negative towards ANC and MiP prevention. There were high trustfulness scores and preference for traditional medicine and distrust in the safety of drugs. The main determinants of the Health System were rationing, copayments, delay in payment to clinics, high out-of-pocket expenses, shortage, low workforce and work overload, shortcomings in care quality, low knowledges of healthcare workers on MiP and negative attitude in care. The socioeconomic and cultural determinants were poverty and low educational level of pregnant women, distance to the hospital, patriarchal-sexist gender roles, and predominance of local conceptions on maternal-fetal-neonatal health. The meta-synthesis demonstrates the difficulty to detect MiP determinants and the importance of performed qualitative research before implementing MiP strategies to understand the multidimensionality of the disease.

Assessing nursing mothers' knowledge, perceptions and uptake of Sulphadoxine Pyrimethamine (IPTp-SP) during pregnancy in the Ho Teaching Hospital of the Volta Region of Ghana

Intermittent preventive therapy during pregnancy with Sulphadoxine Pyrimethamine (IPTp-SP) is one of the potent strategies for preventing malaria in pregnancy (MiP). Factors such as the pregnant woman's knowledge and very importantly perception or belief about IPTp-SP remains key determinant of IPTp-SP uptake. This study assessed the knowledge and perception of nursing mothers and their uptake of IPTp-SP during pregnancy in the Ho Teaching Hospital. We administered a close-ended questionnaire to 303 nursing mothers and obtained their sociodemographic details as well as information on their knowledge and perception of IPTp-SP utilization. We also reviewed the nursing mothers' antenatal care (ANC) booklets to ascertain the number of times IPTp-SP was taken during pregnancy. Pearson chi-square was used to determine the association between the sociodemographic variable and the categories of knowledge, perception, and uptake of IPTp-SP. Analysis, was done using SPSS, and the p-value of less than 5% was considered statistically significant. Of the 303 nursing mothers sampled in this study, 265(87.5%) had heard about IPTp-SP of which 138(52.1%) had average knowledge of IPTp-SP. A total of 168(63.4%) had poor perception, and 168(64.6%) had adequate uptake (3-4 doses) of IPTp. Education was significantly associated with perception and uptake, with the majority of women who demonstrated excellent perception were those who had tertiary education (7, 6.35%, p = 0.05), and the majority who demonstrated excellent uptake (5 completed doses) were women who had tertiary education (47, 37.9%, p = 0.01). While knowledge was average, perception of IPTp-SP was poor for the majority of the nursing mothers which might have hampered their uptake of IPTp-SP during pregnancy. It is important that continuous assessment of the individual factors affecting the uptake of IPTp-SP be done regularly to curb the negative influences on the uptake of IPTp-SP.

Motivators and demotivators to accessing malaria in pregnancy interventions in sub-Saharan Africa: a meta-ethnographic review

Background

Despite the introduction of efficacious interventions for malaria control, sub-Saharan Africa continues to bear the highest burden of malaria and its associated effects on vulnerable populations, such as pregnant women and children. This meta-ethnographic review contributes to literature on malaria in pregnancy interventions in sub-Saharan Africa by offering insights into the multiple factors that motivate or demotivate women from accessing MiP interventions.

Methods

A meta-ethnographic approach was used for the synthesis. Original qualitative research articles published from 2010 to November 2021 in English in sub-Saharan Africa were searched for. Articles focusing on WHO’s recommended interventions such as intermittent preventive treatment with sulfadoxine-pyrimethamine, long-lasting insecticidal nets and testing and treatment of Malaria in Pregnancy (MiP) were included. Selected articles were uploaded into Nvivo 11 for thematic coding and synthesis.

Results

Twenty-seven original qualitative research articles were included in the analysis. Main factors motivating uptake of MiP interventions were: (1) well organized ANC, positive attitudes of health workers and availability of MiP services; (2) Women’s knowledge of the effects of malaria in pregnancy, previous experience of accessing responsive ANC; (3) financial resources and encouragement from partners, relatives and friends and (4) favourable weather condition and nearness to a health facility. Factors that demotivated women from using MiP services were: (1) stock-outs, ANC charges and health providers failure to provide women with ample education on the need for MiP care; (2) perception of not being at risk and the culture of self-medication; (3) fear of being bewitched if pregnancy was noticed early, women’s lack of decision-making power and dependence on traditional remedies and (4) warm weather, long distances to health facilities and the style of construction of houses making it difficult to hang LLINs.

Conclusions

Health system gaps need to be strengthened in order to ensure that MiP interventions become accessible to women. Additionally, health managers need to involve communities in planning, designing and implementing malaria interventions for pregnant women. It is important that the health system engage extensively with communities to facilitate pregnant women and communities understanding of MiP interventions and the need to support pregnant women to access them.